Good Samaritan Algona: Wound Care Harm Violations - IA
The inspection, completed in October 2025, centered on a single licensed practical nurse identified in records as Staff B and a resident identified as Resident 2.
Resident 2 complained that her compression hose was bothering her left ankle. Staff B's response was to apply a Mepilex dressing to the area and put the compression hose back on. Resident 2 said it felt better. Staff B told inspectors the ankle bone was slightly red but not open, and that she had no concerns about cellulitis at the time.
She did not call the physician. She did not get an order. She did not write any of it down.
When inspectors asked Staff B whether a Mepilex dressing was something a nurse could apply without a doctor's order, she said no. When asked whether she should have documented it, she said more than likely. She told inspectors she applied the dressing late in the day, passed the information along to the night nurse verbally, and moved on.
"She said she should have padded the area with something different or notified the physician to obtain an order," the inspection report states. "She said she could have left the compression hose off since it was later in the day."
None of those things happened.
What happened instead is that the ankle went without a proper treatment order, without a clinical record entry, and without any documented follow-up plan. The night nurse received a verbal handoff and nothing more.
Several days later, on October 7, a wound nurse issued recommendations and a fax was sent to the clinic seeking a physician response. Staff B was working that day. She knew the fax had gone out.
She never checked whether it came back.
Staff B told inspectors that the facility's practice was to give the clinic a day or two to respond before following up. She said faxes waiting for responses were kept on a nurses' clipboard, and once a response came in, the fax was removed. She said she did not know whether the fax from October 7 was still on the clipboard or not. She said she was not the one who had sent it, and left it at that.
She did not call the clinic. She did not confirm a response had been received. She did not verify that the wound care recommendations from the wound nurse had been acted on by a physician.
The inspection report does not describe the eventual outcome for Resident 2's ankle in clinical detail, but the violation was cited at the level of actual harm.
The pattern inspectors documented is a straightforward one: a nurse recognized something was wrong, improvised a response that required physician authorization, skipped the authorization, skipped the documentation, told one colleague verbally, and considered the matter handled. Days later, when a formal clinical process was underway to get physician guidance on the same wound, she was present, aware, and still did not follow through.
"She said she did not call or follow up with the clinic regarding the fax," the report states. "She said the faxes that go out are put on the nurses' clipboard while waiting for a response."
Whether the fax ever came back, and whether a physician ever weighed in on Resident 2's ankle before the wound progressed, the inspection report does not say. What it does say is that the nurse responsible for that follow-up, on the day the fax was sent and the days after, took no steps to find out.
Resident 2's compression hose went back on over a dressing applied without authorization. Her ankle, slightly red and not yet open, was left to whatever came next.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Good Samaritan - Algona from 2025-10-22 including all violations, facility responses, and corrective action plans.
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 7, 2026 · Our methodology
Good Samaritan - Algona in Algona, IA was cited for violations during a health inspection on October 22, 2025.
Resident 2 complained that her compression hose was bothering her left ankle.
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.