Inspection Reports for Homestead of Mason City
2501 W State St, Mason City, IA 50401, United States, IA, 50401
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 29, 2025, found no deficiencies during the complaint investigation and recertification visit. Earlier inspections showed a pattern of deficiencies mainly related to medication management, service plan updates, tenant documentation, and staff training. Complaint investigations generally found no regulatory insufficiencies, though a substantiated medication tampering issue was cited in July 2024. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history indicates some improvement over time, with the most recent visit showing compliance after prior citations.
Deficiencies (last 14 years)
Deficiencies (over 14 years)
2.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
41% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
30 residents
Based on a July 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 0
Date: Jul 29, 2025
Visit Reason
The inspection was conducted to investigate Complaints #127561-C and to perform a recertification visit to determine compliance with certification rules for an Assisted Living Program.
Complaint Details
Investigation of Complaints #127561-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the complaint investigation and recertification visit.
Report Facts
Number of tenants without cognitive impairment: 19
Number of tenants with cognitive impairment: 11
Total census: 30
Inspection Report
Complaint Investigation
Census: 24
Deficiencies: 1
Date: Jul 17, 2024
Visit Reason
The inspection was conducted to investigate complaints #116231-C, #115586-C, #115572-C, and incident #115703-I related to medication management and other regulatory concerns at Homestead Assisted Living.
Complaint Details
The investigation involved complaints #116231-C, #115586-C, #115572-C and incident #115703-I. The medication tampering was substantiated during the investigation.
Findings
No regulatory insufficiencies were found for complaints #116231-C and #115586-C. However, a deficiency was cited for failure to follow the Medication Management policy involving altered medication packaging discovered during the investigation of incident #115703-I and complaint #115572-C.
Deficiencies (1)
Failure to follow the established Medication Management policy involving altered medication packaging where 137 of 180 tablets of Hydrocodone/Acetaminophen were replaced with over-the-counter Acetaminophen and resealed.
Report Facts
Number of tenants without cognitive impairment: 17
Number of tenants with cognitive impairment: 7
Total census: 24
Tablets of Hydrocodone/Acetaminophen replaced: 137
Total tablets in bubble packs: 180
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amy Montgomery | Executive Director | Confirmed findings of medication tampering on 7/17/24 |
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 1
Date: Aug 1, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to multiple complaint numbers (#114386-A, #114391-M, #114389-A, and #114408-C) concerning regulatory insufficiencies at Homestead Assisted Living.
Complaint Details
No regulatory insufficiencies were cited during the investigation of Complaint #112611-C. Regulatory insufficiencies were cited during the investigation of Complaints #114386-A, #114391-M, #114389-A, and #114408-C.
Findings
The investigation found regulatory insufficiencies including failure to update individualized service plans to reflect tenants' needs and preferences, specifically for Tenant #1 who had cognitive impairments and safety concerns. No deficiencies were cited for Complaint #112611-C.
Deficiencies (1)
Failure to update service plans to identify individual needs and preferences for assistance, as evidenced by Tenant #1's service plan not reflecting recent changes and safety concerns.
Report Facts
Number of tenants without cognitive disorder: 28
Number of tenants with cognitive disorder: 3
Total census: 31
Inspection Report
Renewal
Census: 31
Deficiencies: 3
Date: Apr 5, 2023
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification of an Assisted Living Program and to investigate Complaints #109159-C and #109198-C.
Complaint Details
The inspection included investigation of Complaints #109159-C and #109198-C.
Findings
The program failed to follow policies and procedures for medication administration and documentation, with multiple instances of missed documentation. Additionally, the program did not provide required dementia-specific education and training for personnel, both initially and annually, as mandated by regulations.
Deficiencies (3)
Failure to follow policies and procedures for medication administration and documentation, including 34 missed documentation instances in October, 6 in November, and 12 in December.
Failure to provide 8 hours of dementia-specific education within 30 days of employment for 6 staff members.
Failure to provide 8 hours of dementia-specific continuing education annually for 3 staff members, with partial completion noted.
Report Facts
Medication documentation failures: 34
Medication documentation failures: 6
Medication documentation failures: 12
Number of tenants without cognitive disorder: 28
Number of tenants with cognitive disorder: 3
Total census: 31
Staff reviewed for dementia-specific training within 30 days: 6
Staff reviewed for annual dementia training: 3
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 0
Date: Jun 29, 2022
Visit Reason
Investigation of Incident 98796-C at Homestead Assisted Living.
Complaint Details
Investigation of Incident 98796-C; no regulatory insufficiencies were cited.
Findings
No regulatory insufficiencies were cited during the investigation of Incident 98796-C.
Report Facts
Number of tenants without cognitive disorder: 19
Number of tenants with cognitive disorder: 8
Total census: 27
Inspection Report
Renewal
Census: 31
Deficiencies: 5
Date: May 18, 2021
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification for an Assisted Living Program, including an onsite infection control survey from 5-13-21 to 5-18-21.
Findings
The inspection found several regulatory insufficiencies related to nurse delegation procedures, staff training, record checks, tenant documentation, and service plans. No regulatory insufficiencies were cited during the infection control survey portion. Deficiencies included failure to provide services in accordance with training, incomplete nurse delegation training, incomplete background checks, inconsistent documentation of nurses' notes, and inadequate service plans reflecting tenant needs.
Deficiencies (5)
Failure to provide services in accordance with training for blood glucose monitoring and insulin administration.
Incomplete nurse delegation training on activities of daily living including dressing/undressing and anti-embolism hose for direct care staff.
Failure to complete background checks prior to employment for staff.
Failure to consistently document nurses' notes by exception for tenants.
Failure to develop individualized service plans reflecting tenant needs and preferences for assistance.
Report Facts
Number of tenants without cognitive disorder: 17
Number of tenants with cognitive disorder: 14
Total census: 31
Number of direct care staff reviewed for nurse delegation training: 5
Number of staff reviewed for background checks: 6
Number of tenants reviewed for nurses' notes documentation: 3
Number of tenants reviewed for service plans: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Observed assisting Tenant #4 with blood glucose monitoring and insulin administration; nurse delegation training documents reviewed | |
| Staff B | Direct care staff with incomplete nurse delegation training | |
| Staff D | Direct care staff with incomplete nurse delegation training | |
| Staff E | Direct care staff with incomplete nurse delegation training | |
| Staff F | Direct care staff with incomplete nurse delegation training | |
| Staff G | Direct care staff with incomplete nurse delegation training | |
| Staff A | Staff with incomplete background checks prior to employment | |
| Executive Director | Interviewed regarding background checks and service plans | |
| Regional Nurse | Responsible for monitoring documentation consistency and auditing employee files |
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 2
Date: Dec 23, 2019
Visit Reason
The inspection was conducted as an investigation of Incident #86488-I related to regulatory insufficiencies in tenant documentation at Homestead Assisted Living.
Complaint Details
Investigation of Incident #86488-I found regulatory insufficiencies in tenant documentation. The findings were substantiated by review and interview on 12-23-19.
Findings
The program failed to maintain required tenant documents including signed authorizations for emergency medical care and advance health care directives for one tenant. The Licensed Practical Nurse confirmed these findings on 12-23-19.
Deficiencies (2)
Failure to ensure a signed authorization for emergency medical care in tenant files.
Failure to include advance health care directives in tenant files as applicable.
Report Facts
Number of tenants without cognitive disorder: 28
Number of tenants with cognitive disorder: 3
Total census of Assisted Living Program for People with Dementia: 31
Date survey completed: Dec 23, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | Confirmed findings on 12-23-19 at 2:17 p.m. |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 0
Date: Jun 27, 2019
Visit Reason
Investigation of Complaint #83624-C at Homestead Assisted Living.
Complaint Details
Investigation of Complaint #83624-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Report Facts
Number of tenants without cognitive disorder: 30
Number of tenants with cognitive disorder: 2
Total Population of Program at time of on-site: 32
TOTAL census of Assisted Living Program: 32
Inspection Report
Renewal
Census: 30
Deficiencies: 4
Date: May 2, 2019
Visit Reason
The inspection was a recertification visit conducted to determine compliance with certification of an Assisted Living Program and investigation of Complaint #82211-C.
Complaint Details
Investigation of Complaint #82211-C was part of the recertification visit.
Findings
The program failed to ensure confidentiality of tenants' medical information, failed to complete functional, cognitive, and health evaluations timely, and failed to maintain valid authorizations for release of medical information. Several tenants' service plans and assessments were incomplete or not updated timely.
Deficiencies (4)
Failure to ensure confidentiality of tenants' medical information and improper release to unauthorized agents.
Failure to complete functional, cognitive, and health evaluations with significant change for tenants in a timely manner.
Failure to maintain valid authorizations for release of medical information for tenants.
Failure to develop and update service plans based on required assessments for tenants.
Report Facts
Number of tenants without cognitive disorder: 28
Number of tenants with cognitive disorder: 2
Total population of program at time of on-site: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan M. Wiley | Executive Director | Named in plan of correction and monitoring compliance |
| Carol Sullivan | LPN/RCC | Named in plan of correction and monitoring compliance |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 0
Date: Aug 22, 2018
Visit Reason
The inspection was conducted as part of investigations of Complaint #77334-C and Incident #77619-I at Homestead Assisted Living.
Complaint Details
Investigations of Complaint #77334-C and Incident #77619-I found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigations of the complaint and incident.
Report Facts
Number of tenants without cognitive disorder: 32
Number of tenants with cognitive disorder: 4
Total Population of Program at time of on-site: 36
TOTAL census of Assisted Living Program: 36
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 0
Date: Jan 24, 2018
Visit Reason
Investigation into Complaint #72889-C at Homestead Assisted Living.
Complaint Details
Investigation into Complaint #72889-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Report Facts
Number of tenants without cognitive disorder: 32
Number of tenants with cognitive disorder: 4
Total census: 36
Inspection Report
Renewal
Census: 35
Deficiencies: 0
Date: May 22, 2017
Visit Reason
The visit was conducted as a recertification visit to determine compliance with certification of an Assisted Living Program.
Findings
No regulatory insufficiencies were cited during the recertification visit, indicating compliance with the Assisted Living Program requirements.
Report Facts
Number of tenants without cognitive disorder: 30
Number of tenants with cognitive disorder: 5
Total census of Assisted Living Program: 35
Inspection Report
Monitoring
Census: 23
Deficiencies: 0
Date: Jun 8, 2015
Visit Reason
The visit was conducted as a Final Recertification Monitoring Evaluation to determine compliance with certification for an Assisted Living Program.
Findings
No regulatory insufficiencies were found during this evaluation. The review of recertification documents was completed and accepted, and the State Fire Marshal's inspection report and Facility Engineer's approval of evacuation plans were received.
Report Facts
Number of tenants without cognitive disorder: 20
Number of tenants with cognitive disorder: 3
Total Population of Program at time of on-site: 23
Total census of Assisted Living Program: 23
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 4
Date: Apr 23, 2014
Visit Reason
The inspection was conducted as a complaint/incident investigation following concerns regarding tenant admission and medication administration at Homestead Assisted Living.
Complaint Details
The complaint alleged concerns regarding a tenant's admission to the program and not being allowed to leave, and that a tenant was made to take medications that did not look like normal medications and staff had over medicated the tenant. The complaint was investigated with tenant file reviews, staff interviews, and observations. The complaint was substantiated with findings of regulatory insufficiencies.
Findings
The investigation found regulatory insufficiencies related to medications, service plans, tenant documents, and nurse review. Specific issues included failure to conduct nurse reviews as required, incomplete medication administration documentation, and failure to update service plans and tenant documents appropriately.
Deficiencies (4)
Failure to conduct nurse reviews as required.
Medications or treatments not documented as administered or refused on the MAR.
Service plans were not updated as needed and did not reflect identified tenant needs.
Tenant documents for admission were not signed or properly enacted at the time of admission.
Report Facts
Civil penalty amount: 500
Census: 33
Number of tenants without cognitive disorder: 28
Number of tenants with cognitive disorder: 5
Fine reduction amount: 325
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan M. Wiley | Executive Director | Named as Executive Director of Homestead Assisted Living in relation to the complaint and report |
| Rose Boccella | Program Coordinator | Contact person for the program coordinator regarding the report and appeal process |
| Stephanie Cummins | Monitor | Monitor who conducted the complaint/incident investigation |
| Jim Friberg | Acting Bureau Chief, Adult Services Bureau | Signed the demand letter and report |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 1
Date: Sep 25, 2013
Visit Reason
The inspection was conducted as a complaint/incident investigation following allegations that tenants had strokes and were not evaluated, resulting in a decline in their health.
Complaint Details
The complaint alleged tenants had strokes and were not evaluated, leading to health decline. The investigation found incomplete nurse reviews and monitoring but no regulatory insufficiency in tenant evaluations.
Findings
The investigation reviewed tenant evaluations, nurse reviews, and documentation related to incidents involving four tenants. No regulatory insufficiencies were noted regarding tenant evaluations, but nurse reviews were incomplete and did not consistently document adverse reactions or medication administration as required.
Deficiencies (1)
Nurse reviews were not completed every 90 days and did not document a review of adverse reactions or administration of medications consistent with orders.
Report Facts
Total census: 32
Number of tenants without cognitive disorder: 30
Number of tenants with cognitive disorder: 2
Number of tenants: 4
MMSE scores: 22
MMSE scores: 25
MMSE scores: 26
MMSE scores: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lori Miner | RN BSN | Monitor conducting the complaint/incident investigation |
Inspection Report
Monitoring
Census: 35
Deficiencies: 4
Date: Apr 8, 2013
Visit Reason
The visit was a Final Recertification Monitoring Evaluation conducted to review the Plan of Correction and regulatory compliance of Homestead Assisted Living in Mason City, IA.
Findings
The report found several regulatory insufficiencies related to tenant evaluations, service plans, tenant documentation, and food service. The Plan of Correction was accepted by the Department of Inspections and Appeals.
Deficiencies (4)
Lack of evidence of completion of cognitive, health, and functional evaluations prior to admission or within 30 days after occupancy for multiple tenants.
Service plans did not identify nursing facility preferences and lacked inclusion of interventions for dietary restrictions.
Documentation for each tenant was incomplete, including missing incident reports and nurses' notes.
Therapeutic diets were not clearly prescribed or documented according to regulations.
Report Facts
Number of tenants without cognitive disorder: 33
Number of tenants with cognitive disorder: 2
Total population at time of on-site: 35
Community meeting attendees: 20
Tenant ages: 90
Tenant ages: 85
Tenant ages: 79
Tenant ages: 102
Tenant ages: 97
Global Deterioration Scale score: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Kix | RN | Monitor conducting the evaluation |
Inspection Report
Monitoring
Census: 22
Deficiencies: 3
Date: Jun 6, 2011
Visit Reason
An on-site monitoring evaluation was conducted at Homestead Assisted Living on June 6, 2011, as part of the Final Recertification Monitoring Evaluation process.
Findings
The program had no regulatory insufficiencies during this certification period but failed to ensure multiple staff received at least two hours of dependent adult abuse reporter training approved by the state's abuse education review panel within six months of employment and every five years thereafter.
Deficiencies (3)
Multiple staff did not receive the required two hours of dependent adult abuse reporter training approved by the state's abuse education review panel within six months of employment and every five years thereafter.
A person required to report cases of dependent adult abuse did not complete two hours of training related to identification and reporting within six months of initial employment or self-employment.
The curriculum used in the electronic training system for dependent adult abuse prevention, recognition, and reporting had never been verified as adequate and approved by the state's abuse education review panel.
Report Facts
Current number of tenants without cognitive disorder: 21
Current number of tenants with cognitive disorder: 1
Total Population: 22
Staff #1 hire date: 2010
Staff #2 hire date: 2010
Staff #3 hire date: 2002
Staff #4 hire date: 2007
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maribeth Freland | RN | Monitor conducting the on-site monitoring evaluation |
Inspection Report
Monitoring
Census: 37
Deficiencies: 2
Date: Mar 20, 2007
Visit Reason
An on-site recertification monitoring evaluation was conducted at The Homestead Assisted Living to assess compliance with assisted living program regulations.
Complaint Details
There were no substantiated complaints during this certification period.
Findings
The program had regulatory insufficiencies including failure to consistently complete required functional, cognitive, and health evaluations annually and upon change in condition, and failure to update and have tenants sign individualized service plans reflecting changes in tenant needs and services provided.
Deficiencies (2)
The program did not consistently complete functional, cognitive and health evaluations annually and when a change in condition existed.
The program did not consistently have the tenant sign the updated service plan and did not update the service plan to reflect additional services performed by the program.
Report Facts
Current number of tenants without cognitive disorder: 37
Current number of tenants with cognitive disorder: 0
Total Population: 37
Tenant attendance at community meeting: 27
Multi-disciplinary team members: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor conducting the on-site evaluation |
| Mary Montgomery | Administrator | Administrator of The Homestead Assisted Living |
Inspection Report
Monitoring
Census: 27
Deficiencies: 6
Date: Apr 26, 2005
Visit Reason
An on-site monitoring evaluation was conducted at The Homestead on April 26, 2005, to assess compliance with assisted living program regulations and evaluate tenant care and services.
Findings
The evaluation identified several regulatory insufficiencies including failure to evaluate tenant functional and cognitive status prior to occupancy, incomplete service plans, inadequate documentation of nurse reviews, insufficient staff training, and lack of appropriately licensed transportation staff. Plans of correction were submitted to address these issues.
Deficiencies (6)
The program did not evaluate tenant’s functional, cognitive and health status prior to occupancy, within 30 days of occupancy and as needed with change in condition.
The program did not develop a preliminary service plan for all tenants prior to taking occupancy.
The program did not appropriately update and sign service plans as needed with change in condition and annually.
The program LPN did not appropriately document reviews showing the time, date and signature.
The program did not have staff appropriately trained.
The program did not have employees appropriately licensed as required for the vehicle being used for transportation of tenants.
Report Facts
Current number of tenants without cognitive disorder: 20
Current number of tenants with cognitive disorder: 7
Total Population: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Montgomery | RN, Director | Director of The Homestead Assisted Living Program |
| Stephanie Cummins | SW, MA | Monitor conducting the evaluation |
| Sharon Agnitsch | Health Services/Staffing Coordinator, LPN | Signed Plan of Correction letter |
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