Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mason City Area Nursing Home during CMS and state inspections, most recent first.
A cognitively intact resident with multiple medical conditions and a history of wandering and observing others was documented as placing his hand on the breast of a severely cognitively impaired resident in a common TV lounge, in violation of facility policy prohibiting sexual abuse and unwanted intimate touching. The cognitively impaired resident, who had dementia and was on 15-minute checks for wandering, was later again the focus of inappropriate contact concerns, including staff observing the other resident touching the back of her head and pacing the hallways looking for her. After an earlier incident, the resident who initiated contact had been placed on 15-minute checks for a limited period, which were then discontinued when no further concerns were noted, preceding the subsequent inappropriate interactions.
A resident with significant physical disabilities suffered two second-degree burns after spilling hot coffee on her thigh on separate occasions, due to the facility's failure to implement individualized care interventions and to identify the hot beverage dispenser as a burn hazard. The hot liquids were served at unsafe temperatures, and staff were not adequately trained or aware of care plan requirements, placing all residents at risk.
Two cognitively impaired residents were improperly restrained in their wheelchairs using gait belts by an LPN, without physician orders or consent, due to insufficient staff to provide one-on-one attention. The residents, both with severe cognitive impairments, were restrained without medical justification, violating facility policies.
The facility did not have a Registered Nurse (RN) on duty for at least eight consecutive hours on five days in January, as required by their staffing policy. This deficiency was confirmed by the Director of Nursing and potentially affects all 56 residents in the facility.
The facility failed to immediately report the inappropriate use of physical restraints on two residents. An LPN used a gait belt to restrain residents in their wheelchairs, which was witnessed by another LPN and a CNA who did not report the incident. The issue was eventually reported by another CNA to the Administrator, who is the facility's Abuse Coordinator.
The facility did not have an RN on duty for eight consecutive hours on eight specific days in October and November, as required by policy. The administrator acknowledged the difficulty in hiring an RN for weekends, potentially affecting all 52 residents.
The facility failed to document diagnoses, identify behaviors, and monitor targeted behaviors for residents on psychotropic medications, leading to inappropriate use without attempts at gradual dose reduction (GDR). For example, a resident on Seroquel for dementia without behavioral disturbance had no documented behaviors justifying the medication, and GDR recommendations were denied due to family preferences. Staff confirmed that residents did not exhibit behaviors warranting antipsychotic use, and the facility did not adhere to its policy requiring documentation and GDR attempts.
A facility failed to follow Enhanced Barrier Precautions for a resident with a burn on her thigh. CNAs did not wear gowns and one wore only one glove while changing the resident's brief. An LPN also did not wear a gown during wound care. Both incidents were acknowledged by staff, and the Director of Nursing confirmed the requirement for PPE as per facility policy.
Failure to Prevent Resident-to-Resident Sexual Abuse of a Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to prevent abuse when a cognitively intact resident engaged in inappropriate sexual contact with a severely cognitively impaired resident. Facility policy dated 8/25/2025 states that all residents have the right to be free from verbal, sexual, physical, and mental abuse, and defines sexual abuse as non-consensual sexual contact, including unwanted intimate touching of the breasts. The Final Facility Incident Report for 01/02/2026 documents a resident-to-resident interaction in the TV lounge in which one resident was observed with his hand on another resident’s chest and admitted he had a moment of weakness and placed his hand on the other resident’s breast over clothing. The resident who initiated the contact had diagnoses including a displaced right acetabulum fracture, COPD, heart failure, atrial fibrillation, peripheral vascular disease, and hypertension, and was documented as cognitively intact with a BIMS score of 15/15 and able to understand and be understood. The resident who was touched had diagnoses including dementia, depression, hypertension, and hyperlipidemia and was documented as severely cognitively impaired. This resident also had an existing physician’s order for 15-minute observation checks due to wandering. A CNA later reported visualizing another resident making inappropriate contact with this severely cognitively impaired resident. The administrator reported that after an incident on 12/28/2025, the cognitively intact resident was placed on 15-minute checks for three days and, when no concerns were identified, those checks were discontinued. Subsequently, staff observed this same resident touching the back of the cognitively impaired resident’s head, and a CNA reported observing him pacing the hallways looking for her. These events, in the context of the facility’s stated abuse-prevention policy, demonstrate that the facility did not effectively prevent sexual abuse of a vulnerable resident by another resident.
Failure to Prevent Burns from Hot Liquids Due to Lack of Individualized Interventions and Hazard Identification
Penalty
Summary
The facility failed to implement individualized care planned interventions to prevent a resident with significant physical disabilities from sustaining multiple burns. The resident, who had diagnoses including Spastic Cerebral Palsy, Scoliosis, Dysphagia, and Muscle Spasms, required supervision or assistance with eating and was dependent on staff for all other activities of daily living. Despite these needs, the resident was allowed to handle hot coffee independently, resulting in two separate incidents where hot coffee was spilled on her left posterior thigh, causing second-degree burns on both occasions. The care plan did not include a hot liquid risk assessment, and interventions to prevent such injuries were either not in place or not followed by staff. The facility also failed to identify the hot water/coffee dispenser in the main dining room as a potential burn hazard. The dispenser was accessible to all residents, and the coffee and hot water were routinely served at temperatures ranging from 170 to 177 degrees Fahrenheit, well above the threshold known to cause burns. There were no protocols or adequate monitoring in place to ensure that hot liquids were served at safe temperatures. Staff interviews revealed a lack of awareness regarding residents' care plans and the need for assistance with hot liquids, and some staff did not know how to access or update care plans. Additionally, the dining room doors were sometimes left open or unlocked, allowing residents unsupervised access to the hot beverage dispenser. The facility did not have a Hot Liquids Policy in place prior to the incidents, and staff were not in-serviced on the risks associated with hot liquids or the need for individualized interventions. The lack of a systematic approach to assessing residents' risk for hot liquid injuries, combined with inadequate staff training and supervision, directly contributed to the resident's repeated injuries. The failures affected not only the resident who was burned but also placed all 59 residents who accessed the hot beverage dispenser at risk.
Removal Plan
- All residents were interviewed by V8/Wound Nurse, V22/Restorative Nurse, V23/Business Office Manager, and V24/Social Service Director for hot liquid spills with injury.
- R1 was removed from the dining room, laid down, clothes were removed, and a head-to-toe skin assessment was completed. V7/R1's Physician and V25/R1's Family member was notified. A wound dressing was ordered, R1's care plan was updated to ensure staff assisted R1 with a waterproof clothing protector and lap blanket to be worn during all meals and as needed for food and fluid intake and to continue Occupation therapy three times a week for twelve weeks.
- A Hot Liquid Policy was developed and implemented.
- A Hot Liquid Risk Assessment was developed and implemented.
- V1/Administrator in-serviced Department Managers (V2/Director of Nursing, V3/Dietary Manager, V4/MDS Coordinator, V6/Activity Director, V22/Restorative Nurse, V23/Business Office Manager, V24/Social Service Director, V26/Assistant Director of Nursing, and V27/Environmental Service Director) regarding the facility's Hot Liquid Policy. The facility's Department Managers then carried out the same in-services for their respective employees. All employees of the facility have been in-serviced on these topics and policies.
- All residents, including R1, were assessed with the facility hot liquids assessment to determine if they are at risk of being injured.
- R1's care plan was updated to include interventions for hot liquid spills with injury and for Speech Therapy to Evaluation and Treat.
- The facility implemented utilizing colored napkins to alert each member of the team that the resident is at high risk for burn injury.
- All at risk residents for being injured due to hot liquids were identified on meal tray cards.
- V4/MDS Coordinator updated all resident care plan with interventions that were identified as at risk for spilling hot liquids causing injuries.
- The coffee machine in the main dining room was disconnected.
- The coffee machine was removed from the main dining room. Coffee and other hot liquids are being served from the kitchen and temped prior to being served.
- A new coffee machine was ordered and will be dispensed at 150 degrees Fahrenheit.
- Waterproof adult clothing protectors and waterproof blankets were ordered for the residents identified at risk for injury from hot liquid.
- A Food Temperature Log for Meal Services was implemented with coffee/hot water to be served at 150 degrees Fahrenheit or less.
- V1 in-serviced each department manager (V2/Director of Nursing, V3/Dietary Manager, V4/MDS Coordinator, V6/Activity Director, V22/Restorative Nurse, V23/Business Office Manager, V24/Social Service Director, V26/Assistant Director of Nursing, and V27/Environmental Service Director) regarding the appropriate temperature of hot liquids and utilizing the audit tool to confirm if resident received hot liquids at mealtime and what temperature it was serviced. Audit tool will be utilized for breakfast, lunch, dinner to ensure hot liquid temperatures are serviced at a minimum of 135 degrees Fahrenheit but not to exceed 150 degrees Fahrenheit, residents who were identified to be at risk for injury from hot liquids, following care plan interventions, and that kitchen will be temping all hot coffee and water to ensure facility is serving 135 degrees Fahrenheit to 150 degrees Fahrenheit. The facility's Department Managers then carried out the same in-services for their respective employees. All employees of the facility have been in-serviced on these topics and policies.
- A system was put in place for an audit to be done by V2/Director of nursing, for five residents daily, five days a week, for six weeks to ensure compliance with interventions being put in place. V2/Director of Nursing is utilizing the audit tool to ensure care plan interventions are being followed. These are monitored/audited for compliance by V1/Administrator one time per week.
- V4/MDS Coordinator reviewed and updated R1 and the residents identified to be at risk for injury from hot liquids care plans.
- V1/Administrator provided all staff in-servicing regarding the use of red napkins at meals for the residents identified at risk for injury from hot liquids.
- V1/Administrator in-serviced all Agency Staff regarding the appropriate temperature of hot liquids and utilizing the audit tool to confirm if resident received hot liquids at mealtime and what temperature it was serviced. Audit tool will be utilized for breakfast, lunch, dinner to ensure hot liquid temperatures are serviced at a minimum of 135 degrees Fahrenheit but not to exceed 150 degrees Fahrenheit, residents who were identified to be at risk for injury from hot liquids, following care plan interventions, that kitchen will be temping all hot coffee and water to ensure facility is serving 135 degrees Fahrenheit to 150 degrees Fahrenheit, and the use of red napkins at meals for the residents identified at risk for injury from hot liquids.
- A copy of the facility's Hot Liquid Policy was added to the new orientation manual and the agency orientation manual.
- A system was put in place for an audit to be done by V3/Dietary Manager, for five residents daily, five days a week, for six weeks to ensure compliance with temperatures of hot liquids prior to being served to ensure they are below the appropriate temperatures. V3/Dietary Manager is utilizing this audit form to ensure hot liquids are being served at appropriate temperatures. These are monitored/audited for compliance by V1/Administrator once time per week.
Improper Use of Physical Restraints on Cognitively Impaired Residents
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary physical restraints, as evidenced by the improper restraint of two residents, R1 and R2, using gait belts fastened behind their wheelchairs. This action was taken by an LPN who admitted to restraining the residents to prevent them from standing up due to a lack of available staff to provide one-on-one attention. The restraint was applied without physician orders, medical justification, or consent from the residents or their responsible parties, which is a violation of the facility's policies and procedures. Both residents, R1 and R2, were severely cognitively impaired, with BIMS scores indicating significant cognitive deficits. R1 had diagnoses including unspecified dementia with agitation and Alzheimer's dementia, while R2 had dementia with behavioral disturbance and was identified as a fall risk. Despite their conditions, there was no documentation in their medical records justifying the use of restraints, nor were there any physician orders or medical symptoms warranting such measures. The incident was not reported immediately by the staff who witnessed it, and the facility's policies on restraint usage and abuse prevention were not followed. The LPN involved acknowledged the inappropriate use of restraints, citing a busy and hectic time with insufficient staff as the reason for her actions. The facility's Director of Nursing and Administrator were notified of the Immediate Jeopardy situation, which was identified to have started when the restraints were applied, causing psychosocial harm to the residents.
Removal Plan
- Department Managers were in-serviced by V1 Administrator on the facility's restraint policy, care of residents with restlessness and agitation, improper restraint usage, the need for alternative interventions, appropriate diagnosis, physician's orders, care planning, the facility's abuse policy and reporting procedure. The facility's Department Managers then carried out the same in-services for their respective employees. All employees of the facility have been in-serviced on these topics and policies.
- All residents have been assessed to ensure that none are restrained improperly or unnecessarily.
- Care Plans were reviewed by the Care Plan Coordinator and updated as needed for residents with restlessness or agitation.
- A full physical assessments of R1 and R2 were conducted for any signs of injury from restraint usage with no findings of injury.
- All facility staff, contracted Therapy staff and Agency staff utilized by the facility were in-serviced on the following: care of the resident with restlessness and/or agitation; the facility's restraint policy, improper restraint usage, the need for alternative interventions, care of the resident with restlessness and/or agitation, appropriate diagnosis, physician's orders, care planning, the facility's abuse policy and reporting procedure.
- V15 verified R2 was care planned with interventions addressing potential for abuse and proper restraints related to her diagnoses. Restraint consents were present in R2's medical record for R2's cushioned lap restraint, mattress, and bed pressure alarm. V15 verified R1 was care planned for falls and restlessness, agitation with interventions. No restraints were in use for R1.
- A system was put in place for an audit to be done by the V1 Administrator or designee three times weekly to ensure compliance with the interventions put in place. V2 DON conducted daily reviews of the 24-hour Report for any new or additional restraint usage. These are monitored/audited for compliance by V1 three times per week. The results of the audits will be discussed at the next Quality Assurance meeting.
- All residents were interviewed regarding history or existence of unnecessary restraint usage and abuse incidents. No incidents were reported by the residents. These interviews were conducted and documented by the V2 DON, V1 Administrator, V15 MDS/Care Plan Coordinator, V13 ADON/Assistant Director of Nursing and Department Managers.
- V15 Care Plan Coordinator reviewed and updated Care Plans for those residents with restraints, agitation, restlessness or exhibition of behaviors. R2 was the only resident identified with restraint utilization.
- Agency staff were inserviced and Resident Rights, improper restraint usage and the Abuse/Neglect policy to the Agency Orientation Binder.
- The Interdisciplinary Team met and reviewed, discussed and approved the facility's Immediate Jeopardy Removal Plan.
- V15 Care Plan Coordinator completed Care Plan audits for all residents and a system was put in place to audit five residents' Care Plans per week.
Failure to Ensure RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight consecutive hours daily, as required by their staffing policy dated January 16, 2018. This policy mandates that a skilled nursing facility must have at least one RN on duty for eight consecutive hours, seven days a week. However, a review of the facility's nurse schedules for January 2025 revealed that there were no RNs on duty for the required duration on five specific days: January 1, January 4, January 5, January 18, and January 19. The Director of Nursing confirmed the accuracy of these schedules, acknowledging the absence of an RN for the mandated hours on the specified dates. This deficiency potentially affects all 56 residents residing in the facility, as documented in the facility's Resident Roster dated February 11, 2025.
Failure to Report Inappropriate Use of Physical Restraints
Penalty
Summary
The facility failed to immediately report the inappropriate use of physical restraints on two residents to the facility's Abuse Coordinator. The incident involved a Licensed Practical Nurse (LPN) who fastened a gait belt around two residents while they were seated in their wheelchairs, securing the belt behind the chairs, which constituted an inappropriate physical restraint. This action was witnessed by another LPN and a Certified Nursing Assistant (CNA), both of whom recognized the action as wrong but did not report it to a supervisor or the Abuse Coordinator immediately. The incident was eventually reported by another CNA who was informed by an unidentified colleague about the restraint of one of the residents. This CNA reported the incident to a supervising nurse and the Administrator, who is also the facility's Abuse Coordinator. The Director of Nursing (DON) confirmed that the physical restraint should have been reported immediately but was not brought to her attention until several days later.
Failure to Maintain RN Coverage for Required Hours
Penalty
Summary
The facility failed to have a Registered Nurse (RN) on duty for eight consecutive hours in a 24-hour period on eight specific days across October and November, as per the facility's nursing schedules. This deficiency was identified on four weekend days in October and four weekend days in November. The facility's policy, dated 1/16/18, mandates that there must be at least one RN on duty for eight consecutive hours every day in a skilled nursing facility. The absence of an RN for the required hours was acknowledged by the facility's administrator, who stated that efforts to hire an RN for the weekend schedule have been challenging. This deficiency has the potential to affect all 52 residents residing in the facility.
Failure to Document and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to document a diagnosis, identify behaviors, and monitor for identified targeted behaviors to warrant the use of psychotropic medications and attempt a gradual dose reduction (GDR) of an antipsychotic medication for five residents. For instance, one resident, who was on Seroquel for dementia without behavioral disturbance, had no documented behaviors that justified the use of the medication. Despite recommendations for a GDR, the resident's physician denied these due to family preferences, even though the resident did not exhibit psychotic behaviors or pose a risk to themselves or others. Another resident was prescribed Seroquel for unspecified dementia without behavioral disturbance. The resident's behavior monitoring report documented only one incident of public sexual acts, which was resolved with redirection. Staff confirmed that the resident did not exhibit behaviors warranting the use of antipsychotic medication. Similarly, another resident was on Seroquel for visual hallucinations, but there was no documentation of behavior monitoring for the identified target behaviors. The facility's policy on psychotropic medication use requires that these medications be given to treat a specific condition or medical symptom that is diagnosed and documented in the clinical record. However, the facility did not adhere to this policy, as evidenced by the lack of documentation and monitoring for the residents' behaviors. Additionally, the policy mandates attempts at GDR within the first year and annually thereafter, unless clinically contraindicated, which was not consistently followed for the residents in question.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precautions during the care of a resident with a burn on her thigh, leading to a deficiency in infection prevention and control. On two separate occasions, staff members did not wear the required personal protective equipment (PPE) while providing care to the resident. During the first incident, two CNAs were observed changing the resident's adult incontinent brief without wearing gowns, and one CNA only wore a glove on her right hand. After completing the care, they did not apply gowns or gloves before transferring the resident into her wheelchair. Both CNAs acknowledged that they should have been wearing gowns and gloves throughout the care process. In a subsequent incident, an LPN performed a dressing change and wound care on the resident's left thigh without wearing a gown, despite the resident being on Enhanced Barrier Precautions. The LPN confirmed the oversight and acknowledged the requirement to wear a gown during such procedures. The Director of Nursing also stated that staff should be wearing the required PPE when providing care to residents under Enhanced Barrier Precautions, as outlined in the facility's protocol policy. The policy specifies the use of gowns and gloves during high-contact resident care activities to prevent the transfer of Multi-Drug-Resistant Organisms (MDROs).
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 48 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mason City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Clara's Rehab & Senior Care | 15.6 mi | — | 1 | 0 |
| Sunny Acres Nursing Home | 16.9 mi | — | 6 | 0 |
| Lincoln Village Healthcare | 18 mi | — | 8 | 0 |
| Arcadia Care Havana | 20.9 mi | — | 14 | 0 |
| Villa Health Care East | 21.9 mi | — | 6 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Mason City Area Nursing Home.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.