Good Samaritan - Red Oak
201 Alix Avenue, Red Oak, IA 51566 · Montgomery County · 53 certified beds · avg 39 residents/day · certified since Jan 24, 1993
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: ★☆☆☆☆1/5 · CMS overall rating: 1/5
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 12, 2025 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
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 26, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Apr 23, 2026 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: May 7, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Apr 17, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 29, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (34)
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 23, 2026 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Apr 23, 2026 | E · Potential for harm, repeated | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| Apr 23, 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 23, 2026 | E · Potential for harm, repeated | The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status. |
| Apr 23, 2026 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Apr 23, 2026 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Apr 23, 2026 | D · Potential for harm, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| Apr 23, 2026 | D · Potential for harm, one-off | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). |
| Apr 23, 2026 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Apr 23, 2026 | 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. |
| Apr 23, 2026 | 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. |
| Apr 23, 2026 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Apr 23, 2026 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Feb 18, 2026 | D · Potential for harm, 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 |
| Feb 18, 2026 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Aug 12, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Apr 17, 2025 | ▲ G · Actual 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. · from a complaint |
| Apr 17, 2025 | E · Potential for harm, repeated | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Apr 17, 2025 | 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 17, 2025 | E · Potential for harm, repeated | 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. |
| Apr 17, 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. |
| Apr 17, 2025 | 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. |
| Apr 17, 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. · from a complaint |
| Apr 17, 2025 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Apr 17, 2025 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| Jul 3, 2024 | 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. |
| Jul 3, 2024 | D · Potential for harm, one-off | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Jul 3, 2024 | 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. |
| Jul 3, 2024 | C · Minimal risk, facility-wide | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| Apr 18, 2024 | 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. · from a complaint |
| Apr 18, 2024 | D · Potential for harm, 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 |
| Apr 18, 2024 | 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. · from a complaint |
| Apr 18, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Apr 18, 2024 | D · Potential for harm, one-off | The facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life. · from a complaint |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (8 → 13).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2024 | 9 | 0 | E |
| 2025 | 10 | 2 | J ▲ |
| 2026 | 15 | 1 | G ▲ |
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 $29,894.
| Date | Type | Amount / length |
|---|---|---|
| Aug 12, 2025 | Fine | $29,894 |
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) | 3.79 | 4.37 | 3.95 | bottom 23% in Iowa; top 49% in the U.S. |
| Registered Nurse hours | 0.86 | 0.85 | 0.69 | top 39% in Iowa; top 23% in the U.S. |
| Weekend total nurse staffing | 2.98 | 3.86 | 3.50 | bottom 6% in Iowa; bottom 30% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.58 | 0.51 | 0.48 | top 28% in Iowa; top 25% in the U.S. |
| Total nursing staff turnover (%) | 17.9 | 44.0 | 45.8 | top 1% in Iowa; top 2% in the U.S. |
| RN turnover (%) | 16.7 | 42.1 | 42.9 | top 13% in Iowa; top 9% 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 3.29, RN 0.75, weekend 2.60. 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: 3/5 · long-stay residents: 2/5 · short-stay residents: 4/5
Who owns this facility
Non profit - Corporation
| 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 |
| Brown, George | Individual | Corporate Director | NOT APPLICABLE | 01/01/2025 |
| Butz, William | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/01/2023 |
| Butz, William | Individual | ADP of the SNF | NOT APPLICABLE | 10/01/2023 |
| Dykhouse, Dana | Individual | Corporate Director | NOT APPLICABLE | 05/30/2024 |
| Early, Michael | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/19/2023 |
| Early, Michael | Individual | ADP of the SNF | NOT APPLICABLE | 11/19/2023 |
| Engbrecht, Wesley | Individual | Corporate Director | NOT APPLICABLE | 05/30/2024 |
| Fluit, Joel | Individual | Corporate Officer | 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 |
| Gulsvig, Neil | Individual | Corporate Director | NOT APPLICABLE | 05/30/2024 |
| Herseth Sandlin, Stephanie | Individual | Corporate Director | NOT APPLICABLE | 05/30/2024 |
| Lundeen, Mark | Individual | Corporate Director | NOT APPLICABLE | 05/30/2024 |
| McCausland, Maureen | Individual | Corporate Director | NOT APPLICABLE | 01/01/2025 |
| Middleton, Aimee | Individual | Corporate Officer | NOT APPLICABLE | 01/27/2022 |
| Molbert, Lauris | Individual | Corporate Director | NOT APPLICABLE | 05/30/2024 |
| Morrison, Tony | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2019 |
| Morrison, Tony | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2019 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Where do you post your daily staffing numbers, and can I see today's?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "How do you handle COVID-19 vaccination for residents and staff, and what happens during an outbreak?"
- "How do you explain health changes and treatment options to residents and their families?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
- "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 |
|---|---|---|---|---|---|
| Red Oak Rehab and Care Center | 0.9 mi | Red Oak, IA | ★★★☆☆ | 3/5 | |
| Accura Healthcare of Stanton | 7.4 mi | Stanton, IA | ★★★☆☆ | 3/5 | |
| Good Samaritan - Villisca | 14.3 mi | Villisca, IA | ★★★☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 165191.