Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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.
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 | — | 13 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.