Cycle 1
Health 2024-12-05 · Fire 2024-12-05
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Villisca, IA
Good Samaritan Society - Villisca
4-star overall rating with 3-star inspections with 9 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
202 North Central Avenue, Villisca, IA
(712) 826-9592
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
46
Certified beds
Average residents
38
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Good Samaritan Society
Operator or chain grouping
Approved since
1993-11-01
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
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
0.67
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.89
Licensed practical nurse staffing · state 0.57 · national 0.87
Aide hours / resident day
1.87
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
3.42
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.56
RN + LPN hours · state 1.30 · national 1.54
Weekend hours
2.72
Weekend nurse staffing · state 3.35 · national 3.43
Weekend RN hours
0.29
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.80
CMS adjusted RN staffing hours
Adjusted total hours
4.07
CMS adjusted total nurse staffing hours
Case-mix index
1.15
Higher values indicate more complex resident acuity
RN turnover
14%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
16%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,677
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
54.84
Composite VBP score used to determine payment impact.
Payment multiplier
1.0098
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
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
10
Baseline 37.50% · Performance 24.00% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
0.97
Baseline 3.60 hours · Performance 3.35 hours · Measure score 0.97 · Achievement 0.97 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.27% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 39 · Observed rate 7.69% · Lower 95% interval 6.09% |
| Discharge to community | 35.16% |
50.57%
15.4 pts worse
|
Worse than the National Rate · Eligible stays 28 · Observed rate 21.43% · Lower 95% interval 22.59% |
| Medicare spending per beneficiary | 0.72 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 24 · Denominator 24 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 24 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 10 · Denominator 20 |
| Discharge mobility score | 30% |
50.94%
20.9 pts worse
|
Numerator 6 · Denominator 20 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 24 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 54 |
| Staff flu vaccination coverage | 93.55% |
42%
51.5 pts better
|
Numerator 58 · Denominator 62 |
| Discharge function score | 70% |
56.45%
13.5 pts better
|
Numerator 14 · Denominator 20 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 12 · 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 | 1.3 |
1.5
0.2 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.1 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
2.1
About the same
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.0 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
94.0%
5.3 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 97.3% · 4Q avg 99.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.3% |
95.2%
2.1 pts better
|
95.5%
1.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.6% |
3.7%
2.9 pts worse
|
3.3%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 8.1% · Q3 4.9% · Q4 2.7% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.0%
4 pts better
|
11.4%
11.4 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 who lose too much weight | 2.5% |
4.9%
2.4 pts better
|
5.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 0.0% · Q3 0.0% · Q4 6.2% · 4Q avg 2.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.4% |
20.6%
9.8 pts worse
|
19.6%
10.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.2% · Q2 27.6% · Q3 31.2% · Q4 31.2% · 4Q avg 30.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.2% |
19.8%
12.6 pts better
|
16.7%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 4.2% · Q3 11.5% · Q4 4.5% · 4Q avg 7.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 2.0% |
0.2%
1.8 pts worse
|
0.1%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.4% · Q3 2.4% · Q4 0.0% · 4Q avg 2.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 18.1% |
18.5%
0.4 pts better
|
16.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 37.3% · Q3 15.7% · Q4 4.2% · 4Q avg 18.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.3% |
18.3%
5 pts better
|
14.9%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 22.2% · Q3 11.1% · Q4 13.8% · 4Q avg 13.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.7%
1.7 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
2.5%
1.1 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.7% · Q3 2.6% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.8% |
26.0%
10.2 pts better
|
19.8%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.1% · Q2 8.3% · Q3 23.7% · Q4 10.8% · 4Q avg 15.8% |
| Percentage of long-stay residents with pressure ulcers | 4.3% |
4.3%
About the same
|
5.1%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 2.6% · Q3 4.8% · Q4 6.3% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 78.0% |
84.3%
6.3 pts worse
|
81.7%
3.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 77.3% · Q2 69.6% · Q4 81.0% · 4Q avg 78.0% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 6.5% |
1.9%
4.6 pts worse
|
1.6%
4.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 6.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 73.9% |
73.3%
0.6 pts better
|
79.7%
5.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 73.9% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-14 · Fire 2023-09-14
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-06-10 · Fire 2022-06-10
0 health deficiencies
No concentrated health issue counts in this cycle.
9 fire-safety deficiencies
Top issue: Miscellaneous (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-05
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-12-18
F · Potential for more than minimal harm
2024-12-05
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2025-01-13
F · Potential for more than minimal harm
2024-12-05
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 2024-12-09
F · Potential for more than minimal harm
2024-12-05
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-12-18
D · Potential for more than minimal harm
2024-12-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-12-09
D · Potential for more than minimal harm
2024-12-05
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-12-09
F · Potential for more than minimal harm
2023-09-14
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-09-28
F · Potential for more than minimal harm
2023-09-14
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Not marked corrected
F · Potential for more than minimal harm
2023-09-14
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-10-03
F · Potential for more than minimal harm
2023-09-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-10-03
D · Potential for more than minimal harm
2023-09-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-03
D · Potential for more than minimal harm
2023-09-14
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2023-10-03
F · Potential for more than minimal harm
2022-06-10
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2022-07-09
F · Potential for more than minimal harm
2022-06-10
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-07-09
F · Potential for more than minimal harm
2022-06-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-06-30
F · Potential for more than minimal harm
2022-06-10
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-07-09
F · Potential for more than minimal harm
2022-06-10
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 2022-06-22
E · Potential for more than minimal harm
2022-06-10
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 2022-07-09
D · Potential for more than minimal harm
2022-06-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-06-15
D · Potential for more than minimal harm
2022-06-10
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-06-30
D · Potential for more than minimal harm
2022-06-10
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-06-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-10-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-10-24
D · Potential for more than minimal harm
2025-10-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-10-24
D · Potential for more than minimal harm
2025-09-03
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-09-17
D · Potential for more than minimal harm
2025-09-03
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 2025-09-17
D · Potential for more than minimal harm
2024-12-05
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 2025-01-05
D · Potential for more than minimal harm
2024-12-05
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-01-05
D · Potential for more than minimal harm
2024-12-05
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-01-05
D · Potential for more than minimal harm
2024-12-05
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2025-01-05
D · Potential for more than minimal harm
2024-12-05
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 2025-01-05
G · Actual harm
2024-09-24
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 2024-09-12
E · Potential for more than minimal harm
2023-09-14
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 2023-10-12
E · Potential for more than minimal harm
2023-09-14
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-09-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-09-14
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 2023-10-12
Penalties and ownership
What sits behind the stars
Ownership
Sanford
5% Or Greater Direct Ownership Interest · Organization
Brown, George
Corporate Director · Individual
Dykhouse, Dana
Corporate Director · Individual
Early, Michael
Operational/Managerial Control · Individual
Engbrecht, Wesley
Corporate Director · Individual
Fluit, Joel
Corporate Officer · Individual
Freeman, Steven
Operational/Managerial Control · Individual
Gassen, William
Corporate Director · Individual
Gassen, William
Corporate Officer · Individual
Gulsvig, Neil
Corporate Director · Individual
Herseth Sandlin, Stephanie
Corporate Director · Individual
Lundeen, Mark
Corporate Director · Individual
Mccausland, Maureen
Corporate Director · Individual
Middleton, Aimee
Corporate Officer · Individual
Molbert, Lauris
Corporate Director · Individual
Morrison, Tony
Operational/Managerial Control · Individual
North, Andrew
Corporate Director · Individual
Olson, Nicholas
Corporate Officer · Individual
Schema, Nathan
Corporate Officer · Individual
Schieffer, Kevin
Corporate Director · Individual
Shulkin, David
Corporate Director · Individual
Teiken, Brent
Corporate Director · Individual
Ventling-Herrmann, Marnie
Corporate Director · Individual
Wenzel, Thomas
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Accura Healthcare of Stanton
Stanton, IA
4-star overall rating with 3-star inspections with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Red Oak Rehab and Care Center
Red Oak, IA
3-star overall rating with 3-star inspections with 2 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Corning Specialty Care
Corning, IA
3-star overall rating with 2-star inspections with 11 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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