State: Nursing home resident called 911 after being left ‘gasping for air’

An Iowa nursing home where a resident called 911 to receive medical attention while struggling to breathe could be facing fines of more than $27,000.

According to state inspectors, the Good Samaritan care facility in Red Oak failed to provide quality nursing care when it neglected to intervene when one of the home’s 34 residents showed signs of critically low oxygen levels and another resident was coughing up blood.

Inspectors allege that on April 15, 2026, a female resident of the home whose oxygen levels had been dropping called 911 for medical assistance. When paramedics arrived at the home, they inquired about the resident’s condition and one staff member allegedly responded, “She’s been like this all day.”

According to the inspectors’ written report, as the paramedics “approached the patient’s room, audible screams for help were heard.” The woman was lying in bed and exhibited signs of an altered mental status, with possible hallucinations.

Inspectors alleged the woman’s oxygen levels, when first measured by paramedics, was in ranged from the “high 60s to low 70s” — with anything below 80 generally considered to be life-threatening. The woman was taken by ambulance to a hospital emergency room to be assessed for possible pneumonia, was placed on high-flow oxygen, and then transferred to a larger hospital that was better equipped to handle her medical condition.

Inspectors allege the woman later reported that she had been “gasping for air” so much that she was hallucinating and seeing things, while adding that she had called 911 because the Good Samaritan staff had not been answering her call light.

The woman’s primary care physician allegedly told inspectors that oxygen levels in the 60s were “a very big concern” and under those circumstances, the nursing staff should have had the woman transferred to the emergency room.

Home cited for failure to adequately respond to resident with lung condition

Inspectors also faulted the Good Samaritan home for its alleged failure to adequately respond to a male resident who was coughing up blood on March 30 and March 31, 2026. The inspectors reported that caregivers in the home had noticed two paper cups on the man’s windowsill that appeared to be partially filled with blood the man was coughing up.

On April 2, 2026, the resident was admitted to an acute care hospital and diagnosed with hemoptysis – a potentially serious condition caused by bleeding in the lungs or the respiratory tract. According to the inspectors, doctors then discovered a blood clot that obstructed the man’s airway and caused active bleeding.

The man reportedly told inspectors he was never asked if he wanted to go to the hospital’s emergency room, and that he would have gone if that was presented as an option.

As a result of the state inspection, the Iowa Department of Inspections, Appeals and Licensing has cited the Good Samaritan home for violations related to medications and treatment; overall quality of care; unsafe or unsanitary food storage and preparation; the failure to maintain a safe, clean, homelike environment; the improper use of chemical restraints; inadequate respiratory care, and other issues.

State: No COVID-19 vaccines in 2025

According to the inspectors, none of the home’s 34 residents had been offered, or had received, the COVID-19 vaccine during 2025 – although the staff reportedly provided conflicting reasons for the situation.

The home’s infection preventionist, who is also a registered nurse, reportedly told the inspectors “COVID-19 vaccines were not given to residents at the facility at all unless the residents specifically requested the vaccine.” The home’s director of nursing allegedly told inspectors the home’s pharmacy “could not get the new vaccine” for COVID-19, while the home’s pharmacist allegedly told inspectors the vaccine was available to give residents once it was ordered.

Inspectors noted that the Centers for Disease Control and Prevention states that it is “especially important to get the 2025-26 COVID-19 vaccine for ages 65 and older” since that population is more at risk for “severe” forms of COVID-19.

The state inspections department has proposed a state fine of $27,750, but has held that fine in suspension while the Centers for Medicare & Medicaid Services decides whether a federal fine is warranted.

Currently, the Red Oak Good Samaritan home has a one-star rating for inspection results and overall quality on CMS’ five-star quality scale. CMS reports that in August 2025, it imposed a federal fine of $29,894 against the facility.

The administrator of the Red Oak home, Mike Early, who also serves as the administrator of the Good Samaritan home in Villisca, could not be reached at either of two facilities Wednesday.