Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 - Estherville during CMS and state inspections, most recent first.
Improper food storage and expired food items were observed in the kitchen. Surveyors found multiple refrigerated items ready for service past their dates, an open container of orange juice without a lid or date, an undated cake in a plastic bag, and uncovered dinner buns on a rack. The CDM stated leftovers are good for 3 days, while the facility policy required leftover items to be used within 7 days and use-by items to be checked and discarded when expired.
A resident with severely impaired cognition, dementia, depression, and anxiety-related diagnoses was receiving lorazepam and olanzapine. The record showed only one GDR was completed for the routine psychotropic medications, and the DON verified that a second GDR in separate quarters within the first year of admission was not found.
Incomplete care plans failed to address key needs for two residents. One resident with intact cognition, TBI, HTN, and depression had active O2 orders for hypoxia, but the care plan did not include oxygen therapy. Another resident with severely impaired cognition, HTN, renal insufficiency, and DM had multiple insulin orders, but the care plan lacked guidance for diabetes management, BG monitoring, physician notification parameters, and signs/symptoms of hyperglycemia or hypoglycemia.
Physician orders for wound care and compression were not accurately transcribed or carried out for a resident with BLE wounds and multiple chronic conditions including HTN, HF, CKD, DM2, and morbid obesity. An ET nurse and the MD ordered daily wound care and gradual compression with ace wraps, but the TAR listed the RLE treatment for bath days instead of daily, some treatments were missed, and the ace wraps were not documented as worn on multiple days.
A resident with intact cognition, multiple chronic conditions, and dependence for all transfers had repeated incidents during mechanical sit to stand lift use. Staff used the lift alone despite the care plan calling for 2-person assistance, the sling was not applied correctly, and the resident slipped or went limp during transfers and was found on the floor. The RN and DON interviews confirmed the unsafe transfer practices and that the only documented response was verbal education.
A resident with moderate cognitive impairment accused a nurse of abuse, which was documented by an LPN and later brought to the attention of the administrator by the resident's family and police. Although the facility's policy required immediate reporting of such allegations to state authorities, the incident was not self-reported because the administrator relied on the police investigation, resulting in a failure to follow mandated reporting procedures.
The facility inaccurately submitted staffing data to CMS, failing to include correct hours for an agency CNA who worked overnight. The CNA's hours were mistakenly recorded for a day she did not work, and agency staff hours were not consistently reported.
The facility failed to serve food at appropriate temperatures to two residents with intact cognition. One resident reported that food delivered to her room was often cold, while another stated that food was frequently cold when it should have been hot. An observation revealed that the temperature of the food on the last tray delivered was below the facility's policy requirement for hot foods. The Certified Dietary Manager confirmed the expectation for food to be served at appropriate temperatures.
The facility failed to follow professional standards in food preparation and serving. Staff A was observed making extra servings of pureed brownie and handling various items without performing hand hygiene until later. The CDM confirmed that hand hygiene should be completed at appropriate times, as per the facility's policy on hand washing and glove usage.
A facility failed to update a resident's care plan to include the use of alprazolam, an antianxiety medication prescribed for agitation. The resident, with diagnoses of depression and psychotic disorder, had an order for the medication documented in their EHR, but it was not reflected in the care plan. The DON confirmed the oversight, which contradicted the facility's policy requiring care plans to reflect current care needs.
Two residents reported that a CNA was rude and dismissive, failing to uphold their rights to dignity and respect. One resident, with intact cognition and multiple diagnoses, was told not to use the call light, while another described the CNA as 'barky' and rude. The facility's policy on resident dignity was not adhered to, as confirmed by staff interviews and a facility investigation.
Improper Food Storage and Expired Food Items in Kitchen
Penalty
Summary
The facility failed to store food items according to professional standards and failed to discard food items after the product recommended date. During an initial kitchen tour, surveyors observed multiple items in the kitchen refrigerator ready for service that were past their dates or improperly stored, including shredded lettuce turning brown dated 1/2/26, breaded chicken dated 1/4/26, fruit cocktail dated 1/3/26, tomato sauce dated 1/2/26, egg salad with a used-by date of 12/29/25, low fat cottage cheese with a use-by date of 11/11/25, and mildly thick orange juice that was open, had no lid, and was not dated even though the container directions stated it may be kept up to 7 days under refrigeration after opening. Surveyors also observed an angel food cake inside a plastic bag that was not dated and a tray of dinner buns on a rack that were not covered. The Certified Dietary Manager stated that leftovers are good for 3 days then discarded otherwise they go by the expiration date on the food item. The facility policy stated leftover food items are to be used within 7 days per food code and food items with a use-by date are checked regularly and discarded when expired.
Failure to Complete Required GDR for Psychotropic Medications
Penalty
Summary
The facility failed to complete a gradual dose reduction (GDR) for one resident reviewed for unnecessary psychotropic medications. The resident’s MDS assessment identified severely impaired cognition and listed diagnoses including non-Alzheimer’s dementia, depression, frontotemporal cognitive disorder, adjustment disorder with depressed mood, and emotional lability. The MDS also documented use of high-risk medications, including an antipsychotic and antianxiety medications. The clinical record showed the resident was admitted to the facility on [DATE], and the care plan identified use of an antipsychotic for dementia-related behavioral symptoms and an antianxiety medication for adjustment issues and anxiety disorder, with directions to consult pharmacy and health care providers to consider dosage reduction when clinically appropriate. The January 2026 MAR showed routine administration of lorazepam 0.5 mg in the morning and at bedtime, and olanzapine 2.5 mg twice daily. The record showed one GDR was completed on 9/17/25 for the routine lorazepam and olanzapine, with no medication changes made, but the clinical record lacked a second GDR in two separate quarters within the first year of admission. On 1/15/26, the DON verified that only one GDR had been completed for the olanzapine and routine lorazepam and stated the pharmacist could not locate a second GDR. The DON agreed it was expected to complete two GDRs within the first year, in two separate quarters with a month in between.
Incomplete Care Plans for Oxygen Therapy and Diabetes Management
Penalty
Summary
The facility failed to develop comprehensive care plans that addressed the needs of 2 of 13 residents reviewed, including Resident #7 and Resident #10. Resident #7’s MDS dated 11/3/2025 showed a BIMS score of 14, indicating intact cognition, and listed diagnoses of traumatic brain injury, hypertension, and depression. The January 2026 MAR listed oxygen therapy orders for 4 LPM via nasal cannula, with titration and weaning as tolerated and oxygen saturation monitoring every shift for hypoxia, but the care plan initiated on 5/5/25 did not include a care plan for oxygen therapy. Resident #10’s MDS dated 12/8/2025 showed a BIMS score of 3, indicating severely impaired cognition, and listed diagnoses of hypertension, renal insufficiency, and diabetes mellitus. The January 2026 MAR included orders for insulin glargine 25 units twice daily, insulin aspart 14 units before meals, and additional sliding-scale insulin four times daily for diabetes. The care plan initiated on 8/26/25 did not include direction for treatment and management of type 2 diabetes mellitus or insulin use, and it lacked risk factors and interventions for blood sugar monitoring, parameters for reporting the physician, signs and symptoms of hyperglycemia and hypoglycemia, and potential adverse reactions or complications.
Physician Orders for Wound Care and Compression Were Not Followed
Penalty
Summary
The facility failed to provide care and services according to accepted standards of clinical practice for one resident with physician orders related to wound care and compression therapy. Resident #2 had a BIMS score of 15 and diagnoses including hypertension, heart failure, chronic kidney disease, type 2 diabetes mellitus, and morbid obesity. The care plan identified open wounds on both lower extremities related to a fall and directed staff to monitor the location, size, and treatment of the skin injury, but it did not include direction regarding ace wraps or compression to the bilateral lower extremities. An ET nurse evaluated the resident’s bilateral lower extremity wounds and recommended specific wound treatments and gradual compression to both legs, and the physician agreed with those recommendations. The November 2025 TAR did not correctly transcribe the right lower extremity treatment order, listing it for bath days instead of daily, and the treatment was not completed on 11/15 and 11/16. After the resident returned from the hospital, the ET nurse again recommended restarting gradual compression to both lower extremities daily, and the physician agreed. The December 2025 TAR showed the ace wraps were not signed off on multiple dates, indicating the resident did not wear the ace wraps according to the physician order on those days. The DON and wound nurse acknowledged the right lower extremity treatment had not been transcribed correctly and stated staff should follow physician orders and document administration or refusals on the TAR.
Inadequate Supervision During Mechanical Lift Transfers
Penalty
Summary
The facility failed to provide adequate nursing supervision to prevent accidents and injuries for a resident with intact cognition, a BIMS score of 15, and diagnoses including hypertension, heart failure, chronic kidney disease, type 2 diabetes mellitus, and morbid obesity. The resident was dependent on staff for all transfers and had a care plan directing staff to use a mechanical sit to stand lift with assist of 2 for transfers, or a sit to stand with assist of 2 staff members, walker, and gait belt depending on fluctuating level of consciousness. The care plan was revised to reflect these transfer needs related to weakness and limited mobility. The resident had multiple transfer-related incidents involving the mechanical sit to stand lift. One incident report documented the resident fell to the floor when one staff member transferred the resident from a recliner to a commode using the lift, and the resident slipped out of the sling. Another incident report documented the resident almost slipped out of the lift, was readjusted, and was then assisted onto the commode; the RN instructed the CNA not to transfer the resident alone and to call for help when the resident was ready to get off the commode. Later, the resident was found on the floor after the CNA reported the resident went limp during the transfer. Staff interviews confirmed the CNA used the mechanical sit to stand lift by herself, the sling was not applied correctly, and the resident could not hold onto the lift bar. The DON reported the intervention for the fall was verbal education and stated it was not documented.
Failure to Report Alleged Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident with moderate cognitive impairment and a history of an ankle fracture. According to documentation, the resident was heard screaming and accused a nurse of hitting her, while the nurse was reportedly at the nurse station charting. The incident was documented by an LPN, who stated she notified a supervisor but could not recall who. The administrator and DON later confirmed that the allegation was documented, but the administrator stated they were not notified at the time and only became aware when the resident's son and a police officer arrived. The police reviewed video footage and found no evidence of abuse, and the resident did not sustain any injury or trauma. Despite the facility's policy requiring immediate reporting of alleged or suspected abuse to the administrator and designated agencies, including the State Survey and Certification Agency, the incident was not self-reported to the state. The administrator decided not to self-report because the police had already investigated and found the allegation unfounded. The facility's records showed that self-reports had been made in other cases, but in this instance, the required notification to state authorities did not occur as outlined in the facility's abuse and neglect policy.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to submit complete and accurate staffing information to CMS for the period of April 1 to June 30, 2024, as required by the Payroll Based Journal (PBJ) system. The CMS PBJ Staffing Data Report indicated a trigger for investigation due to discrepancies in staffing data. Specifically, the facility's schedule showed that an agency Certified Nursing Assistant (CNA), referred to as Staff E, worked from 6 p.m. on May 4th to 6:15 a.m. on May 5th. However, the PBJ report did not include the hours worked by Staff E on May 5th. Instead, her hours were incorrectly recorded for April 28th, a day she did not work. This error was confirmed by the Administrator, who acknowledged that the information was inputted incorrectly and that agency staff hours were not always accurately included in the PBJ report.
Failure to Serve Food at Appropriate Temperatures
Penalty
Summary
The facility failed to provide food at an appetizing temperature to two residents with intact cognition, as evidenced by interviews and observations. Resident #27 reported that the food delivered to her room was often cold. Similarly, Resident #43 stated that the food was frequently cold when it should have been hot. During an observation, the last room trays were sent out of the kitchen, and the temperature of the food on the last tray delivered was measured. The ham and beans were at 126 degrees Fahrenheit, and the mashed potatoes were at 122 degrees Fahrenheit, both below the facility's policy requirement of 135 degrees Fahrenheit or higher for hot foods. The Certified Dietary Manager confirmed that the expectation was for food to be served at appropriate temperatures.
Failure in Hand Hygiene During Food Preparation
Penalty
Summary
The facility failed to adhere to professional standards in food preparation, serving, and distribution, as observed during a survey. Staff A was seen making extra servings of pureed brownie without performing hand hygiene. Subsequently, Staff A touched door jams, prepared room trays, handled spatulas, touched plates, and handled bowls for lunch service before finally completing hand hygiene. An interview with the Certified Dietary Manager (CDM) confirmed that the expectation is for hand hygiene to be completed at appropriate times. A review of the facility's policy on hand washing and glove usage in food nutrition services, dated 6/13/24, indicated that employees involved in food preparation, distribution, and serving must consistently utilize good hygienic practices and techniques.
Failure to Update Care Plan with Antianxiety Medication
Penalty
Summary
The facility failed to update the care plan of a resident to accurately reflect the use of antianxiety medication. The resident, who was admitted from a critical access hospital, had diagnoses of depression and psychotic disorder. The resident's Minimum Data Set (MDS) and Electronic Healthcare Record (EHR) indicated an order for alprazolam, an antianxiety medication, to be administered as needed for agitation. However, the resident's care plan, dated 10/30/24, did not document the use of this medication. The Director of Nursing confirmed the existence of the medication order and expressed the expectation that such medications should be included in the care plan. The facility's policy requires that care plans be modified to reflect the current care required or provided to the resident.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to uphold the residents' rights to dignity and respect, as evidenced by interactions involving two residents. Resident #2, who has intact cognition and diagnoses including cancer and diabetes, reported that a CNA, identified as Staff B, was rude and dismissive, telling her not to use the call light and that she would attend to her when she had time. This behavior was corroborated by a facility investigation, which led to Staff B's suspension. Resident #43, also with intact cognition and diagnosed with heart failure and diabetes, described Staff B as 'barky' and rude, expressing relief when Staff B was no longer employed at the facility. The resident mentioned that Staff B spoke disrespectfully to him and others, which was confirmed by a Registered Nurse who had received similar complaints from other residents. The Director of Nursing and the facility Administrator both expressed expectations for staff to treat residents with dignity and respect, aligning with the facility's policy on resident dignity. However, the interactions reported by the residents and staff interviews indicate a failure to meet these expectations. The facility's policy emphasizes addressing residents as individuals when providing care, which was not adhered to in the cases involving Staff B. The deficiency highlights a lapse in maintaining a respectful and dignified environment for residents, as required by the facility's standards and policies.
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What surveyors actually found near you
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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 Estherville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Estherville Community Care Center | 0.4 mi | ★★★★★ | 18 | 0 |
| Accura Healthcare Of Spirit Lake | 15 mi | ★★★★★ | 9 | 0 |
| Valley Vue Care Center | 16.9 mi | ★★★★★ | 4 | 0 |
| Good Samaritan Society - Jackson | 17.4 mi | ★★★★★ | 0 | 0 |
| Accura Healthcare Of Milford | 17.8 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.