Good Samaritan - Holstein
505 West Second Street · Holstein, IA · 51025 · 7123684304
60 certified beds Non profit - Other Chain: Good Samaritan Society
- Inspection results have improved across recent cycles.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
2 immediate-jeopardy citations in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
2 abuse-related citations at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
$99,103 in federal fines in the last 24 months
1 fine — CMS fines are reserved for verified, serious non-compliance.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 3 of 5 Inspections: 2 of 5 Staffing: 4 of 5 Quality measures: 5 of 5
| Total nurse hours / resident-day | 3.51 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 1.01 | 0.55–0.75 |
| Weekend hours / resident-day | 3.04 | ≈ weekday level |
| Nursing turnover / year | 39% | median 45% |
| Fines (3-yr window) | 1 · $99,103 |
Inspection citations (24 in the current record)
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Potential for harm · D April 9, 2026
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected April 30, 2026 · Resident Rights
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Potential for harm · D April 9, 2026
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected April 30, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E April 9, 2026
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected April 30, 2026 · Nutrition and Dietary
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Potential for harm · E April 9, 2026
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected April 30, 2026 · Nutrition and Dietary
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Potential for harm · D April 9, 2026
Provide and implement an infection prevention and control program.
Corrected April 30, 2026 · Infection Control
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Potential for harm · D June 2, 2025 · found via complaint
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected June 15, 2025 · Resident Assessment and Care Planning
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Potential for harm · D March 20, 2025
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected April 12, 2025 · Resident Rights
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Potential for harm · D March 20, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected April 12, 2025 · Resident Assessment and Care Planning
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Potential for harm · D March 20, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected April 12, 2025 · Quality of Life and Care
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Potential for harm · D March 20, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected April 12, 2025 · Quality of Life and Care
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Potential for harm · D March 20, 2025
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 April 12, 2025 · Pharmacy Service
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Potential for harm · D March 20, 2025
Provide and implement an infection prevention and control program.
Corrected April 12, 2025 · Infection Control
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Immediate jeopardy · J August 17, 2024 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected August 27, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Immediate jeopardy · J August 17, 2024 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected August 27, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E August 17, 2024 · found via complaint
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Corrected August 27, 2024 · Quality of Life and Care
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Potential for harm · E June 17, 2024 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected June 27, 2024 · Pharmacy Service
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Potential for harm · D December 21, 2023
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected January 18, 2024 · Resident Rights
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Potential for harm · D December 21, 2023
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected January 18, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D December 21, 2023
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected January 18, 2024 · Resident Assessment and Care Planning
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Potential for harm · E December 21, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected January 18, 2024 · Quality of Life and Care
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Potential for harm · E December 21, 2023
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected January 18, 2024 · Nursing and Physician Services
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Potential for harm · D December 21, 2023
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected January 18, 2024 · Pharmacy Service
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Potential for harm · E December 21, 2023
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected January 18, 2024 · Nutrition and Dietary
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Potential for harm · D December 21, 2023 · found via complaint
Ensure each resident receives an accurate assessment.
Corrected January 18, 2024 · Resident Assessment and Care Planning
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| August 17, 2024 | Fine | $99,103 |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 165207 · certified since April 1, 1994. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.