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

Compare this facility

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

Staffing

Hours and turnover

RN hours / resident day

0.67

Registered nurse staffing

LPN hours / resident day

0.89

Licensed practical nurse staffing

Aide hours / resident day

1.87

Nurse aide staffing

Weekend hours

2.72

Weekend nurse staffing

RN turnover

14%

Annual RN turnover

Total nurse turnover

16%

Annual nurse turnover

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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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

Survey summary

Recent inspection cycles

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)

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

100% 89 facilities 2019-01-01
Brown, George

Corporate Director · Individual

0% 64 facilities 2025-01-01
Dykhouse, Dana

Corporate Director · Individual

0% 85 facilities 2024-05-30
Early, Michael

Operational/Managerial Control · Individual

0% 2 facilities 2023-11-19
Engbrecht, Wesley

Corporate Director · Individual

0% 89 facilities 2024-05-30
Fluit, Joel

Corporate Officer · Individual

0% 88 facilities 2022-10-01
Freeman, Steven

Operational/Managerial Control · Individual

0% 2 facilities 2021-05-01
Gassen, William

Corporate Director · Individual

0% 89 facilities 2024-05-30
Gassen, William

Corporate Officer · Individual

0% 89 facilities 2024-05-30
Gulsvig, Neil

Corporate Director · Individual

0% 89 facilities 2024-05-30
Herseth Sandlin, Stephanie

Corporate Director · Individual

0% 86 facilities 2024-05-30
Lundeen, Mark

Corporate Director · Individual

0% 89 facilities 2024-05-30
Mccausland, Maureen

Corporate Director · Individual

0% 61 facilities 2025-01-01
Middleton, Aimee

Corporate Officer · Individual

0% 88 facilities 2022-01-27
Molbert, Lauris

Corporate Director · Individual

0% 89 facilities 2024-05-30
Morrison, Tony

Operational/Managerial Control · Individual

0% 89 facilities 2019-01-01
North, Andrew

Corporate Director · Individual

0% 89 facilities 2024-05-30
Olson, Nicholas

Corporate Officer · Individual

0% 87 facilities 2024-04-08
Schema, Nathan

Corporate Officer · Individual

0% 88 facilities 2022-01-01
Schieffer, Kevin

Corporate Director · Individual

0% 61 facilities 2025-01-01
Shulkin, David

Corporate Director · Individual

0% 85 facilities 2024-05-30
Teiken, Brent

Corporate Director · Individual

0% 89 facilities 2024-05-30
Ventling-Herrmann, Marnie

Corporate Director · Individual

0% 89 facilities 2024-05-30
Wenzel, Thomas

Corporate Director · Individual

0% 61 facilities 2025-01-01

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