Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Samaritan - Waukon during CMS and state inspections, most recent first.
Dishwasher sanitation testing and documentation were inconsistent. Staff used different methods, including a digital thermometer, orange test strips, and the dishwasher display, but were unsure which method was correct and did not consistently document the checks. The NFSS reported there were no training records for the new dishwasher or for use of the digital thermometer, and the temperature log did not show whether sanitation testing had been completed.
Bare hands contacted food during meal prep and service, and cold foods were not held at the required temperature. A staff member opened buns and handled cookies with bare hands while preparing pureed food for one resident, and later a supervisor bagged cookies while touching them with a gloved hand. Salsa and sour cream were placed over ice, but temperatures rose during meal service, and a staff member’s thumb contacted lettuce while plating taco salads for two residents.
A resident with severe cognitive impairment, PTSD, major depression, anxiety, and a history of trauma had ongoing behavioral and psychotropic medication issues documented in the record, but the facility did not submit a new PASRR assessment. Staff acknowledged the active PTSD diagnosis, while Social Services and the Administrator described uncertainty about when an updated PASRR was required despite policy language calling for notification of the state authority when a resident with MD or ID has a significant change in status.
Failure to complete a Baseline Care Plan for a resident with severe cognitive impairment, dementia, anxiety, depression, and total ADL dependence. The MDS Coordinator confirmed the plan should have been completed within 48 hours of admission, while the DON said there was a breakdown in communication because the MDS Coordinator covered two facilities. Record review showed only limited care plan items were entered, including bed rails, skin impairment related to incontinence without interventions, pain, and ADLs.
Failure to include psychotropic meds in a resident’s comprehensive care plan. A resident with MDS-triggered CAAs for cognitive loss/dementia, urinary incontinence, psychosocial well-being, activities, falls, nutritional status, pressure ulcers, and psychotropic drugs was receiving an antipsychotic, an antianxiety med, and an antidepressant, and was also receiving PT. Review of the care plan showed no psychotropic med monitoring or side effects documented, and the MDS Coordinator stated the antianxiety and antidepressant care plans were completed later, citing human error.
A resident with dementia, a history of UTIs, and BPH developed UTI symptoms, including malodorous urine and increased weakness, and was started on Cipro for the infection. The MDS Coordinator stated that a new antibiotic and a UTI required a care plan revision, but the care plan did not include the UTI diagnosis or the antibiotic treatment.
A resident with dementia, a history of UTIs, BPH, weakness, and urinary incontinence showed foul-smelling, dark urine and increased weakness, but the facility did not complete timely assessment and monitoring or obtain the ordered UA promptly. The physician ordered a UA with C&S, yet the urine sample was not collected until later by straight cath, and the record lacked ongoing vital signs and assessments during the suspected UTI episode; the lab later showed significant bacterial growth and the PA-C ordered Cipro.
Failure to provide ordered restorative programs for two residents. One resident with severe cognitive impairment, traumatic brain injury, and mobility limitations had three restorative programs on the care plan, but records showed many missing entries and only limited completion of the programs. Another resident with severe cognitive impairment, no ambulation, and transfer dependence had two restorative programs ordered 3 times weekly, but documentation showed refusals, missing charting, and limited completion. A CNA/restorative aide reported both residents had gone months without restorative services during her absence, and the DON confirmed they should have received the programs as ordered.
A resident with dementia, blindness, and a history of exit-seeking was able to leave the facility unsupervised due to a malfunctioning electronic lock on a maintenance office door. The resident was missing for about 45 minutes before being found outside near a dumpster by a CNA, and was later assessed for injury. Staff interviews and documentation confirmed the resident's prior exit-seeking behavior and the failure of staff to ensure all exit doors were properly secured.
The facility did not ensure that all required members, including the DON, Medical Director, and IP, attended QAA committee meetings during the first quarter of 2025, as documented by meeting sign-in sheets and confirmed by the Administrator.
A resident's six completed MDS assessments were not submitted to CMS because the MDS Coordinator incorrectly marked the unit as neither Medicare nor Medicaid certified, despite the facility's dual certification. This error led to the assessments being completed but not transmitted as required, as confirmed by staff interviews and review of the facility's records.
A resident with severe cognitive impairment and multiple respiratory diagnoses experienced repeated low oxygen saturation levels that were not consistently rechecked or addressed according to physician orders. The care plan lacked interventions for oxygen therapy, and facility policies did not provide clear direction for managing out-of-range SpO2 readings, resulting in inadequate respiratory care.
Two residents receiving high-risk medications, including antipsychotics, antidepressants, diuretics, and opioids, did not have care plans specifying side effects to be monitored. One resident's care plan omitted all required monitoring for multiple medications, while another's care plan failed to address all prescribed diuretics and lacked interventions for monitoring adverse effects. Staff confirmed these omissions and facility policy required such monitoring.
Two residents' dignity was compromised when a CNA and an LPN engaged in inappropriate conversations about other staff and residents while providing care in a resident's room. The conversation was overheard by a resident's daughter, violating the facility's policy on maintaining resident dignity and respect.
A resident with severe cognitive impairment and an indwelling catheter was at risk of UTI due to improper catheter care. Observations showed the urinary drainage bag in contact with the floor, contrary to facility policy. Staff interviews revealed inconsistent use of dignity bags and uncertainty about proper procedures, highlighting a deficiency in catheter care management.
The facility failed to complete the SCSA MDS within the required timeframe for two residents admitted to hospice care. One resident's assessment was completed more than 14 days after the significant change determination, while another's was completed 19 days after hospice admission. The MDS Coordinator acknowledged the delay, and the DON was unaware of the requirements, leading to the deficiency.
Dishwasher sanitation testing and documentation were not performed consistently
Penalty
Summary
The facility failed to ensure staff were competent in procedures to test and document the hot water sanitation of the dishwasher. The facility had a new high temperature dishwasher installed, and the dishwasher placard required a wash temperature of 150 degrees Fahrenheit and a final rinse temperature of 180 degrees Fahrenheit. During observation, staff used a quat bucket test strip at first, then a digital thermometer placed on a dishrack inside the dishwasher, and later a different orange test strip. The digital thermometer readings during two additional cycles showed a maximum final temperature of 170.6 degrees Fahrenheit, which did not reach the required 180 degrees Fahrenheit, while the orange strip later turned orange to indicate 180 degrees Fahrenheit. Staff interviews showed confusion about how the dishwasher sanitation was supposed to be checked and documented. One staff member reported she had only recorded the temperatures shown on the dishwasher display and had never used the digital thermometer or orange test strips on the current dishwasher. Another staff member stated she had been using the digital thermometer daily but did not realize the testing needed to be documented. The Nutrition and Food Services Supervisor reported she used the digital thermometer daily, did not know the staff needed to document the testing, and did not have training records showing staff had been trained on the new dishwasher or on how to use the digital thermometer. She also stated there was no specific frequency for checking calibration of the digital thermometer. Review of the April 2026 Dish Machine Temperature Log showed staff were directed to document wash and final rinse temperatures morning, noon, and evening, but the log did not include direction or documentation showing that a digital thermometer check or sanitation test strip check had been completed. Vendor service reports documented wash and rinse temperatures on the dishwasher display, but did not document whether a digital thermometer had been used to verify sanitation. The dishwasher instruction manual required a hot water rinse temperature of 180 degrees Fahrenheit, and the facility policy directed staff to record the results of all completed tests on the appropriate form.
Bare Hand Contact With Food and Improper Cold Food Holding
Penalty
Summary
The facility failed to prevent bare hands from contacting food during food preparation. During lunch meal service, Staff D opened a plastic package of buns with bare hands and removed buns from the bag to place into a blender while preparing a pureed taco burger for Resident #10. Later, Staff D moved a dirty blender, measuring cup, and spatula aside, wiped her hands on her uniform, and used a spatula to scrape cookies from a baking sheet while her left hand contacted the cookies before placing them into a blender to puree for the same resident. The pureed taco burger and cookie were then served to Resident #10. The facility also failed to keep cold foods at the required temperature during meal service. The Nutrition and Food Service Supervisor placed cookies into plastic bags using a gloved hand, and Staff D placed salsa and sour cream in pans over ice on the steam table. Pre-meal temperatures showed the salsa at 40.4 degrees Fahrenheit and the sour cream at 42.4 degrees Fahrenheit. Meal service began at 12:00 PM and ended at 1:15 PM, and post-meal temperatures showed the salsa at 61.7 degrees Fahrenheit and the sour cream at 63.1 degrees Fahrenheit. During service, Staff D plated taco salads and her left thumb contacted the lettuce before the salads were served to two residents.
Failure to Submit Updated PASRR for Resident With PTSD and Major Depression
Penalty
Summary
The facility failed to submit a new Preadmission Screening and Resident Review (PASRR) assessment for one resident with a history of mental health diagnoses and behavioral concerns. The resident’s MDS showed a BIMS score of 00, indicating severe cognitive impairment, and listed anxiety disorder, depression, and PTSD. The resident’s EHR also showed active diagnoses of PTSD and major depressive disorder, and the care plan identified psychosocial well-being deficits related to childhood trauma and PTSD. Behavioral health documentation noted a history of physical and emotional abuse and neglect, along with current psychotropic medications including sertraline, duloxetine, and Xanax for anxiety, mood, chronic pain, and anxiety disorder. The resident’s record also included mood and behavior notes documenting refusal of medications and treatments, repeated medication refusal, and yelling out while demanding to know where everyone was. Staff interviews confirmed the resident had an active PTSD diagnosis, and Social Services stated they were responsible for submitting PASRR updates but believed PTSD did not always require an updated PASRR. The Administrator stated Social Services was responsible for PASRR updates and later said an update might not be needed unless there was a significant behavior change, describing the issue as a gray area. The facility policy stated that if a resident is diagnosed with a mental disorder while in the facility, Social Services or the designated individual will contact the state agency for a Level II screening, and that the state-designated authority will be notified promptly when a resident with MD or ID experiences a significant change in status.
Failure to Complete Baseline Care Plan After Admission
Penalty
Summary
The facility failed to implement a Baseline Care Plan for Resident #21 within 48 hours of admission. Resident #21 had an MDS assessment showing a BIMS score of 0 out of 15, indicating severely impaired cognition, and diagnoses of dementia, anxiety, and depression. The resident required staff assistance for all ADLs and used a walker and wheelchair for mobility. The MDS Coordinator confirmed the Baseline Care Plan should have been completed within 48 hours of admission, and the DON stated there was a breakdown in communication about who was responsible for completing it because the MDS Coordinator covered two facilities. Review of the record showed that from 4/1/26 through 4/5/26, the only care plan information entered addressed bed rails, skin impairment related to incontinence without interventions, pain, and ADLs.
Failure to Include Psychotropic Medications in the Care Plan
Penalty
Summary
The facility failed to implement a Comprehensive Care Plan for Resident #21 to include psychotropic medications. Resident #21’s MDS assessment triggered CAAs for cognitive loss/dementia, urinary incontinence, psychosocial well-being, activities, falls, nutritional status, pressure ulcers, and psychotropic drugs. The resident was receiving an antipsychotic, an antianxiety medication, and an antidepressant, and was also working with physical therapy. A review of the Comprehensive Care Plan on 4/28/26 showed that it did not include psychotropic medication monitoring or side effects. During an interview on 4/30/26, the MDS Coordinator stated that a Comprehensive Care Plan should include medications, ADLs, diagnoses, skin integrity, treatments, falls, infections, and triggered items from the MDS, and stated that the antianxiety and antidepressant medication care plans were completed on 4/29/26, attributing the delay to human error.
Failure to Revise Care Plan After UTI and Antibiotic Start
Penalty
Summary
The facility failed to revise Resident #16’s care plan after the resident developed urinary tract infection (UTI) symptoms and was started on antibiotic treatment. Resident #16 had a BIMS score of 12 out of 15, indicating moderately impaired cognition, and diagnoses included dementia, personal history of UTIs, and benign prostatic hyperplasia. A physician was notified of malodorous urine and increased weakness and ordered a urinalysis with C&S. Later, the PA-C ordered Ciprofloxacin 500 mg twice daily for 7 days to treat the UTI. During interview, the MDS Coordinator stated that a new antibiotic and a UTI required a revision to the care plan, but the care plan review did not include the UTI diagnosis or the antibiotic treatment.
Failure to Assess and Timely Obtain UA for Suspected UTI
Penalty
Summary
The facility failed to assess and intervene for a resident with signs of a suspected urinary tract infection and did not obtain a urinalysis in a timely manner after the provider ordered it. The resident had dementia, a history of UTIs, benign prostatic hyperplasia with lower urinary tract symptoms, weakness, substantial to maximal assistance needs for toileting and transfers, and was always incontinent of urine. A CNA noted foul-smelling urine during toileting care, and an LPN assessed the urine as dark and malodorous while also observing increased weakness during transfers and bowel and urinary incontinence. The physician was notified by fax and ordered a urinalysis with C&S due to increased weakness, with permission for straight catheterization if needed. A urine sample was not collected until two days later by straight catheter, and the sample was then taken to the hospital laboratory. The record lacked documentation of vital signs and other assessments from the time the symptoms were identified through the period before the urine testing was obtained, except for one set of vital signs on 4/22/26. The lab later showed multiple abnormal values and greater than 100,000 colony-forming units of two different bacteria, after which the PA-C prescribed ciprofloxacin for UTI. Interviews with staff and leadership confirmed that the expected change-of-condition and clinical monitoring assessments were not completed when the resident showed weakness and odorous urine.
Failure to Provide Ordered Restorative Programs
Penalty
Summary
Facility staff failed to provide restorative programs as frequently as ordered for 2 residents. Resident #28 had severe cognitive impairment with a BIMS score of 0, relied on staff for toileting, bathing, and transfers, and had diagnoses including traumatic brain injury and gait and mobility abnormalities. His care plan included three restorative programs related to his traumatic brain injury: hallway ambulation, pedaled bike riding for 15 minutes, and lifting a 4-pound weight with seated functional reaching. Documentation for February 2026 and April 2026 showed multiple days where documentation did not apply, numerous missing entries with no charting completed, and only one of his programs completed on a few days each month. His MDS also documented only one active ROM session of 15 minutes or greater in the past 7 days. Resident #4 also had severe cognitive impairment with a BIMS score of 0 and needed substantial to maximal assistance for transfers and moving from sitting to standing; she did not walk and had diagnoses including pain, atrial fibrillation, depression, and hypertension. Her care plan included two restorative programs to be completed 3 times a week. Documentation for February 2026 and April 2026 showed days where documentation did not apply, days she refused the programs, multiple missing charting entries, and only one restorative program completed on limited days each month. A CNA/restorative aide stated that both residents had declined since her return from leave and reported they had not received restorative services for months during her absence. The DON confirmed that both residents should have received their restorative programs as ordered.
Failure to Secure Exit Doors Leads to Resident Elopement
Penalty
Summary
Facility administrative staff failed to ensure that all locked exit doors were properly secured, resulting in a resident with impaired cognitive function, dementia, and blindness being able to exit the building without staff knowledge. The resident, who had a history of exit-seeking behavior and was identified as at risk for elopement and falls, was able to leave his room, navigate through several hallways and rooms, and ultimately exit the facility through the maintenance office door. The door's electronic lock was not functioning due to dead batteries, which allowed the resident to leave the premises undetected. The resident was missing for approximately 45 minutes before staff became aware of his absence. During this time, the resident was found outside on the facility grounds near the dumpster, lying on the cement sidewalk. The resident was fully clothed and was discovered by a CNA who was on break and heard the resident calling for help. Upon discovery, the resident was assessed and found to have bruising on his right flank. Documentation and staff interviews confirmed that the resident had previously demonstrated exit-seeking behavior, including attempts to leave the facility and statements expressing a desire to go home. The failure to maintain functional security on exit doors and to provide adequate supervision directly contributed to the resident's unsupervised exit and subsequent exposure to potential harm.
QAA Committee Lacked Required Members at Meetings
Penalty
Summary
The facility failed to maintain a Quality Assessment and Assurance (QAA) committee with the required members present at each meeting for the first quarter of 2025. Record review of QAPI committee meeting sign-in sheets showed that the Medical Director and Infection Preventionist (IP) were not in attendance at meetings held in January and February, and the Director of Nursing (DON) and IP were not present at the March meeting. The facility's QAPI plan specifies that the committee must include, at a minimum, the DON, Medical Director or designee, at least three other staff members (including at least one in a leadership role), and the IP. During an interview, the Administrator acknowledged difficulties in scheduling but expected all required staff to attend. The facility had a reported census of 51 residents at the time.
Failure to Submit Required MDS Assessments Due to Incorrect Unit Certification Entry
Penalty
Summary
The facility failed to submit six completed Minimum Data Set (MDS) assessments for one resident, despite being dually certified for Medicare and Medicaid for all beds. Review of the electronic health record and MDS detail listing showed that multiple assessments, including annual, quarterly, and admission assessments, were completed but not submitted to the Centers for Medicare and Medicaid Services (CMS). Staff interviews revealed that the MDS Coordinator incorrectly identified the unit as neither Medicare nor Medicaid certified in section A0410 of the MDS, which led to the system indicating that MDS data submission was not required. This error resulted in the assessments not being transmitted to the state or CMS as required. Further interviews with facility staff, including the Business Office Manager and Director of Nursing, confirmed that the facility is certified to participate in both Medicare and Medicaid programs and that the RAI manual is followed for MDS completion and submission. However, the MDS Coordinator acknowledged the mistake in the certification designation and confirmed that six of the seven required MDS assessments for the resident had not been submitted. The RAI manual specifies that all required MDS records for residents in Medicare- or Medicaid-certified beds must be submitted, regardless of payer source, which was not followed in this instance.
Failure to Monitor and Care Plan Oxygen Therapy for Resident with Respiratory Illness
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with a history of severe cognitive impairment, pneumonia, COPD with acute exacerbation, and other significant medical conditions. The resident had a physician order for oxygen therapy to maintain SpO2 above 90%, but multiple documented oxygen saturation readings fell below this threshold. Despite these low readings, there was inconsistent follow-up to recheck oxygen saturation levels to ensure they returned to or remained within the prescribed parameters. Documentation revealed that the resident frequently removed her nasal cannula, resulting in further drops in oxygen saturation. Staff notes indicated that the resident required frequent redirection to keep the oxygen in place, and her oxygen levels varied significantly, sometimes remaining below the ordered threshold for extended periods. Progress notes also described diminished lung sounds and episodes of shortness of breath, but there was a lack of consistent, timely reassessment of oxygen saturation after low readings. Additionally, review of the resident's care plan and baseline care plan showed that they did not include goals or interventions related to her oxygen therapy needs, despite her ongoing use of supplemental oxygen and her tendency to remove the device. The facility's policies provided no clear guidance on managing oxygen saturation levels or responding to out-of-range readings, contributing to the deficiency in respiratory care for this resident.
Failure to Care Plan and Monitor High-Risk Medication Side Effects
Penalty
Summary
The facility failed to ensure that the care plans for two residents receiving high-risk medications included monitoring for side effects as required. One resident was prescribed an antipsychotic, antidepressant, diuretic, and opioid pain medication, but their care plan did not specify the side effects to be monitored for any of these drugs. The MDS coordinator confirmed that these omissions were present and stated she was unaware that side effects needed to be included in the care plan. Facility policies directed staff to monitor for side effects of psychotropic medications and to maintain individualized, comprehensive care plans reflecting current care needs. Another resident with diagnoses including heart failure, hypertension, renal insufficiency, diabetes, and dementia was receiving multiple diuretics, including Metolazone and various doses of Torsemide. The care plan for this resident referenced monitoring for loop diuretic use but failed to mention Metolazone and did not list specific interventions to monitor for adverse effects associated with diuretic therapy. The MDS coordinator acknowledged these omissions during an interview.
Breach of Resident Dignity Due to Inappropriate Staff Conversations
Penalty
Summary
The facility failed to uphold the dignity and respect of two residents during an incident involving staff members. On the evening of 1/23/25, a Certified Nursing Assistant (CNA) and a Licensed Practical Nurse (LPN) engaged in inappropriate conversations about other staff members and residents while providing care in a resident's room. The CNA, along with another CNA, was involved in a transfer and care of a resident, during which they discussed frustrations related to work and other staff members. Unbeknownst to them, the daughter of one of the residents was present in the room, overhearing the conversation. The facility's policy on resident dignity, dated 12/11/24, emphasizes the importance of maintaining an environment that respects each resident's individuality and dignity. The policy specifically instructs staff to avoid discussing residents in settings where private information can be overheard. The Administrator acknowledged the inappropriateness of the staff's actions, expressing disappointment that such conversations occurred in a resident's room. The incident highlights a breach of the facility's policy and the residents' right to a dignified existence.
Inadequate Catheter Care Leading to Potential UTI Risk
Penalty
Summary
The facility failed to provide appropriate catheter care for a resident, leading to potential cross-contamination and risk of urinary tract infection (UTI). The resident, who has severe cognitive impairment and is dependent on staff for managing an indwelling urinary catheter, was observed with the catheter tubing and urinary drainage bag in direct contact with the floor on multiple occasions. The resident's care plan indicated a risk of infection and outlined specific interventions, including catheter care by CNAs and monitoring for signs of UTI. Observations revealed that the urinary drainage bag was not properly managed, as it was seen touching the floor and not covered with a dignity bag as required. Staff interviews confirmed that the urinary drainage bags should not touch the floor and should be covered, but there was a lack of adherence to these protocols. Staff members admitted to not using dignity bags consistently and were unsure of the facility's policy regarding barriers for low beds. The facility's policy on catheter care, revised in February 2023, directed that catheter tubing should never touch the floor and that urinary drainage bags should be covered when visible. However, the policy lacked specific instructions for preventing contact with the floor, contributing to the deficiency. The Director of Nursing Services (DNS) acknowledged the expectation that dignity bags should be used to prevent contact with the floor, but there was a lack of clarity and enforcement of this practice among staff.
Failure to Timely Complete SCSA MDS for Hospice Residents
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required time frame for two residents who were admitted to hospice care. Resident #40 was admitted to hospice care on June 17, 2024, but the SCSA MDS was not completed until July 5, 2024, which was more than 14 days after the significant change determination date. The MDS Coordinator acknowledged the delay and admitted to not reporting the error to the facility. The Director of Nursing Services was unaware of the requirements for completing a SCSA MDS and deferred to the MDS Coordinator and facility policy. Resident #10 was admitted to hospice services on June 12, 2024, but the SCSA was not signed off as complete until July 1, 2024, which was 19 days after admission to hospice. The facility's policy and the LTC RAI 3.0 User's Manual require that the SCSA MDS be completed no later than 14 days after the determination of a significant change in the resident's status. The failure to adhere to these timelines resulted in the deficiency noted in the report.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Waukon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Northgate Care Center | 0.8 mi | ★★★★★ | 18 | 1 |
| Thornton Manor Nursing And Care Center | 13.6 mi | ★★★★★ | 0 | 0 |
| Wellington Place | 13.7 mi | ★★★★★ | 0 | 0 |
| The Highlands | 16.3 mi | ★★★★★ | 2 | 0 |
| Ossian Care Center | 17 mi | ★★★★★ | 15 | 0 |
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