Cycle 1
Health 2025-12-11 · Fire 2025-12-11
8 health deficiencies
Top issue: Resident Rights (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Mason City, IA
Good Shepherd Health Center
2-star overall rating with 2-star inspections with $87,458 in total fines with 8 recent health deficiencies
302 Second Street NE, Mason City, IA
(641) 424-1740
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
180
Certified beds
Average residents
156
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1968-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.36
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.64
Licensed practical nurse staffing · state 0.57 · national 0.87
Aide hours / resident day
2.69
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
3.69
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.00
RN + LPN hours · state 1.30 · national 1.54
Weekend hours
3.47
Weekend nurse staffing · state 3.35 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.44
CMS adjusted RN staffing hours
Adjusted total hours
4.48
CMS adjusted total nurse staffing hours
Case-mix index
1.13
Higher values indicate more complex resident acuity
RN turnover
53%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
66%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,259
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
50.62
Composite VBP score used to determine payment impact.
Payment multiplier
1.0048
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
9.33
Baseline 18.80% · Performance 17.11% · Measure score 9.33 · Achievement 9.33 · Improvement 9
Healthcare-associated infections
5.23
Baseline 4.61% · Performance 6.27% · Measure score 5.23 · Achievement 5.23 · Improvement 0
Total nurse turnover
1.94
Baseline 41.30% · Performance 55.77% · Measure score 1.94 · Achievement 1.94 · Improvement 0
Adjusted total nurse staffing
3.75
Baseline 3.68 hours · Performance 4.15 hours · Measure score 3.75 · Achievement 3.75 · Improvement 1.70
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.24% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 133 · Observed rate 9.02% · Lower 95% interval 6.93% |
| Discharge to community | 34.18% |
50.57%
16.4 pts worse
|
Worse than the National Rate · Eligible stays 94 · Observed rate 27.66% · Lower 95% interval 26.19% |
| Medicare spending per beneficiary | 0.52 |
1.02
0.5 pts better
|
|
| Drug regimen review with follow-up | 96.88% |
95.27%
1.6 pts better
|
Numerator 93 · Denominator 96 |
| Falls with major injury | 1.04% |
0.77%
0.3 pts worse
|
Numerator 1 · Denominator 96 |
| Discharge self-care score | 39.02% |
53.69%
14.7 pts worse
|
Numerator 32 · Denominator 82 |
| Discharge mobility score | 41.46% |
50.94%
9.5 pts worse
|
Numerator 34 · Denominator 82 |
| Pressure ulcers or injuries, new or worsened | 5.21% |
2.29%
2.9 pts worse
|
Numerator 5 · Denominator 96 · Adjusted rate 6% |
| Healthcare-associated infections requiring hospitalization | 6.27% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 79 · Observed rate 3.8% · Lower 95% interval 3.66% |
| Staff COVID-19 vaccination coverage | 9.18% |
8.2%
1 pts better
|
Numerator 19 · Denominator 207 |
| Staff flu vaccination coverage | 57.89% |
42%
15.9 pts better
|
Numerator 121 · Denominator 209 |
| Discharge function score | 51.22% |
56.45%
5.2 pts worse
|
Numerator 42 · Denominator 82 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 96.97% |
96.28%
0.7 pts better
|
Numerator 32 · Denominator 33 |
| Resident COVID-19 vaccinations up to date | 47.73% |
25.2%
22.5 pts better
|
Numerator 21 · Denominator 44 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.5
0.6 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.7 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
2.1
0.1 pts better
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.6 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.1% |
94.0%
0.1 pts better
|
93.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.2% · Q2 95.3% · Q3 93.8% · Q4 91.9% · 4Q avg 94.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.8% |
95.2%
3.6 pts better
|
95.5%
3.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.1% |
3.7%
2.4 pts worse
|
3.3%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 5.4% · Q3 8.2% · Q4 8.1% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.6% |
4.0%
3.6 pts worse
|
11.4%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 5.8% · Q3 6.1% · Q4 11.8% · 4Q avg 7.6% |
| Percentage of long-stay residents who lose too much weight | 4.6% |
4.9%
0.3 pts better
|
5.4%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 7.4% · Q3 4.0% · Q4 2.3% · 4Q avg 4.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.8% |
20.6%
0.2 pts worse
|
19.6%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.0% · Q2 21.1% · Q3 18.9% · Q4 22.0% · 4Q avg 20.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.2% |
19.8%
5.4 pts worse
|
16.7%
8.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 23.8% · Q3 28.2% · Q4 27.4% · 4Q avg 25.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 24.9% |
18.5%
6.4 pts worse
|
16.3%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.0% · Q2 29.8% · Q3 25.2% · Q4 18.5% · 4Q avg 24.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.7% |
18.3%
4.4 pts worse
|
14.9%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.3% · Q2 29.2% · Q3 20.3% · Q4 22.8% · 4Q avg 22.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.5% |
1.7%
0.8 pts worse
|
1.0%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 2.7% · Q3 2.6% · Q4 1.6% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
2.5%
1.3 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.7% · Q3 0.7% · Q4 1.4% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.5% |
26.0%
2.5 pts worse
|
19.8%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.8% · Q2 30.0% · Q3 30.2% · Q4 24.0% · 4Q avg 28.5% |
| Percentage of long-stay residents with pressure ulcers | 4.2% |
4.3%
0.1 pts better
|
5.1%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 6.2% · Q3 3.9% · Q4 3.2% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 81.6% |
84.3%
2.7 pts worse
|
81.7%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 71.2% · Q2 80.0% · Q3 82.4% · Q4 93.4% · 4Q avg 81.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.8% |
13.1%
6.3 pts better
|
12.0%
5.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.8% · Observed 6.4% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.2% |
1.9%
2.3 pts worse
|
1.6%
2.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.3% · Q3 4.3% · Q4 4.9% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 52.2% |
73.3%
21.1 pts worse
|
79.7%
27.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 52.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.4% |
21.3%
1.1 pts worse
|
23.9%
1.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.4% · Observed 20.2% · Expected 21.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-31 · Fire 2024-10-31
11 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2023-07-06 · Fire 2023-07-06
7 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-31
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-10-31
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-10-31
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-20
F · Potential for more than minimal harm
2023-07-06
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-07-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-07-13
D · Potential for more than minimal harm
2023-07-06
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2023-07-13
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-11
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2026-01-05
E · Potential for more than minimal harm
2025-12-11
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2026-01-05
D · Potential for more than minimal harm
2025-12-11
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2026-01-05
D · Potential for more than minimal harm
2025-12-11
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2025-06-02
D · Potential for more than minimal harm
2025-12-11
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2026-01-05
G · Actual harm
2025-03-13
F713 · Nursing and Physician Services Deficiencies
Health
Provide or arrange emergency care by a doctor 24 hours a day.
Corrected 2025-04-03
D · Potential for more than minimal harm
2025-03-13
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-04-03
D · Potential for more than minimal harm
2025-03-13
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-04-03
D · Potential for more than minimal harm
2024-10-31
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-11-16
D · Potential for more than minimal harm
2024-10-31
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-16
D · Potential for more than minimal harm
2024-10-31
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-11-16
D · Potential for more than minimal harm
2024-10-31
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-16
D · Potential for more than minimal harm
2024-10-31
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-11-16
D · Potential for more than minimal harm
2024-10-31
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2024-11-16
D · Potential for more than minimal harm
2024-10-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-16
D · Potential for more than minimal harm
2024-09-06
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-09-27
J · Immediate jeopardy
2024-08-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-17
E · Potential for more than minimal harm
2024-08-30
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-09-27
D · Potential for more than minimal harm
2024-08-30
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-09-27
D · Potential for more than minimal harm
2023-11-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-20
F · Potential for more than minimal harm
2023-07-06
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-08-06
F · Potential for more than minimal harm
2023-07-06
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-08-06
D · Potential for more than minimal harm
2023-07-06
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-08-06
D · Potential for more than minimal harm
2023-07-06
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-08-06
D · Potential for more than minimal harm
2023-07-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-06
D · Potential for more than minimal harm
2023-07-06
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-08-06
Penalties and ownership
What sits behind the stars
$87,458
2024-08-30
Fine
Fine · fine $87,458
Fine
Ownership
Alden, Kathryn
Corporate Director · Individual
Boedeker, John
Corporate Director · Individual
Demaris, Anne
W-2 Managing Employee · Individual
Douglas, Tom
Corporate Director · Individual
Everist, Burton
Corporate Director · Individual
Flynn, Anne
Corporate Director · Individual
Gerrietts, Dan
Corporate Director · Individual
Good Shepherd Geriatric Center Inc
Operational/Managerial Control · Organization
Hunt, Samuel
Corporate Director · Individual
Madden, Thelma
Corporate Director · Individual
Paulson, Kirk
Corporate Director · Individual
Schumaker, Terry
Corporate Director · Individual
Shipman, Scott
Corporate Director · Individual
Smed, Scott
Corporate Director · Individual
Stockbeger, Ian
Corporate Officer · Individual
Stockbeger, Ian
W-2 Managing Employee · Individual
White, Jerrold
Corporate Director · Individual
Zook, Anne
Corporate Director · Individual
Nearby options
Other facilities in reach
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Heritage Care And Rehabilitation Center
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2-star overall rating with 3-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
I O O F Home and Community Therapy Center
Mason City, IA
1-star overall rating with 2-star inspections with $30,876 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Manly Specialty Care
Manly, IA
3-star overall rating with 2-star inspections with $13,627 in total fines with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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