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 Maquoketa Care Center during CMS and state inspections, most recent first.
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 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.
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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 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 | — | 0 | 0 |
| Mill Valley Care Center | 17.8 mi | — | 0 | 0 |
| Fieldstone Of Dewitt | 18 mi | — | 0 | 0 |
| Wheatland Manor | 18.3 mi | — | 2 | 0 |
| Clarence Nursing Home | 23.5 mi | — | 0 | 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.