Good Samaritan Villisca: Doctor Order Violations - IA
Federal inspectors found the facility violated care standards by failing to follow physician orders and not communicating with providers when prescribed treatments couldn't be implemented.
The case involved Resident #2, described by staff as "very particular with his treatments." When a physician ordered compression stockings for the resident's medical condition, the man chose to order the equipment himself rather than rely on facility procurement.
Staff C, interviewed by inspectors on September 2, explained that Resident #2 "did get some stockings in but they were the wrong size, and sent them back." Despite knowing the physician-ordered treatment wasn't being provided, nobody contacted the prescribing doctor.
The staff member acknowledged the obvious gap: "She would expect someone to follow up with the physician who ordered the stockings to be notified that they were not being worn."
Staff D, a Licensed Practical Nurse, confirmed the sequence of events during her interview. She told inspectors that Resident #2 "supposedly ordered his own compression stockings, and when they came in they did not fit."
Like her colleague, the LPN understood the facility's responsibility. She said she "would expect that with a physician's order staff would follow up with the provider whether that be the primary care provider or the clinic that prescribed them if the supplies had not come in."
The Director of Nursing made the facility's policy clear during her interview with inspectors. "Orders should be followed as written," she stated, "and if the facility or resident was not wearing or did not have compression stockings that the facility should have followed up with the physician who ordered them."
The facility's own written policy supported this expectation. A document titled "Physician/Practitioner Orders" with a revision date of April 6, 2025, stated that such orders "are a critical component to providing quality care to residents."
The policy emphasized that "accurate processing of physician/practitioner orders is important" and outlined shared responsibilities between nursing services and health information management departments for "processing physician/practitioner orders in a timely and accurate manner."
The document stressed that "teamwork and communication between the two departments is essential."
Yet none of this communication happened in Resident #2's case.
The breakdown occurred at multiple levels. While the resident took initiative to order his own medical equipment, the facility knew the physician's order remained unfulfilled when the stockings didn't fit. Staff members at different levels understood their responsibility to notify the prescribing physician, but nobody acted.
The violation represents a fundamental failure in care coordination. Compression stockings are typically prescribed for serious medical conditions including blood clots, circulation problems, or swelling that can lead to complications if left untreated.
When medical equipment doesn't work as intended, the prescribing physician needs to know immediately. The doctor might need to adjust the prescription, recommend alternative treatments, or monitor the patient more closely for complications.
In this case, the physician remained unaware that the prescribed treatment wasn't happening. The resident sent back ill-fitting stockings, but the medical professional who determined the equipment was necessary never learned about the problem.
The inspection found the facility failed to ensure physician orders were properly implemented and failed to maintain necessary communication with healthcare providers. Staff knew what should happen, facility policy required it, but the system broke down when it mattered.
Federal inspectors classified the violation as having "minimal harm or potential for actual harm" affecting "few" residents. However, the case illustrates how seemingly minor administrative failures can compromise medical care.
Resident #2's particular nature about his treatments may have contributed to the situation, but it didn't excuse the facility's responsibility to ensure physician orders were followed or providers were notified when treatments couldn't be completed as prescribed.
The facility's policy revision from April 2025 suggests recent attention to physician order processing, yet the September inspection found the same fundamental problems the policy was designed to prevent.
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.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Good Samaritan - Villisca in Villisca, IA was cited for violations during a health inspection on September 3, 2025.
The breakdown occurred at multiple levels.
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.