Good Samaritan Villisca: Physician Order Failures - IA
That was the finding from a complaint inspection conducted September 3, 2025, at Good Samaritan in Villisca, Iowa, a small town in the southwest corner of the state.
Compression stockings are prescribed to manage circulation problems, reduce swelling, and lower the risk of blood clots. When they don't fit, they don't work. When nobody calls the prescribing provider, the problem stays unfixed.
The resident at the center of the complaint, identified in inspection records as Resident 2, had supposedly ordered his own compression stockings. When the stockings arrived, they didn't fit. According to inspection records, staff did not contact the primary care provider or the clinic that had prescribed them to address the problem.
A licensed practical nurse identified in the report as Staff D told inspectors during an interview on September 2, 2025, that she would expect staff to follow up with the provider if supplies had come in and were not working. She said that clearly. She said it as though it were obvious. It apparently hadn't happened.
The Director of Nursing was equally direct. In an interview the same afternoon at 4:15 PM, she told inspectors that orders should be followed as written, and that if a resident was not wearing compression stockings or did not have stockings that fit, the facility should have followed up with the physician who ordered them.
The Director of Nursing was describing the standard her own facility had failed to meet.
The facility's internal policy on physician and practitioner orders, revised as recently as April 6, 2025, stated that such orders are "a critical component to providing quality care to residents" and that "accurate processing of physician/practitioner orders is important." The policy went further, emphasizing that teamwork and communication between nursing services and health information management are essential to processing orders in a timely and accurate manner.
The policy was five months old when inspectors arrived. Resident 2's stockings still didn't fit.
What the inspection report does not contain is any indication of how long Resident 2 went without properly fitting compression stockings, what condition the stockings were prescribed to treat, or what, if any, physical consequences followed from the gap in care. The record shows a problem was identified and not corrected. It does not say for how long.
The deficiency was classified as causing minimal harm or potential for actual harm, and inspectors noted that few residents were affected. That classification sits at the lower end of the federal harm scale, but it does not mean nothing happened. It means inspectors determined that whatever happened, or could have happened, to Resident 2 did not rise to the level of serious injury as defined under federal inspection standards.
What it does reflect is a breakdown that both the staff nurse and the Director of Nursing described in their own words as something that should not have occurred. Neither interviewed staff member disputed what the standard was. Both confirmed it. Neither could explain why it hadn't been followed.
The facility's own policy language about teamwork and communication between departments reads differently once you know that a resident was left with stockings that didn't fit and no one made a call.
Resident 2 is still there.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Good Samaritan - Villisca from 2025-09-03 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Good Samaritan - Villisca in Villisca, IA was cited for violations during a health inspection on September 3, 2025.
Compression stockings are prescribed to manage circulation problems, reduce swelling, and lower the risk of blood clots.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.