Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Maquoketa Care Center during CMS and state inspections, most recent first.
Failure to Maintain Separation Between Residents With Known Aggression: A resident with a known hx of resident-to-resident physical aggression struck another resident in the head with a cane in the dining room, causing a bump, laceration, and bruising. The assaulted resident was non-ambulatory, dependent on staff for transfers, and had dementia, while the aggressive resident had intact cognition, used a cane, and had a care plan for prior physical altercations. Staff placed the residents in the same area with limited supervision, and the aggressive resident stated the other resident deserved it and that he would hit him again.
Infection control failures occurred during wound care, EBP care, and med passes. An RN failed to wear a gown during feeding tube care for a resident on EBP, another RN failed to perform hand hygiene between glove changes during wound care for a resident with venous stasis ulcers, and a nurse handling wound supplies placed a pen and measuring tape on the floor and used contaminated gloves during treatment. During two med passes, staff dropped oral tablets onto the med cart and picked them up with bare hands before administering them to residents.
A resident with intact cognition and diagnoses including anxiety, depression, and pain was not allowed to choose her own bedtime even though her MDS said this was very important to her. Her care plan and Kardex did not include her bedtime preference, and she reported being delayed by late meds or staff availability, sometimes not getting to bed until 12:30 AM. The DON and an RN confirmed the resident had received meds and assistance to bed later than she wanted, despite the facility’s rights policy supporting self-determination.
A quarterly MDS assessment for a resident was completed but not submitted within the required timeframe. The DON deferred questions about submission timing to the MDS Coordinator, who said the timeline depended on the assessment type and later acknowledged the assessment was 40 days overdue and had been missed after a similar issue with another resident.
Delayed call light response times were documented for multiple residents with intact cognition, including one resident who reported waits of 45 minutes to 1 hour and another who was left waiting on a commode after staff did not return. Observation confirmed an active call light that remained unanswered for 16 minutes, and a third resident reported a 45-minute wait in the bathroom. The DON acknowledged ongoing long call light wait times, and resident council records noted calls taking 20 minutes or more to be answered.
A resident with anxiety, restless leg syndrome, and acute pain repeatedly received evening meds late, with scheduled 7:00 PM doses often not given until later in the evening and the resident reporting she sometimes stayed up until after midnight because of delayed meds and cares. In a separate event, an RN preparing Novolog for a resident with DM and dementia combined the insulin pen prime and dose into one step, setting the pen to 5 units instead of following the manufacturer’s separate priming and dosing instructions.
A resident struck another resident in the face with a cane handle several times in the dining room while the other resident sat in a Broda chair. Staff observed the assault, separated the residents, and the injured resident had a swollen eye and bruising under the eye. The striking resident had a hx of stroke, depression, and impaired cognition, while the other resident had dementia, impaired cognition, and required extensive assistance with ADLs and transfers.
Staff did not consistently assess or document a resident's oxygen saturation levels as required by a physician order for supplemental oxygen to maintain saturation above 88%. Despite the resident's diagnoses of COPD and respiratory failure, and care plan interventions, oxygen saturation checks were not recorded, and staff confirmed these assessments should have occurred every shift.
The facility failed to provide sufficient staffing, resulting in delayed responses to call lights and unmet resident needs. Residents reported waiting up to two hours for assistance, with staffing shortages evident from November to December 2024. The facility's policy required call lights to be answered within 15 minutes, but this standard was not consistently met, particularly during busy periods. Staff and administration acknowledged the issue, but staffing levels remained inadequate to meet resident needs.
A medication cart was found unlocked and unattended, with medications exposed and accessible. An RN admitted to leaving the cart unlocked, thinking it was secure. The DON expressed concern about the potential access to medications by residents. Facility policy requires all medication compartments to be locked when not in use.
The facility failed to maintain a sanitary shower room environment, with missing floor sections, stained tiles, and damaged vents. Residents and staff reported difficulties with shower chairs getting stuck and concerns about infection control. The administrator was aware of the damage, but repairs were not completed.
A resident with intact cognition and requiring assistance with bathing experienced privacy violations in a facility's shower room. The shower curtain was inadequate, and staff and other residents entered the room without permission during bathing. The DON and Administrator were unaware of these practices, which violated the facility's policy on residents' rights to dignity and privacy.
Failure to Maintain Separation Between Residents With Known History of Aggression
Penalty
Summary
The facility failed to protect a resident from resident-to-resident abuse when one resident struck another resident in the head with a cane in the main dining room. The assaulted resident was non-ambulatory, dependent on staff for bed-to-chair transfers, used a Broda wheelchair, and had diagnoses including non-Alzheimer’s dementia and depression. He had a BIMS score of 12 out of 15 and was documented as having potential verbally aggressive behaviors toward other residents related to dementia. After the assault, he was found with a 5 cm bump and a 1 cm laceration to the left forehead, along with facial bruising, and he stated he felt unsafe around the other resident. The resident who struck him had a BIMS score of 13 out of 15, walked with a cane, transferred independently, and had diagnoses including stroke and depression. His care plan identified a history of resident-to-resident physical aggression and directed staff to monitor for agitation, assist him to a quiet area, and maintain separation from the other resident. Despite that history, he independently approached the other resident in the dining room and struck him multiple times with the cane. During the interview, he stated the other resident deserved it and said he would hit him again if he saw him, indicating the assault was intentional and unprovoked. The investigation also documented a prior resident-to-resident altercation between the same two residents in which the aggressive resident had struck the other resident in the face with his cane several times, causing bruising to the eye and cheek. Staff statements showed the two residents were placed in the same dining area with limited supervision, and staff were occupied with other residents when the assault occurred. Several staff members stated they believed the aggressive resident was simply walking back to his room and did not realize he would attack the other resident. The facility’s investigation concluded that previously identified supervision and separation interventions were not consistently maintained, allowing the aggressive resident to reach and assault the other resident again.
Infection Control Failures During Wound Care, EBP, and Medication Administration
Penalty
Summary
The facility failed to maintain infection prevention and control practices during wound care, Enhanced Barrier Precautions (EBP), and medication administration. During observation of feeding tube care for one resident with intact cognition and a care plan requiring EBP, an RN performed hand hygiene and applied clean gloves but did not don a protective gown while providing feeding tube site treatment and a gauze dressing change, despite an EBP sign posted on the door. The RN later acknowledged she should have worn a gown and that the procedure was performed incorrectly. During wound care for another resident with intact cognition, multiple venous stasis ulcers, and EBP interventions in the care plan, an RN performed hand hygiene and donned a gown and gloves, but then failed to perform hand hygiene after removing contaminated gloves and before donning clean gloves during the same dressing change. The RN also failed to perform hand hygiene after removing gloves and before returning to the wound, and again after removing gloves following placement of an ABD pad. The DON stated staff were expected to perform hand hygiene between glove changes and during wound care, and that EBP applied to wound care, catheter care, and other direct contact care. A separate wound treatment observation for a resident with CAD, HTN, PVD, DM, stroke, an unhealed stage 3 pressure injury, and a diabetic foot ulcer showed the nurse placing measuring tape and a pen directly on the floor, picking up the pen from the floor with a gloved hand to write measurements, changing gloves without hand hygiene, and using the same dirty gloves to apply lotion to both lower legs and toes. The nurse also touched wound materials and the resident’s dressings with contaminated gloves while continuing treatment. The DON stated supplies should be on a clean barrier and dirty items should be contained separately. Medication administration observations showed two staff members dropped oral tablets onto the top of the medication cart and then picked them up with bare hands before giving them to residents. In one instance, a CMA dropped a Tramadol tablet onto the cart surface, retrieved it with her bare hand, placed it back into the medication cup, and administered it. In another instance, an RN knocked pills out of a medication cup during setup, picked up the pills from the cart surface with her bare hand, returned them to the cup, and administered them. Staff interviews confirmed the pills should have been discarded or handled with a glove or spoon, and the DON stated a pill that falls on the cart should be picked up with a glove or spoon.
Resident bedtime preference not honored
Penalty
Summary
The facility failed to respect a resident’s right to choose when to go to bed in the evening. Resident #28 had diagnoses including limitation of activities due to disability, anxiety and depression, and acute pain due to trauma, and her BIMS score was 15/15, indicating intact cognition. Her MDS documented that it was very important to her to choose her own bedtime, but her care plan and Kardex did not include her bedtime preference. The care plan also noted she needed assistance from one staff member for evening cares, toilet transfers, and getting in and out of bed because of weakness and balance deficits, and she was at risk for falls, injury, and skin breakdown. During interview, the resident stated she was not able to choose when to go to bed at night because her medications were sometimes late or she was waiting for staff, and she reported being taken to bed as late as 12:30 AM because she had to go around staff schedules. The DON confirmed the resident had reported receiving medications later than she wanted and stated that 11:30 PM or 12:00 AM was too late. An RN acknowledged medication administration occurred within a window of time and confirmed the resident had been given medications and assisted to bed later than she wanted. The facility’s Resident’s Rights policy stated that all residents have the right to a dignified existence and self-determination.
Late Submission of Quarterly MDS Assessment
Penalty
Summary
The facility failed to submit a quarterly MDS assessment within the required time frame for Resident #38. The resident’s quarterly assessment dated [DATE] was completed on 05/22/2026, but the record showed it was not marked as submitted and the MDS summary screen indicated the assessment had been marked as not required. During the annual recertification survey, staff interviews showed the DON did not know the submission timeline and deferred to the MDS Coordinator, Staff M, who stated the timeline depended on the type of assessment and that the system reported when it had to be submitted. The Administrator also deferred to Staff M, who later stated this was the same issue that happened with another resident, that she had caught the first one but missed this one, and that the assessment was 40 days overdue and needed to be corrected.
Delayed Call Light Response and Insufficient Nursing Coverage
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available to answer call lights in a timely manner for 3 of 3 residents reviewed for staffing concerns. The facility reported a census of 33 residents. A policy titled "Call Lights: Accessibility and Timely Response" stated all staff members who saw or heard an activated call light were responsible for responding, and the first step was to turn off the signal light in the resident's room, but the policy did not specify a required response time. Resident #5 had a BIMS score of 15/15, indicating intact cognition, and reported prolonged call light response times throughout his stay, often 45 minutes to one hour. He stated the delays were worse in the morning before breakfast when multiple residents needed help getting out of bed. On 6/30/26, he stated his call light had remained active and unanswered from 7:00 AM to 7:30 AM, and Staff A, CNA, later confirmed the call light had gone unanswered for an extended period because she was completing cares for other residents with higher acuity needs. Resident #24 had a BIMS score of 13/15, indicating intact cognition, and reported waiting 30 minutes for staff to answer his call light, including an episode where he was left on the commode and staff did not return as promised. Observation showed his call light active at 6:23 AM, and he stated no staff had entered his room by 6:36 AM; staff answered the call light at 6:39 AM, resulting in a 16-minute response time. Resident #28 had a BIMS score of 15/15 and required assistance with ADLs due to weakness and balance deficits. She reported waiting until as late as 12:30 AM to get to bed because she was waiting for staff, and described a bathroom call light remaining on for 45 minutes before she called the front desk for help. Resident council records also documented residents reporting call lights taking 20 minutes or more to be answered, and the DON acknowledged ongoing long call light wait times.
Late Medication Administration and Improper Insulin Pen Use
Penalty
Summary
The facility failed to ensure timely medication administration for one resident with diagnoses including restless leg syndrome, anxiety disorder, and acute pain due to trauma. The resident’s care plan directed staff to administer buspirone and lorazepam as ordered, but a resident council follow-up documented concern that medications were not being given until 10:00 PM on one occasion. The resident later stated she often did not get to bed on time because evening medications were given late, and she reported being up as late as 12:30 AM while medications and cares were completed. A medication administration audit showed several scheduled 7:00 PM medications, including Tylenol PM, lorazepam, and primidone, were repeatedly administered later in the evening on multiple dates, including times ranging from 8:23 PM to 9:39 PM. The DON confirmed the resident had verbalized that medications were often received later than desired and stated that 11:30 PM or 12:00 AM was too late for medications and treatments. The DON also stated late medication administration was technically a medication error and acknowledged that not all of the expected reporting and follow-up steps had been completed for all of the listed dates. The facility also failed to administer insulin in accordance with manufacturer instructions for another resident with diabetes mellitus and non-Alzheimer’s dementia. During observation, an RN prepared Novolog insulin by setting the pen to 5 units, stating that 2 units were for an air shot to prime the pen and 3 units were the ordered dose, and was stopped before administration. The RN then attempted to prime the pen by dialing 2 units and depressing the button, but no insulin was observed at the needle tip before she set the pen to 3 units and administered the insulin. The pharmacist stated nurses should prime the pen with 2 units and then set it to the ordered dose, and the DON confirmed staff were expected to perform priming and administration as separate steps and follow the manufacturer’s directions.
Resident-to-Resident Abuse in Dining Room
Penalty
Summary
The facility failed to protect a resident from resident-to-resident abuse when one resident struck another resident in the face with the handle of a cane several times in the dining room. The incident occurred while the second resident was seated in a reclined Broda wheelchair against the wall. Staff observed the first resident standing over the second resident and hitting him before staff intervened and took the cane away. The resident who struck the other resident had diagnoses including stroke, difficulty walking, and depression, and his care plan noted impaired cognitive function or impaired thought processes related to encephalopathy, a history of TIAs, and a recent CVA. The resident who was struck had moderately impaired cognitive skills, dementia, dependence on staff for transfers using a mechanical lift, wheelchair use for mobility, and required supervision with eating. He was also described in the care plan as needing assistance with ADLs and comfort-focused care. The facility investigation documented that the struck resident sustained a slightly swollen eye with bruising to the left cheek under the eye, measuring 3 cm by 2.5 cm. Statements obtained during the investigation showed the striking resident said the other resident had upset him and used insulting language, and the facility’s own policy stated that resident-to-resident incidents may constitute abuse and include hitting or other aggressive behaviors. The report also states the nursing home is disputing the citation.
Failure to Assess and Document Oxygen Saturation for Resident on Supplemental Oxygen
Penalty
Summary
Facility staff failed to properly assess and document a resident's oxygen saturation levels as required by physician orders. The resident, who had a history of chronic obstructive pulmonary disease and respiratory failure, had a physician order for supplemental oxygen to be administered via nasal cannula at 0.5-1 liter per minute to maintain oxygen saturation above 88 percent, as needed. However, review of the medication administration records for two months showed that while the oxygen order was present, there was no documentation of oxygen saturation checks. The care plan also directed staff to maintain oxygen saturation above 88 percent, but this intervention was not consistently monitored or recorded. Staff interviews confirmed that with such an order, oxygen saturation should be checked at least every shift to determine the need for oxygen. Both a registered nurse and the DON acknowledged that the resident's oxygen saturation should have been monitored every shift according to the order, but this was not done. Observations showed the resident had an oxygen concentrator in the room and was not in respiratory distress at the time, but the required assessments to guide oxygen administration were not performed or documented.
Staffing Shortages Lead to Delayed Resident Assistance
Penalty
Summary
The facility failed to employ sufficient numbers of staff to meet resident needs, as evidenced by the review of staff schedules and resident interviews. From November 2nd through December 7th, 2024, the facility was missing one Certified Nursing Aide (CNA) on 14 days and two CNAs on 3 days during the day shifts. This staffing shortage led to delays in answering call lights, with residents reporting waiting times of up to two hours for assistance. The Director of Nursing (DON) and the Administrator acknowledged the staffing issues, noting that the facility assessment and staffing plans were based on resident volume and acuity, but the actual staffing did not meet the required ratios. Residents reported significant delays in receiving assistance, which impacted their care and safety. An anonymous resident and Resident #1 both reported waiting over an hour for call lights to be answered, with Resident #1 experiencing a delay of over an hour during the night. This resident also had a non-functioning call light and had to use a cell phone to contact staff. Resident #3 reported waiting an hour on the toilet for assistance, highlighting the impact of staffing shortages on resident dignity and comfort. Staff interviews confirmed that call lights were often delayed, especially during meal times and other busy periods. The facility's policy required call lights to be answered within 15 minutes, but this standard was not consistently met. Staff acknowledged the challenges in meeting this requirement, particularly during peak times such as meal service. The DON and Administrator were aware of the complaints and conducted call light audits, but the staffing levels remained insufficient to meet the needs of the residents, as evidenced by the ongoing delays and resident dissatisfaction.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that all medications were securely locked in the medication cart as required by their policy. During an observation, a surveyor found the bottom drawer of a medication cart in the back hall open with medications exposed and accessible. No staff members were present near the cart or in the hallway at the time. A Registered Nurse (RN) admitted that she thought the cart was locked when she left to assist another staff member and did not realize it was open until she returned. The Director of Nursing expressed concern about the cart being open and the potential access it could have provided to other residents. The facility's policy, updated in February 2007, mandates that compartments containing drugs and biologicals must be locked when not in use, and carts should not be left unattended if open.
Inadequate Maintenance of Shower Room
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the shower room across from a specific room, as observed during a survey. The deficiencies included a missing section of the gray floor, holes with wet black substances, and a puddle of water near the drain covered with hair and fuzz. The shower tiles on the floor and wall were stained with orange and brown marks, and a bumpy substance was coming out from the surface of the tile. The corners of the stall had black and white spots, and a musty smell was present. There was a gap between the metal transition strip and the tile, with missing chunks of flooring stained with a wet black substance. Additionally, the vent around a ceiling light contained fuzzy fibers, broken slats, and was stained with an orange/brown color. Interviews with residents and staff revealed concerns about the condition of the shower room. A resident expressed feeling mostly safe but noted that the shower chairs often got stuck in the floor, making it difficult to move them. Another resident was concerned about infection control, stating that the room was dirty and the holes in the floor were not disinfected. Staff members confirmed the damage had been present for a long time and reported it to maintenance, but repairs were not completed. The administrator acknowledged awareness of the damage and was in communication with maintenance about finding matching tiles. The facility's maintenance log showed that the issue was noted but not repaired.
Privacy and Dignity Breach During Resident Bathing
Penalty
Summary
The facility failed to uphold the dignity and privacy of a resident during bathing, as observed and reported by the resident and staff. The resident, who had intact cognition and required assistance with bathing due to conditions such as spinal stenosis and stress incontinence, expressed concerns about privacy violations. The shower room used by the resident lacked effective privacy barriers, with a shower curtain that was tangled and unable to cover the stall adequately. Additionally, the room had a large opening that was not covered, allowing visibility into the shower area. The resident reported that staff and other residents entered the shower room without permission during her bathing, particularly to use the wheelchair scale located in the same room. Interviews with staff confirmed the inadequacy of the shower curtain and the practice of entering the shower room while it was in use. A CNA acknowledged that the curtain did not provide sufficient coverage and that staff sometimes entered the room to retrieve items, although she was unaware of residents being brought in for weighing. The Director of Nursing and the Administrator were not aware of these practices, which were contrary to the facility's policy on residents' rights to dignity and privacy. The facility's policy, dated October 2023, emphasized the residents' right to a dignified existence and personal privacy, which was not upheld in this instance.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 17 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Maquoketa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Jackson Ridge Healthcare Center | 0.4 mi | ★★★★★ | 2 | 0 |
| Mill Valley Care Center | 17.8 mi | ★★★★★ | 0 | 0 |
| Fieldstone Of Dewitt | 18 mi | ★★★★★ | 7 | 0 |
| Wheatland Manor | 18.3 mi | ★★★★★ | 2 | 0 |
| Clarence Nursing Home | 23.5 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Maquoketa Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.