Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Samaritan - Algona during CMS and state inspections, most recent first.
Failure to provide an ordered restorative exercise program was identified for a resident with Parkinson’s disease, knee pain, muscle weakness, and intact cognition. The care plan directed PROM hand strengthening, AROM with overhead pulleys, and LE exercises several times per week, but restorative charting showed no documentation that the program was completed for the past 3 months, and progress notes did not document refusal. The Administrator stated there was no documentation that restorative was offered or completed, and the resident reported staff do not offer the exercises.
Failure to provide adequate supervision allowed a resident with dementia, stroke, impaired vision, and high fall risk to elope from the facility and fall outside. Staff documented repeated confusion, statements about going home, and prior attempts to get out, while interviews showed the front door could be accessed during the day without an alarm for residents without a wander guard. The resident was later found face down at the front entrance with facial bleeding, knee pain, and severe HTN.
Two residents with pressure ulcers did not receive care and services consistent with professional standards, including failures in wound assessment, documentation, physician notification, and care planning. One resident with multiple comorbidities experienced worsening wounds that were not properly documented or treated, leading to hospitalization for sepsis. Another resident received a wound dressing without a physician order, and staff did not implement or communicate wound care recommendations or alternative interventions when the resident refused offloading boots. Facility policy requirements for skin inspection, documentation, and notification were not followed, as confirmed by staff and administration.
A resident with severe cognitive impairment was recorded in a video by a CNA, who then shared it on social media without consent. The video, which showed the CNA conversing with the resident, was reported by a dietary aide who received it from a former employee. Despite being aware of HIPAA policies, the CNA admitted to sending the video, believing it was harmless. The facility's failure to prevent this incident breached its policies on resident abuse and exploitation.
A facility failed to report an allegation of abuse within the required 2-hour timeframe. A staff member sent a video via social media involving a resident with severe cognitive impairment. The staff member was aware of the incident but did not report it to the Administrator until several days later due to not knowing how to contact them. Interviews revealed a lack of clarity in the reporting process, leading to a delay in addressing the incident.
A resident with severe cognitive impairment was involved in an abuse allegation when a CNA recorded and shared a video of the resident without consent. The incident was not reported to the appropriate authorities in a timely manner, and the staff member was not immediately removed from resident care duties, violating facility policy.
Failure to Provide Ordered Restorative Exercise Program
Penalty
Summary
Failure to provide a restorative exercise program for Resident #24 was identified. The resident’s MDS dated [DATE] showed a BIMS score of 15, indicating intact cognition, and listed diagnoses of Parkinson’s Disease, pain in an unspecified knee, and muscle weakness. The current care plan updated 5/22/25 directed staff to provide PROM hand strengthening with blue digi-flex, AROM to the upper extremities using overhead pulleys against resistance, and lower extremity supine exercises including ankle pumps, heel slides, hip abduction, SAQ exercises, SLR, and quad sets several times per week. The care plan also identified the resident as at risk for pressure ulcer development related to limited mobility. The resident’s restorative charting did not document the program being completed as ordered by therapy for the past 3 months, and the progress notes did not document any refusal to complete the restorative program during that same period. On 12/02/2025 at 4:00 PM, the Administrator stated there was no documentation that restorative was offered or completed for Resident #24 and said he expected the restorative programs to be completed. On 12/03/2025 at 10:55 AM, Resident #24 stated staff do not offer restorative exercises, but if they did, he would do them. The facility policy titled Rehab/Skilled and Long Term Care: Therapy and Rehab, revised 7/7/25, described how to document restorative nursing but did not direct staff to ensure the program was completed.
Failure to Supervise Resident With Cognitive Impairment and Elopement Risk
Penalty
Summary
The facility failed to provide adequate supervision to prevent elopement with a fall for one resident who had moderate cognitive impairment, dementia, stroke, disorientation, impaired vision from cataracts, and a history of high fall risk. The care plan documented that the resident thought people were stealing her snacks, went into other residents’ rooms, rummaged through belongings, and needed a safe environment because of vision loss and fall risk. Staff notes also described confusion and unsafe behaviors, including tearing items off her door, stating she needed to pack up because she heard an overhead page telling everyone to leave, reaching for things that were not there during a bus ride, and having cream spread over her face, hands, clothes, and bedside table. The resident’s elopement risk record stated she had not exhibited increased confusion, forgetfulness, packing belongings, or verbalizing statements about leaving, despite the documented behaviors. Staff interviews showed the resident frequently talked about going home, was considered an elopement risk by some staff, and had previously been stopped after going through the first door before reaching the outside. One CNA stated that anyone without a wander guard could go out the front door and there was no alarm during the day, while the administrator stated the front door had a wander guard and the alarm only automatically engaged at 10 p.m. and disengaged at 6 a.m. On the evening of the incident, the resident was found face down off the curb at the front entrance of the facility after another resident reported she had fallen outside. A CNA returning from break was present at the resident’s side. The resident had bleeding from the left upper forehead and under the right eye, complained of left knee pain, and had a blood pressure of 215/124. The nurse notified the hospital and the on-call physician, and the physician ordered transfer to the Emergency Department.
Failure to Provide Consistent Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to ensure that residents with pressure ulcers received treatment and services consistent with professional standards of practice, as evidenced by multiple deficiencies in assessment, documentation, notification, and care planning for two residents with pressure ulcers. For one resident with multiple comorbidities, including end-stage renal disease, diabetes, and morbid obesity, the care plan lacked specific interventions for pressure ulcer prevention and treatment, such as repositioning and heel elevation. There were repeated failures to document wound assessments, measurements, and characteristics, as well as to notify the physician and family of new or worsening wounds. Treatment Administration Records (TARs) were missing documentation of completed treatments for identified wounds, and there was no evidence that all physician orders were obtained or followed for wound care. The resident experienced a decline in wound status, with wounds becoming infected and ultimately leading to hospitalization for septic shock, where extensive necrotic wounds and skin failure were documented. For another resident with a pressure area on the left outer ankle, the facility did not document when or why a Mepilex dressing was applied, and the dressing was initiated without a physician order. The clinical record lacked documentation of wound characteristics and failed to show that recommendations from an outside wound nurse were implemented or communicated to the physician or dietician. When the resident refused to wear an offloading boot, there was no documentation of alternative interventions to prevent further skin breakdown. Staff interviews confirmed that treatments were sometimes initiated without proper orders and that follow-up on physician communication, such as faxes, was inconsistent. Facility policy required systematic skin inspections, timely notification of physicians and families, individualized care planning, and thorough documentation of wound assessments and treatments. However, these procedures were not consistently followed, as evidenced by missing or incomplete documentation, lack of timely notifications, and failure to update care plans with appropriate interventions. Staff and administration acknowledged these deficiencies during interviews, noting issues with documentation, communication, and oversight of wound care.
Resident Privacy Breach Due to Unauthorized Video Recording
Penalty
Summary
The facility failed to protect a resident from personal degradation, as evidenced by a video posted on social media by a Certified Nursing Assistant (CNA). The resident, who had severe cognitive impairment and multiple medical conditions, was recorded in a video without consent. The video showed the CNA having a conversation with the resident, which was then shared with a former employee of the facility. This incident was reported by a dietary aide who received the video from a friend, a previous employee of the facility. The facility's investigation revealed that the CNA, Staff B, admitted to recording the video while waiting for assistance to put the resident to bed. Staff B claimed she was unaware that the resident's face was captured in the video and did not realize it was a violation of the Health Insurance Portability and Accountability Act (HIPAA). Despite being aware of the facility's policies on social media and HIPAA, Staff B sent the video to a former employee, believing it was harmless due to their close relationship with the resident. Interviews with other staff members, including the Dietary Manager and Dietary Aide, confirmed the receipt and reporting of the video. The Dietary Manager reported the incident to the Administrator after viewing the video. The facility's policy on abuse and neglect emphasizes the residents' right to be free from abuse and exploitation, and mandates prompt reporting and investigation of such incidents. However, the facility's failure to prevent the recording and distribution of the video constituted a breach of these policies.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse within the required 2-hour timeframe to the Iowa Department of Inspections, Appeals and Licensing (DIAL). The incident involved a staff member sending a video via social media that included a resident with severe cognitive impairment. The staff member became aware of the allegations on 10/18/24, but the Administrator was not informed until 10/22/24. The delay occurred because the staff member did not know how to contact the Administrator. The resident involved had a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment and required assistance with various activities of daily living. The facility's policy mandates immediate reporting of any alleged or suspected violations involving mistreatment, neglect, exploitation, or abuse to the Administrator or designated representatives. However, the staff failed to adhere to this policy, resulting in a delay in reporting the incident. Interviews with staff members revealed a lack of clarity and communication regarding the reporting process. Staff C, who received the video, reported it to Staff D, who then advised her to inform Staff A. Staff A eventually reported the incident to the Administrator, but only after a few days had passed. The facility's policy outlines specific steps for reporting and handling such incidents, but these were not followed promptly, leading to the deficiency.
Failure to Report Abuse Allegation and Protect Resident
Penalty
Summary
The facility failed to immediately report an allegation of abuse involving a resident with severe cognitive impairment, as indicated by a BIMS score of 03. The resident, who required assistance with various activities of daily living, was the subject of a video taken by a CNA. The video was shared with a former employee, which was a violation of the resident's privacy. The incident was not reported to the Department of Inspection and Appeals and Licensing (DIAL) in a timely manner, as required by the facility's policy. Staff interviews revealed a breakdown in communication and reporting procedures. Staff A, the Dietary Manager, was informed of the video by Staff C, a Dietary Aide, who had received it from a former employee. Staff C reported the incident to Staff D, a Cook, who advised her to inform Staff A. However, the Administrator was not made aware of the situation until several days later, on 10/22/24, despite the facility's policy requiring immediate reporting of such allegations. The facility's policy mandates that any employee who witnesses or receives an allegation of abuse must protect the resident and report the incident to a supervisor immediately. The policy also requires the removal of the accused employee from direct care duties pending an investigation. In this case, the staff failed to follow these procedures, resulting in a delay in reporting the incident and a failure to separate the staff member from the resident involved.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Algona
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Algona Manor Care Center | 1.6 mi | ★★★★★ | 0 | 0 |
| West Bend Health And Rehabilitation | 12.9 mi | ★★★★★ | 0 | 0 |
| Titonka Care Center | 15.4 mi | ★★★★★ | 0 | 0 |
| Accura Healthcare Of Bancroft | 15.8 mi | ★★★★★ | 0 | 0 |
| Westview Care Center | 21.7 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.