Good Samaritan - Waukon
21 East Main Street, Waukon, IA 52172 · Non profit - Corporation · 60 certified beds · (563) 568-3447 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a high payroll-based staffing rating (4/5)
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (16) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $8,281 in federal fines (most recent 2025-09-11)
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 16.9% | 17.1% | 15.4% | typical |
| Long-stay residents who lose too much weight | 2.8% | 4.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 2.9% | 1.5% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 3.2% | 2.4% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 4.2% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 5.3% | 3.8% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 20.1% | 16.6% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 11.6% | 20.8% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.1% | 95.3% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.2% | 4.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 25.8% | 25.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 18.5% | 19.5% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 1.8% | 2.1% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 73.9% | 73.3% | 79.4% | typical |
| Long-stay hospitalizations per 1,000 resident days | 0.69 | 1.49 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.88 | 2.08 | 1.80 | typical |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Met the expected recovery: 57.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 21 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.13 therapist hours per resident per day in 2026Q1 — more than 10% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 10% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.9%CMS range 6.2–15.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 57.1% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 38.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 47.6% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 95.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 4.5% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.86 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 60 beds and averages 51.8 residents a day — about 86% occupied, or roughly 8 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.17 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.89 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.81 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.70 hrs/resident/day on weekends vs 3.36 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 1.04 to 0.51 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 44% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
16 citations, most serious first. The 11 most serious are shown; the remaining 5 are one tap away and print in full.
- Immediate jeopardy · J2025-09-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, document review, and staff interview, the facility's administrative staff failed to ensure the staff secured all locked exit doors, resulting in 1 of 3 reviewed residents (Resident #1) at risk for elopement exiting the facility without the nursing staff's knowledge. Due to the facility staff's failures, Resident #1 eloped from the building through the maintenance office door without the nursing staff's knowledge and was missing for approximately 45 minutes before the nursing staff realized Resident #1 was missing by locating Resident #1 laying outside on the ground. The facility's administrative staff identified a census of 51 residents at the time of the on-site investigation.The Iowa State Survey Agency (SA) notified the facility's administrative staff that the situation presented an Immediate Jeopardy situation on [DATE] at 6:00 PM. The immediacy began on [DATE]. The facility's administrative staff removed the immediacy on [DATE] when they took the following actions:- The nursing staff…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-04-30 · tag F0802 — failed to prepare enough nourishing food — patternProvide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, dishwasher instructional manual, document review, policy review, and staff interview, the facility failed to ensure staff were competent in procedures to test and document the hot water sanitation of the dishwasher. The facility identified a census of 57 residents.Findings include:A Vendor Service Ticket dated 10/1/25 documented the installation of a new high temperature dishwasher.Observation on 4/27/26 at 1:26 PM revealed a hot water sanitation dishwasher. The dishwasher placard located on the right upper side of the dishwasher documented a required wash temperature of 150 degrees Fahrenheit (F) and a final rinse temperature of 180 degrees (F). Staff D, Lead [NAME] obtained the quat bucket test strips and dipped the test strip in the water, then reported she didn't think that was right. Staff E, [NAME] voiced they use the digital thermometer to check the dishwasher to ensure it is sanitizing to temperature. After four cycles, the dishwasher displayed a wash temperature of 156 degrees Fahrenheit (F) and a final rinse temperature of 187 degrees F. Staff E…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-04-30 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, policy review, and staff interview the facility failed to prevent bare hands from contacting food during food preparation and keep cold foods below 41 degrees Fahrenheit (F) during meal service. The facility reported a census of 57 residents.Findings include:Observation on 4/28/26 at 10:26 AM Staff D, Lead [NAME] opened a plastic package of buns with her bare hands and proceeded to remove three buns from the bag and place the buns into a blender as she prepared a pureed taco burger for Resident #10. At 10:50 AM Staff D moved a dirty blender, measuring cup and spatula to the left side of the countertop, wiped her hands on along her uniform at both sides of her hips, then used a spatula to scrape three cookies off a baking sheet touching the cookies with her left hand as she scraped them from the baking sheet onto the spatula to place into a blender to puree. The pureed taco burger and cookie were served out to resident #10 during the lunch meal service. Observation on 4/28/26 at 11:25 AM the Nutrition and Food Service Supervisor (NFSS) washed her hands, applied…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-30 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on an electronic health record (EHR) review, policy review, and staff interview, the facility failed to submit a new Preadmission Screening and Resident Review (PASRR) assessment for 1 of 4 residents reviewed (Resident #7). The facility reported a census of 57 residents.Findings include: Resident #7's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment. The MDS included diagnoses of anxiety disorder, depression and Post Traumatic Stress Disorder (PTSD- mental health condition triggered by experiencing or witnessing terrifying events). Resident #7 current PASRR Level 1 Screening Outcome dated 10/11/23 reflected a PASRR Level 1 outcome for no Level II required- no serious mental illness (MI)/intellectual disability (ID)/related condition (RC). The Level I included diagnosis of anxiety disorder and depression.Review of the EHR medical diagnoses listed active diagnoses of PTSD and major depressive disorder…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-30 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and policy review, the facility failed to implement a Baseline Care Plan for 1 of 3 newly admitted residents (Resident #21). The facility reported a census of 57 residents.Findings include:Resident #21's Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 0 out of 15, indicating severely impaired cognition. Resident #21's diagnoses included dementia, anxiety, and depression. Resident #21 required staff assistance for all Activities of Daily Living (ADLs) and used a walker and wheelchair for mobility.In an interview on 4/30/26 at 10:17 AM, the MDS Coordinator confirmed that Resident #21 was admitted on [DATE] and the Baseline Care Plan should have been completed within 48 hours.In an interview on 4/29/26 at 11:35 AM, the Director of Nursing (DON) stated that the MDS Coordinator covered two facilities. The DON acknowledged that the facility experienced a breakdown in communication regarding who was responsible for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-30 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and policy review, the facility failed to implement a Comprehensive Care Plan to include psychotropic medications for 1 of 3 newly admitted residents (Resident #21). The facility reported a census of 57 residents.Findings include: Resident #21's MDS assessment dated [DATE], triggered Care Area Assessments (CAAs) for cognitive loss/dementia, urinary incontinence, psychosocial well-being, activities, falls, nutritional status, pressure ulcers, and psychotropic drugs. Resident #21 took antipsychotic, antianxiety, and antidepressant medications and was working with physical therapy.A review of Resident #21's Comprehensive Care Plan on 4/28/26 revealed that it did not include psychotropic medication monitoring or side effects.In an interview on 4/30/26 at 10:17 AM, the MDS Coordinator stated that a Comprehensive Care Plan should include medications, ADLs, diagnoses, skin integrity, treatments, falls, infections, and triggered items from the MDS. Regarding Resident #21, the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-30 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and policy review the facility failed to revise 1 of 1 residents Care Plan after the resident had Urinary Tract Infection (UTI) symptoms and was put on an antibiotic for a UTI (Resident #16). The facility reported a census of 57 residents:Findings include: Resident #16's Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderately impaired cognition. Resident #16's diagnoses included dementia, personal history of urinary tract infections, and benign prostatic hyperplasia (enlarged prostate).Review of Resident #16's Communication/Visit with Physician progress note indicated that on 4/23/26 at 3:16 AM, the Physician responded to a fax regarding malodorous urine and increased weakness, and the Physician ordered a urinalysis with Culture and Sensitivity (C&S) for Resident #16.Resident #16's Health Status progress note showed that on 4/27/26, the Physician Assistant-Certified (PA-C) ordered…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-30 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and policy review the facility failed to provide assessment and intervention for a resident who presented with Urinary Tract Infection (UTI) symptoms and obtain a Urinalysis (UA) timely after it was ordered by his Provider for 1 of 2 residents reviewed for UTI (Resident #16). The facility reported a census of 57 residents. Findings include: Resident #16's Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderately impaired cognition. The MDS noted Resident #16 required substantial to maximal assistance with toileting and transfers and was always incontinent of urine (loss of bladder control). Resident #16's diagnoses included dementia, personal history of urinary tract infections, benign prostatic hyperplasia (enlarged prostate) with lower urinary tract symptoms, and weakness. On 4/20/26 at 4:12 PM, the Health Status progress note indicated a Certified Nursing Assistant (CNA) provided…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-30 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility staff failed to provide 2 of 2 residents restorative programs as frequently as the program ordered (Resident #28 and Resident #4). The facility reported a census of 57 residents. Findings include: 1. Resident #28's Minimum Data Set (MDS) assessment dated [DATE] indicated he entered the facility in October 2011 and had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, indicating severe cognitive impairment. He relied on staff for toileting, shower/bathing, and moving from a sitting to standing position. He did not complete a Restorative Program for at least 15 minutes during the past 7 days. He had diagnoses of a need for assistance with personal care, other abnormalities of gait (walking pattern) and mobility, and a traumatic brain injury. Resident #28's Care Plan, last revised on 12/8/25, included 3 Restorative Programs related to his traumatic brain injury: ambulation in the hallway, riding a pedaled bike for 15 minutes, and lifting a 4…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-04-16 · tag F0868 — patternHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, staff interview, and policy review the facility failed to maintain a quality assessment and assurance committee consisting at a minimum the Director of Nursing (DON), the Medical Director or his/her designee; at least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and the Infection Preventionist (IP) were all in attendance for the first quarter of 2025 Quality Assurance (QA) meeting. The facility reported a census of 51 residents. Findings include: Record review of the facilities Quality Assurance and Performance Improvement Plan (QAPI) committee meeting Sign-in Sheet's for the first quarter of 2025 revealed the following: 1/24/25 - Medical Director and IP not in attendance 2/21/25 - Medical Director and IP not in attendance 3/28/25 - DON and IP not in attendance During an interview on 4/16/25 at 11:08 AM the Administrator revealed she would like the Medical Director to attend monthly meetings but scheduling has been hard and would expect all required…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-16 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on electronic health record (EHR) review, Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 user's manual review, and staff interviews the facility failed to submit six completed Minimum Data Set (MDS) assessments for 1 of 1 residents reviewed (Resident #201). The facility reported a census of 51 residents. Findings include: A review of the EHR, MDS detail listing for Resident #201 revealed the following: 3/13/2025 - Annual - None PPS / M D S 3.0 - Completed 12/19/2024 - Quarterly - None PPS / M D S 3.0 - Completed 10/3/2024 - Quarterly - None PPS / M D S 3.0 - Completed 7/18/2024 - Quarterly - None PPS / M D S 3.0 - Completed 6/11/2024 - End of PPS Part A Stay / M D S 3.0 - Completed 4/20/2024 - admission /Medicare - 5 Day / M D S 3.0 - Completed 4/17/2024 - Entry / M D S 3.0 - Accepted A review of all completed but not accepted MDS's for Resident #201 documented the unit was neither Medicare nor Medicaid certified and MDS data is not required by the state. The submission information for all completed but not accepted MDS's for Resident #201 documented do not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 5 citations
- Potential for harm · D2025-04-16 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review the facility failed to recheck oxygen saturation levels for 1 of 1 residents with a respiratory illness to ensure it remained within set parameters to keep above 90% SpO2 (peripheral oxygen saturation) set by the Doctor and ensure oxygen was care planed and interventions implemented (Resident #26). The facility reported a census of 51 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #26 documented a Brief Interview for Mental Status (BIMS) score of 0 indicating severe cognitive impairment. The MDS documented she received oxygen and was dependent on staff for dressing, toileting, and transferring and does not walk. The MDS also documented diagnoses of pneumonia, chronic obstructive pulmonary disease (COPD) with acute exacerbation, aphasia, non-traumatic brain dysfunction, cancer, diabetes mellitus, and hip fracture. Record review of Resident #26 current orders in her Electronic Health Record (EHR) on 4/16/25 documented a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-16 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, policy review, and staff interview the facility failed to care plan high risk medications to include side effects to be monitored for 2 of 5 residents (Residents #20 and #29) reviewed for high risk medications. The facility reported a census of 51 residents. Findings include: The Minimum Data Set (MDS) for Resident #20 dated 3/20/25 documented the resident received an antipsychotic on a routine basis. The MDS documented the resident was also taking an antidepressant, diuretic (fluid pill), and an opioid (narcotic) pain medication. 1. The Care Plan for Resident #20 lacked side effects to be monitored for the antipsychotic medication. 2. The Care Plan for Resident #20 lacked side effects to be monitored for the antidepressant medication. 3. The Care Plan for Resident #20 lacked side effects to be monitored for the diuretic medication. 4. The Care Plan for Resident #20 lacked side effects to be monitored for the opioid pain medication. During an interview on 4/16/25 at 10:30 AM, the MDS coordinator acknowledged the Care Plan should include side effects…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-30 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review, and policy review the facility failed to treat two out of three residents reviewed with dignity. The facility reported a census of 52 residents. Findings include: Review of Resident #1 face sheet reveals she was in room [ROOM NUMBER]-B. Review of Resident #2 face sheet reveals she was in room [ROOM NUMBER]-A. On 1/29/25 at 12:32 PM Staff A, Certified Nursing Assistant (CNA) stated on 1/23/25 in the evening an incident in room [ROOM NUMBER] occurred. I was in the room for a transfer with my coworker Staff C, CNA and there was a conversation about another staff member. The conversation was related to frustration because someone had left a dirty depend in the trash can and I was frustrated because the same staff member had taken a lift and had two people in a room for a transfer that only needed one person. I was not aware the daughter of Resident #1 was in the room. On 1/29/25 at 1:37 PM Staff B, Licensed Practical Nurse (LPN) stated she was not working but stopped in to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-11 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, policy review, and staff interview the facility failed to provide appropriate catheter care to prevent potential cross contamination that could lead to a urinary tract infection (UTI) for 1 of 1 residents sampled (Resident #38). The facility identified a census of 52 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status Score of 7 indicating severe cognitive impairment with a diagnosis of Non-Alzheimer's Dementia. The MDS documented Resident #38 as dependent upon staff for managing his urinary catheter for diagnoses of benign prostatic hyperplasia and neurogenic bladder. A review of the April and May 2024 Medication Administration Records (MARs) documented Resident #38 received Levaquin (antibiotic) tablet 500 milligrams (MG), one tablet by mouth one time day for UTI for three days from 4/29/24 - 5/01/24. A review of the June 2024 MAR showed Resident #38 received physician ordered Levofloxacin…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2024-07-11 · tag F0637 — patternAssess the resident when there is a significant change in condition
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, Center for Medicare and Medicaid (CMS) Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User's Manual review, and staff interview the facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required time frame for 2 of 2 residents sampled for hospice care (Resident #40 and #10). The facility reported a census of 52 residents. Findings include: 1. Resident #40 Electronic Census Record documented she admitted into hospice care on 6/17/24. Resident #40 SCSA MDS with an assessment reference date of 6/27/24 showed a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive loss. The MDS listed diagnoses of Non-Alzheimer's Dementia, heart failure, diabetes mellitus, and end stage renal failure. The MDS documented Resident #40 received hospice care services. A 7/10/24 review of the MDS Summary Page showed the SCSA MDS completion date as 7/05/24, greater than 14 days after the significant change determination date. On 7/10/24 at 11:43 AM the MDS Coordinator…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$8,281 in federal fines across 1 penalty.
- $8,281 — penalty dated 2025-09-11
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to GOOD SAMARITAN SOCIETY — 92 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 3.0 | -1.0 vs chain |
| Health inspection | 2 of 5 | 2.8 | -0.8 vs chain |
| Staffing | 4 of 5 | 4.0 | ≈ chain avg |
| Quality measures | 2 of 5 | 2.8 | -0.8 vs chain |
The other 91 homes this chain runs (chain average 3.0★, per CMS)
Showing 40 of 91; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| SANFORD | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 01/01/2019 |
| BROWN, GEORGE | Individual | CORPORATE DIRECTOR | — | since 01/01/2025 |
| DYKHOUSE, DANA | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| ENGBRECHT, WESLEY | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| GASSEN, WILLIAM | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 05/30/2024 |
| GULSVIG, NEIL | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| HERSETH SANDLIN, STEPHANIE | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| LUNDEEN, MARK | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| MCCAUSLAND, MAUREEN | Individual | CORPORATE DIRECTOR | — | since 01/01/2025 |
| MOLBERT, LAURIS | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| NORTH, ANDREW | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| SCHIEFFER, KEVIN | Individual | CORPORATE DIRECTOR | — | since 01/01/2025 |
| SHULKIN, DAVID | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| TEIKEN, BRENT | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| VENTLING-HERRMANN, MARNIE | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| WENZEL, THOMAS | Individual | CORPORATE DIRECTOR | — | since 01/01/2025 |
| FLUIT, JOEL | Individual | CORPORATE OFFICER | — | since 10/01/2022 |
| MIDDLETON, AIMEE | Individual | CORPORATE OFFICER | — | since 01/27/2022 |
| OLSON, NICHOLAS | Individual | CORPORATE OFFICER | — | since 04/08/2024 |
| SCHEMA, NATHAN | Individual | CORPORATE OFFICER | — | since 01/01/2022 |
| THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2019 |
| LEDERMAN, MORDECHAI | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2020 |
| MORRISON, TONY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2019 |
| WILKINS, JESSICA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/10/2024 |
CMS files one row per role, so the 28 rows in the source record cover these 24 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $929K paid to related parties — landlords or management companies under common ownership — equal to about 15% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Iowa Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 165240. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-30, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.