Report
TheVardellReport
Good Samaritan - Holstein
Skilled nursing facility and nursing facility
505 West Second Street
Holstein, IA 51025
Report
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The Vardell Report.Good Samaritan - Holstein
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
- Provider Category
- Nursing home
- Location
- Holstein, IA
- Record Period
- 2023–2026
- Source Documents
- 8
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Summary
Across 6 inspections from December 2023 to April 2026, state surveyors documented 24 findings at Good Samaritan - Holstein; 24 have a recorded correction; CMS lists 1 enforcement action in the window.
- Inspections
- 6
- 2023–2026, standard and complaint
- Findings
- 24
- Deficiencies cited by state inspectors
- Corrected
- 24
- Of 24 findings, with a recorded correction date
- Penalties
- 1
- 1 fine; payment not published
Findings by Year
- Findings
- Of which, actual harm (level G or above)
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2023 | 1 | 8 | 0 |
| 2024 | 2 | 4 | 2 |
| 2025 | 2 | 7 | 0 |
| 2026 | 1 | 5 | 0 |
What the Record Shows
- 24 of 24 findings have a recorded correction date.
- CMS lists 1 enforcement action in the window: 1 fine of $99,103, its payment not published.
- 4 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- The latest standard inspection, April 9, 2026, recorded 5 findings (most serious: Level E).
Report at a Glance
- Facility
- Good Samaritan - Holstein
- Address
- 505 West Second Street, Holstein, IA 51025
- CMS Certification Number
- 165207
- Provider Type
- Skilled nursing facility and nursing facility
- Certified Beds
- 60
- Ownership
- Non profit - Other
- Record Window
- December 21, 2023 to October 1, 2026
Chronology
Inspection History
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- 2026
Standard health inspection
5 findings
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Apr 30, 2026
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Apr 30, 2026
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Apr 30, 2026
- F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Level DNo actual harm, potential for moreCorrected Apr 30, 2026
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Apr 30, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
1 finding
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Jun 15, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Standard health inspection
6 findings
- F578Honor 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.Level DNo actual harm, potential for moreCorrected Apr 12, 2025
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Apr 12, 2025
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Apr 12, 2025
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Apr 12, 2025
- F758Implement 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.Level DNo actual harm, potential for moreCorrected Apr 12, 2025
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Apr 12, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
3 findings
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level JImmediate jeopardyCorrected Aug 27, 2024
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level JImmediate jeopardyCorrected Aug 27, 2024
- F741Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.Level ENo actual harm, potential for moreCorrected Aug 27, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
1 finding
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected Jun 27, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Standard health inspection
8 findings
The same visit included a complaint investigation.
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level ENo actual harm, potential for moreCorrected Jan 18, 2024
- F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Level ENo actual harm, potential for moreCorrected Jan 18, 2024
- F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.Level ENo actual harm, potential for moreCorrected Jan 18, 2024
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Jan 18, 2024
- F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Level DNo actual harm, potential for moreCorrected Jan 18, 2024
- F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Jan 18, 2024
- F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Jan 18, 2024
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Jan 18, 2024
Enforcement Action
Civil money penalty, $99,103 imposed August 17, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of December 21, 2023, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
Patterns Worth Examining
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
- 1
Citation F604, Cited in Two Inspections
Inspectors cited F604 in December 2023 and April 2026. The agency describes it this way: Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232424252526F604 across all 6 inspections, oldest to newest - 2
Accident Hazards and Supervision, Cited in Two Inspections
Inspectors cited F689 in December 2023 and March 2025. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232424252526F689 across all 6 inspections, oldest to newest - 3
Pharmacy Services, Cited in Two Inspections
Inspectors cited F755 in December 2023 and June 2024. This citation covers pharmacy services and the licensed pharmacist who oversees them. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232424252526F755 across all 6 inspections, oldest to newest - 4
Infection Control, Cited in Two Inspections
Inspectors cited F880 in March 2025 and April 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232424252526F880 across all 6 inspections, oldest to newest
For Your Next Visit
Questions to Ask on Your Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
- 01
What changed after F604 was cited, and how do you check it now?
Citation F604: cited in two inspections, most seriously at level D.
- 02
What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?
Accident Hazards and Supervision: cited in two inspections, most seriously at level E.
- 03
How often does the consultant pharmacist review each resident’s medications?
Pharmacy Services: cited in two inspections, most seriously at level E.
- 04
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in two inspections, most seriously at level D.
- 05
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.
- 06
What led to the 2024 fine, and has it been paid?
A $99,103 civil money penalty was imposed August 17, 2024. CMS publishes the fine, not whether it has been paid.
The Evidence
Sources and Coverage
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Iowa state survey agency.
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Iowa state survey agency
Inspection Dec 21, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Iowa state survey agency
Inspection Jun 17, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Iowa state survey agency
Inspection Aug 17, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Iowa state survey agency
Inspection Mar 20, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Iowa state survey agency
Inspection Jun 2, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Iowa state survey agency
Inspection Apr 9, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Penalties, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Provider Information, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services · 165207
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Coverage
Record windowDecember 21, 2023 – October 1, 2026
- CMS publishes about three inspection cycles; inspections before December 2023 are not in this release.
- CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.
What This Report Cannot Tell You
- Complaints not investigated onsite
- Allegations screened out by the state before an onsite visit are not published.
- Complaint allegations
- CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
- Facility-reported incidents
- Self-reported incidents appear only if they led to an inspection.
- Follow-up visits
- CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
- Fire safety inspections
- Published by CMS separately and not included in this record yet.
- Staffing levels and ownership history
- Published by CMS separately and not included in this record.
- Whether fines were paid
- CMS publishes the fines imposed, not whether or when they were paid.
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.