Good Samaritan - Holstein
505 West Second Street, Holstein, IA 51025 · Ida County · 60 certified beds · avg 52 residents/day · certified since Apr 1, 1994
Part of chain: GOOD SAMARITAN SOCIETY (92 facilities, chain avg rating 3.0★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Aug 17, 2024 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Aug 27, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Aug 17, 2024 · F-0609 · triggered by a complaint
The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
Why it matters: When incidents aren't reported promptly, abusers may continue harming residents and outside authorities can't step in.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Aug 27, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (24)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 9, 2026 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Apr 9, 2026 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Apr 9, 2026 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Apr 9, 2026 | D · Potential for harm, one-off | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. |
| Apr 9, 2026 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jun 2, 2025 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| Mar 20, 2025 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Mar 20, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Mar 20, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Mar 20, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Mar 20, 2025 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Mar 20, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Aug 17, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Aug 17, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Aug 17, 2024 | E · Potential for harm, repeated | The facility did not have enough staff with the right skills to meet the mental and behavioral health needs of its residents, such as those living with dementia or depression. · from a complaint |
| Jun 17, 2024 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Dec 21, 2023 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Dec 21, 2023 | E · Potential for harm, repeated | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. |
| Dec 21, 2023 | E · Potential for harm, repeated | The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. |
| Dec 21, 2023 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Dec 21, 2023 | D · Potential for harm, one-off | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. |
| Dec 21, 2023 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · from a complaint |
| Dec 21, 2023 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Dec 21, 2023 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (6 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 8 | 0 | E |
| 2024 | 4 | 2 | J ▲ |
| 2025 | 7 | 0 | D |
| 2026 | 5 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $99,103.
| Date | Type | Amount / length |
|---|---|---|
| Aug 17, 2024 | Fine | $99,103 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Iowa avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.87 | 4.37 | 3.95 | bottom 30% in Iowa; top 45% in the U.S. |
| Registered Nurse hours | 1.10 | 0.85 | 0.69 | top 18% in Iowa; top 12% in the U.S. |
| Weekend total nurse staffing | 3.41 | 3.86 | 3.50 | bottom 30% in Iowa; top 47% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.51 | 0.51 | 0.48 | top 39% in Iowa; top 31% in the U.S. |
| Total nursing staff turnover (%) | 33.3 | 44.0 | 45.8 | top 24% in Iowa; top 20% in the U.S. |
| RN turnover (%) | 0.0 | 42.1 | 42.9 | top 1% in Iowa; top 1% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.35, RN 0.95, weekend 2.95. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5
Who owns this facility
Non profit - Other
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Sanford | Organization | 5% or Greater Direct Ownership Interest | 100% | 01/01/2019 |
| The Evangelical Lutheran Good Samaritan Society | Organization | 5% or Greater Indirect Ownership Interest | 100% | 01/01/2019 |
| Anderson, Troy | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/14/2020 |
| Anderson, Troy | Individual | ADP of the SNF | NOT APPLICABLE | 12/14/2020 |
| Brown, George | Individual | Corporate Director | NOT APPLICABLE | 01/01/2025 |
| Brown, George | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2025 |
| DTN Staffing INC | Organization | ADP of the SNF | NOT APPLICABLE | 08/02/2024 |
| Dykhouse, Dana | Individual | Corporate Director | NOT APPLICABLE | 05/30/2024 |
| Dykhouse, Dana | Individual | ADP of the SNF | NOT APPLICABLE | 05/30/2024 |
| Engbrecht, Wesley | Individual | Corporate Director | NOT APPLICABLE | 05/30/2024 |
| Engbrecht, Wesley | Individual | ADP of the SNF | NOT APPLICABLE | 05/30/2024 |
| Fluit, Joel | Individual | Corporate Officer | NOT APPLICABLE | 10/01/2022 |
| Fluit, Joel | Individual | ADP of the SNF | NOT APPLICABLE | 10/01/2022 |
| Gassen, William | Individual | Corporate Director | NOT APPLICABLE | 05/30/2024 |
| Gassen, William | Individual | Corporate Officer | NOT APPLICABLE | 05/30/2024 |
| Gassen, William | Individual | ADP of the SNF | NOT APPLICABLE | 05/30/2024 |
| Grape Tree Medical Staffing LLC | Organization | ADP of the SNF | NOT APPLICABLE | 04/13/2018 |
| Gulsvig, Neil | Individual | Corporate Director | NOT APPLICABLE | 05/30/2024 |
| Gulsvig, Neil | Individual | ADP of the SNF | NOT APPLICABLE | 05/30/2024 |
| Herseth Sandlin, Stephanie | Individual | Corporate Director | NOT APPLICABLE | 05/30/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "Could I join residents for a meal to see the food quality and temperature for myself?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "What is your policy on physical restraints, and what alternatives do you try first?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Correctionville Specialty Care | 11.5 mi | Correctionville, IA | ★☆☆☆☆ | 1/5 | |
| Willow Dale Wellness Village | 12.2 mi | Battle Creek, IA | ★★★★☆ | 4/5 | |
| Accura Healthcare of Aurelia, LLC | 16.6 mi | Aurelia, IA | ★★★☆☆ | 3/5 | |
| Careage Hills Rehabilitation and Healthcare | 18.5 mi | Cherokee, IA | ★★☆☆☆ | 2/5 | |
| Accura Healthcare of Cherokee, LLC | 18.7 mi | Cherokee, IA | ★★★☆☆ | 3/5 | |
| Cherokee Specialty Care | 18.9 mi | Cherokee, IA | ★★★☆☆ | 3/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 165207.