Estherville, IA

Good Samaritan Society - Estherville

1-star overall rating with 2-star inspections with 6 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle

1646 Fifth Avenue North, Estherville, IA

(712) 362-3522

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

1 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Good Samaritan Society

Operator or chain grouping

Approved since

1993-12-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

89 facilities

Chain averages 3 overall / 3 health / 4 staffing / 3 quality stars

Changed ownership

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

0.98

Registered nurse staffing · state 0.73 · national 0.68

LPN hours / resident day

0.31

Licensed practical nurse staffing · state 0.57 · national 0.87

Aide hours / resident day

2.19

Nurse aide staffing · state 2.53 · national 2.35

Total nurse hours

3.49

All reported nurse hours · state 3.83 · national 3.89

Licensed hours

1.29

RN + LPN hours · state 1.30 · national 1.54

Weekend hours

2.84

Weekend nurse staffing · state 3.35 · national 3.43

Weekend RN hours

0.59

Weekend registered nurse coverage · state 0.50 · national 0.47

Physical therapist

0.00

Reported PT staffing

Adjusted RN hours

1.12

CMS adjusted RN staffing hours

Adjusted total hours

3.98

CMS adjusted total nurse staffing hours

Case-mix index

1.20

Higher values indicate more complex resident acuity

RN turnover

60%

Annual RN turnover · state 44% · national 45%

Total nurse turnover

53%

Annual nurse turnover · state 44% · national 46%

SNF VBP

Value-based purchasing

Program rank

11,278

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

17.43

Composite VBP score used to determine payment impact.

Payment multiplier

0.9818

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Baseline 6.18% · Performance 8.12% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

3.63

Baseline 61.36% · Performance 48.84% · Measure score 3.63 · Achievement 3.63 · Improvement 2.93

Adjusted total nurse staffing

1.60

Baseline 3.09 hours · Performance 3.53 hours · Measure score 1.60 · Achievement 1.60 · Improvement 1.14

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.89%	10.72% 1.2 pts worse	No Different than the National Rate · Eligible stays 60 · Observed rate 13.33% · Lower 95% interval 8.08%
Discharge to community	37.54%	50.57% 13 pts worse	Worse than the National Rate · Eligible stays 50 · Observed rate 32% · Lower 95% interval 26.36%
Medicare spending per beneficiary	0.97	1.02 0.1 pts better
Drug regimen review with follow-up	85.29%	95.27% 10 pts worse	Numerator 29 · Denominator 34
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 34
Discharge self-care score	44.83%	53.69% 8.9 pts worse	Numerator 13 · Denominator 29
Discharge mobility score	41.38%	50.94% 9.6 pts worse	Numerator 12 · Denominator 29
Pressure ulcers or injuries, new or worsened	8.82%	2.29% 6.5 pts worse	Numerator 3 · Denominator 34 · Adjusted rate 8.71%
Healthcare-associated infections requiring hospitalization	8.12%	7.12% 1 pts worse	No Different than the National Rate · Eligible stays 29 · Observed rate 10.34% · Lower 95% interval 4.47%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 70
Staff flu vaccination coverage	83.18%	42% 41.2 pts better	Numerator 89 · Denominator 107
Discharge function score	51.72%	56.45% 4.7 pts worse	Numerator 15 · Denominator 29
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.6	1.5 0.1 pts worse	1.9 0.3 pts better	Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.2 · Expected 1.4 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	4.8	2.1 2.7 pts worse	1.8 3 pts worse	Long Stay · 20240701-20250630 · Adjusted 4.8 · Observed 3.9 · Expected 1.4 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	81.2%	94.0% 12.8 pts worse	93.4% 12.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 83.7% · Q2 78.0% · Q3 87.5% · Q4 76.5% · 4Q avg 81.2%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	79.6%	95.2% 15.6 pts worse	95.5% 15.9 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 79.6%
Percentage of long-stay residents experiencing one or more falls with major injury	3.6%	3.7% 0.1 pts better	3.3% 0.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 0.0% · Q3 2.1% · Q4 5.9% · 4Q avg 3.6% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	1.2%	4.0% 2.8 pts better	11.4% 10.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2%
Percentage of long-stay residents who lose too much weight	6.4%	4.9% 1.5 pts worse	5.4% 1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 14.6% · Q3 2.5% · Q4 2.4% · 4Q avg 6.4%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	17.5%	20.6% 3.1 pts better	19.6% 2.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 27.8% · Q2 14.3% · Q3 12.2% · Q4 17.1% · 4Q avg 17.5%
Percentage of long-stay residents who received an antipsychotic medication	16.9%	19.8% 2.9 pts better	16.7% 0.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 20.6% · Q3 13.3% · Q4 13.3% · 4Q avg 16.9% · 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	33.3%	18.5% 14.8 pts worse	16.3% 17 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 47.7% · Q4 7.6% · 4Q avg 33.3% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	31.1%	18.3% 12.8 pts worse	14.9% 16.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 43.8% · Q2 28.6% · Q3 22.5% · Q4 31.7% · 4Q avg 31.1% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	2.9%	1.7% 1.2 pts worse	1.0% 1.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.9% · Q4 7.1% · 4Q avg 2.9% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.6%	2.5% 0.9 pts better	1.7% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.0% · Q3 2.1% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	30.6%	26.0% 4.6 pts worse	19.8% 10.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 40.6% · Q2 16.1% · Q3 36.9% · Q4 30.8% · 4Q avg 30.6%
Percentage of long-stay residents with pressure ulcers	1.6%	4.3% 2.7 pts better	5.1% 3.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.0% · Q3 1.9% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	52.2%	84.3% 32.1 pts worse	81.7% 29.5 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 85.2% · Q2 61.9% · Q3 36.4% · Q4 18.2% · 4Q avg 52.2%
Percentage of short-stay residents who newly received an antipsychotic medication	2.4%	1.9% 0.5 pts worse	1.6% 0.8 pts worse	Short Stay · 2024Q4-2025Q3 · 4Q avg 2.4% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-10-31 · Fire 2024-10-31

6 health deficiencies

Top issue: Nutrition and Dietary (2 deficiencies)

10 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 2 Health 2023-08-30 · Fire 2023-08-30

11 health deficiencies

Top issue: Nutrition and Dietary (3 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2022-06-01 · Fire 2022-06-01

21 health deficiencies

Top issue: Nutrition and Dietary (6 deficiencies)

6 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-10-31

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2024-11-15

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 2024-11-14

F · Potential for more than minimal harm 2024-10-31

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2024-11-01

F · Potential for more than minimal harm 2024-10-31

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-11-01

F · Potential for more than minimal harm 2024-10-31

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-12-01

F · Potential for more than minimal harm 2024-10-31

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2024-11-15

F · Potential for more than minimal harm 2024-10-31

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-11-30

F · Potential for more than minimal harm 2024-10-31

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2024-11-05

F · Potential for more than minimal harm 2024-10-31

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2024-11-19

E · Potential for more than minimal harm 2024-10-31

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-12-01

F · Potential for more than minimal harm 2023-08-30

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-09-15

F · Potential for more than minimal harm 2023-08-30

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-09-18

F · Potential for more than minimal harm 2023-08-30

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2023-09-06

F · Potential for more than minimal harm 2022-06-01

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2022-06-24

F · Potential for more than minimal harm 2022-06-01

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2022-06-24

F · Potential for more than minimal harm 2022-06-01

K347 · Smoke Deficiencies

Fire Safety

Properly provide smoke detection systems in areas open to corridors.

Corrected 2022-06-24

F · Potential for more than minimal harm 2022-06-01

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-06-24

F · Potential for more than minimal harm 2022-06-01

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2022-06-24

F · Potential for more than minimal harm 2022-06-01

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2022-06-24

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-11-10

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 2025-12-10

F · Potential for more than minimal harm 2024-10-31

F851 · Administration Deficiencies

Health

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Corrected 2024-11-12

E · Potential for more than minimal harm 2024-10-31

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2024-11-12

E · Potential for more than minimal harm 2024-10-31

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-11-12

D · Potential for more than minimal harm 2024-10-31

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 2024-11-12

D · Potential for more than minimal harm 2024-10-31

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2024-11-12

E · Potential for more than minimal harm 2023-11-30

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 2023-12-15

E · Potential for more than minimal harm 2023-11-30

F803 · Nutrition and Dietary Deficiencies

Health

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Corrected 2023-12-15

E · Potential for more than minimal harm 2023-11-30

F809 · Nutrition and Dietary Deficiencies

Health

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Corrected 2023-12-15

D · Potential for more than minimal harm 2023-11-30

F802 · Nutrition and Dietary Deficiencies

Health

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Corrected 2023-12-15

E · Potential for more than minimal harm 2023-08-30

F585 · Resident Rights Deficiencies

Health

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected 2023-09-22

E · Potential for more than minimal harm 2023-08-30

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2023-09-22

E · Potential for more than minimal harm 2023-08-30

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2023-09-22

E · Potential for more than minimal harm 2023-08-30

F805 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Corrected 2023-09-22

E · Potential for more than minimal harm 2023-08-30

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-09-22

E · Potential for more than minimal harm 2023-08-30

F868 · Administration Deficiencies

Health

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Corrected 2023-09-22

E · Potential for more than minimal harm 2023-08-30

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-09-22

D · Potential for more than minimal harm 2023-08-30

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2023-09-22

D · Potential for more than minimal harm 2023-08-30

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 2023-09-22

D · Potential for more than minimal harm 2023-08-30

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 2023-09-22

D · Potential for more than minimal harm 2023-08-30

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2023-09-22

K · Immediate jeopardy 2022-06-01

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 2022-06-17

E · Potential for more than minimal harm 2022-06-01

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2022-06-24

E · Potential for more than minimal harm 2022-06-01

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2022-06-24

E · Potential for more than minimal harm 2022-06-01

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2022-06-24

E · Potential for more than minimal harm 2022-06-01

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 2022-06-24

E · Potential for more than minimal harm 2022-06-01

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2022-06-24

E · Potential for more than minimal harm 2022-06-01

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2022-06-24

E · Potential for more than minimal harm 2022-06-01

F800 · Nutrition and Dietary Deficiencies

Health

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

Corrected 2022-06-24

E · Potential for more than minimal harm 2022-06-01

F803 · Nutrition and Dietary Deficiencies

Health

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Corrected 2022-06-24

E · Potential for more than minimal harm 2022-06-01

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2022-06-24

E · Potential for more than minimal harm 2022-06-01

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2022-06-24

D · Potential for more than minimal harm 2022-06-01

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 2022-06-24

D · Potential for more than minimal harm 2022-06-01

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2022-06-24

D · Potential for more than minimal harm 2022-06-01

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2022-06-24

D · Potential for more than minimal harm 2022-06-01

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 2022-06-24

D · Potential for more than minimal harm 2022-06-01

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 2022-06-24

D · Potential for more than minimal harm 2022-06-01

F758 · Pharmacy Service Deficiencies

Health

Corrected 2022-06-24

Penalties and ownership

What sits behind the stars

Ownership

Sanford

5% Or Greater Direct Ownership Interest · Organization

100% 89 facilities 2019-01-01

Berry, Patrick

W-2 Managing Employee · Individual

0% 1 facilities 2018-12-02

Cain, James