Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
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 Northgate Care Center during CMS and state inspections, most recent first.
Two residents experienced deficiencies in care when staff failed to properly assess and intervene after a fall and during wound development. One resident with cognitive impairment and a history of falls was moved multiple times after a fall without a thorough assessment, and was also given medications intended for another resident. Another resident with multiple comorbidities had a blister that was not assessed for two weeks, leading to infection. Staff interviews and documentation confirmed failures to follow facility policies for assessment and reporting.
Staff failed to adhere to infection control protocols during direct care, including performing wound treatments without changing gloves between tasks, not sanitizing treatment supplies before returning them to storage, and conducting procedures in public areas without proper barriers. Supplies were handled and returned to carts without sanitization, and hand hygiene was not performed between resident contact and touching surfaces or oneself.
Two residents did not receive care in a manner that maintained their dignity and privacy when an LPN conducted a physical assessment and a dressing change in a public dining/lounge area, in view of others. The LPN was unaware of facility policies regarding privacy during treatments, despite having signed a job description emphasizing the importance of resident rights and dignity.
A resident was given medications intended for another individual, including Melatonin, Mirtazapine, Alprazolam, and Apixaban. The facility did not promptly notify the resident's family or representative of the medication error and condition change, as required by policy. The family only became aware of the incident after receiving information from the hospital, rather than from facility staff.
A resident with multiple diagnoses, including heart failure and a history of pressure ulcers, was readmitted with active skin issues that were documented but not fully assessed or addressed in the care plan. The care plan failed to include interventions for the resident's current skin conditions, despite facility policy requiring comprehensive assessment and care planning.
Two residents experienced significant delays in call light response, with one waiting over two hours and another reporting frequent extended waits. CNAs confirmed that staff shortages and management wage caps contributed to the inability to consistently meet the facility's 15-minute call light response policy.
Two residents were affected by significant medication errors when a CMA, distracted by interruptions, administered another resident's medications to the wrong individual, and another resident continued to receive an outdated Seroquel regimen due to a failure to update medication orders. These errors were identified through video review, clinical records, and staff interviews.
Staff failed to maintain accurate and complete medical records for two residents, including improper documentation of a fall assessment and a discrepancy in controlled substance records. An LPN documented an assessment that was not performed, as confirmed by video review and interviews, and a medication was recorded as destroyed but was actually administered to another resident.
A resident was mistakenly given another resident's medications, including Seroquel, due to a CMA's distraction from a personal call. This resulted in over-sedation and hypoglycemia, leading to the resident's hospital admission for observation.
The facility failed to maintain sanitary conditions during meal service. A cook was observed touching the drinking rim surfaces of glasses with bare hands and pushing a beverage cart without sanitizing it or performing hand hygiene. The facility lacked a policy on appropriate hand placement during food service, and further observations revealed multiple staff members handling milk jugs without performing hand hygiene.
Failure to Assess and Intervene After Falls and Wound Development
Penalty
Summary
Staff failed to properly assess and intervene for two residents, resulting in deficiencies in care. One resident with significant cognitive impairment, visual deficits, and a history of falls was observed via facility video to have fallen after tripping over her catheter tubing. Staff present did not immediately respond to the fall, and when they did, they moved the resident multiple times without performing a thorough assessment as required by facility policy. The resident complained of severe leg pain, but staff continued to move and ambulate her without using a gait belt or completing a full assessment, including vital signs and range of motion. The resident was later sent to the emergency department, where a femur fracture was diagnosed. Interviews confirmed that staff did not follow the facility's fall policy, which required a nurse to assess the resident on the floor before moving her, and that documentation of the incident was delayed and incomplete. Additionally, the same resident was administered medications intended for another resident, including Melatonin, Mirtazapine, Alprazolam, and Apixaban. The error was not fully reported to the emergency department, as only one of the four medications was disclosed. Staff interviews revealed confusion and lack of adherence to medication administration and error reporting protocols. The Director of Nursing confirmed that the nurse's assessment after the fall was not as thorough as expected and that vital signs were not taken as required. A second resident, with diagnoses including heart failure, diabetes, and dementia, was readmitted with a right trochanter blister. The facility failed to assess the blistered area for two weeks, with no measurements or detailed assessment documented during that period. When the wound was eventually assessed, it had worsened, showing signs of infection and requiring antibiotic treatment. The Director of Nursing confirmed that staff failed to assess the resident's wound as required.
Failure to Follow Infection Control Practices During Resident Care
Penalty
Summary
Staff failed to follow appropriate infection control practices during direct care for three residents. In one instance, an LPN washed and gloved her hands before removing a supportive boot and wound dressing, then performed physician-ordered treatment to multiple areas of a resident's foot using the same gloves. After completing the treatment, the staff member placed unused and/or prescribed treatment supplies into a plastic bag and returned it to the resident's supply basin without sanitizing the surfaces. The Director of Nursing confirmed these observations. Additionally, another staff member performed a dressing change for a resident in a public dining/lounge area without placing a barrier between the table and treatment supplies, and failed to sanitize the supplies before returning them to the treatment cart. This staff member also palpated another resident's hip with bare hands, then touched the resident, furnishings, and herself without washing her hands. The same staff member later confirmed she did not use a barrier or sanitize items as required.
Failure to Maintain Resident Dignity and Privacy During Care
Penalty
Summary
The facility failed to maintain the dignity and respect of two residents during care activities, as evidenced by direct observation, video footage review, clinical record review, and staff interviews. In one instance, a Licensed Practical Nurse (LPN) approached a resident seated in a recliner in the dining/lounge area, pulled out the resident's sweatpants at the waistband, and placed her hands inside to palpate the resident's left hip area following a fall. This examination was conducted in the presence of another resident seated approximately 12 feet away, in direct view. The video footage also showed the LPN pressing on the resident's hip, looking under the resident's pajama bottoms, and returning to palpate the area again after donning gloves, all in a public area. In another instance, the same LPN performed a dressing change on a different resident's foot while the resident's leg was resting on a chair in the dining/lounge area, directly across from the first resident. During an interview, the LPN confirmed that she performed the foot treatment in the dining area and was not aware of the facility's policy and procedure regarding treatments and privacy. The facility's policies, as acknowledged by the LPN, require the promotion of resident rights, dignity, and privacy during care, which were not upheld during these incidents.
Failure to Notify Family of Medication Error and Condition Change
Penalty
Summary
The facility failed to notify the family member or representative of a resident after a significant medication error occurred. According to clinical record review and interviews, a resident was mistakenly administered medications intended for another resident, including Melatonin, Mirtazapine, Alprazolam, and Apixaban. The error was documented as a late entry in the progress notes, and the family was not directly informed by the facility until several days later. Instead, the family learned of the incident through the hospital's History and Physical report, rather than from facility staff. Interviews with the resident's family confirmed that they were not notified by the facility about the administration of the four incorrect medications. The facility's policy and the LPN's job description both require immediate notification of the resident, physician, and family or legal representative in the event of a significant change in condition or medication error. Despite this, the facility only informed the hospital about one of the medications and delayed direct communication with the family, failing to follow established procedures for notification.
Incomplete Care Plan for Resident with Active Skin Issues
Penalty
Summary
Facility staff failed to maintain a complete and accurate care plan for a resident who was readmitted with multiple diagnoses, including heart failure, diabetes mellitus, non-Alzheimer's dementia, altered mental status, adult failure to thrive, and abnormal weight loss. Upon readmission, the resident was documented as having a right trochanter blister and a scabbed area on the coccyx, with a history of pressure ulcers and being at risk for further ulcer development. However, the care plan did not address these active skin issues or specify expected interventions for their management. Clinical documentation showed that the initial assessment upon readmission noted the presence of skin issues but did not provide further assessment details such as measurements, condition of surrounding skin, drainage, or odor. The facility's own Skin Quick Reference Guide required a head-to-toe assessment, documentation, and initiation of care plan interventions, but these steps were not completed as required. The care plan remained incomplete and failed to reflect the resident's current needs related to skin integrity.
Failure to Provide Adequate Staffing and Timely Call Light Response
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple interviews and policy review. One resident reported waiting 2.5 hours for a response to her call light, using the wall clock to time the delay, and expressed frustration over being left in bed in the morning because there were not enough staff available to assist with her transfer, which required 2-3 staff members. Another resident confirmed experiencing extended wait times for staff to respond to call lights, with no particular time of day being worse than others. Certified Nursing Assistants (CNAs) interviewed acknowledged challenges in responding to call lights within the facility's 15-minute policy, citing being occupied in other resident rooms and overall staffing shortages. Staff attributed these issues to difficulties in hiring and retaining healthcare workers, as well as management decisions such as wage caps. The facility's call light policy, revised in September 2023, emphasizes prompt responses, but staff interviews indicated that timely responses were not consistently achieved.
Failure to Prevent Significant Medication Errors for Two Residents
Penalty
Summary
The facility failed to ensure that two out of three residents were free from significant medication errors. In one instance, a Certified Medication Aide (CMA) administered the correct physician-prescribed medications to a resident, but later, due to interruptions including a phone call and a resident's pressure alarm, the CMA mistakenly gave the same resident medications that were prescribed for another resident. The medications erroneously administered included Melatonin, Mirtazapine, Alprazolam, and Apixaban, which were not intended for the resident who received them. This error was confirmed by a review of video footage, clinical records, and a written statement from the Director of Nursing (DON). In another case, a resident continued to receive both Seroquel 12.5 mg and Seroquel 25 mg in the morning, despite a physician's order changing the regimen to Seroquel 25 mg in the morning and 12.5 mg at noon and supper. This discrepancy was discovered during staff rounds, indicating that the medication order change was not properly implemented, resulting in the resident receiving an incorrect dosage for an extended period.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, as evidenced by discrepancies in documentation and assessment following a fall incident. In one case, a resident fell from a recliner in the day room, was witnessed by a nurse, and subsequently complained of left leg pain. Although the progress note indicated that the resident was assessed for physical abnormalities and vital signs while on the floor, video footage revealed that staff did not perform these assessments before moving the resident. The resident was assisted to her feet and walked despite refusing to bear weight on her left leg, and was later found to have a minimally displaced fracture of the left femur. The LPN responsible for the documentation was unable to recall details of the assessment and could not explain where the documented information originated, as confirmed by the DON during an interview. Additionally, there was a discrepancy in the controlled substance record for another resident. The record indicated that Xanax was destroyed, but the DON later confirmed that the medication was actually administered to a different resident. The LPN involved had signed a job description acknowledging the requirement for accurate, contemporaneous charting and completion of medical records in accordance with nursing policies. These failures to accurately document care and medication administration were not in accordance with accepted professional standards and facility policy.
Medication Error Leads to Hospitalization
Penalty
Summary
The facility failed to administer the correct medications to a resident, resulting in the resident receiving another resident's medications, including an anti-psychotic medication, Seroquel. This error led to the resident experiencing over-sedation and hypoglycemia, necessitating hospital admission for observation. The resident, who had no cognitive impairment and did not typically take anti-psychotic medication, was minimally arousable and had a low blood sugar level, likely due to the sedative effects of the Seroquel. The incident occurred when a Certified Medication Aide (CMA) became distracted after receiving an upsetting personal call before the noon medication pass. Despite performing the correct checks, the CMA inadvertently administered the wrong medications to the resident. The error was identified immediately upon returning to the medication cart, and the resident's doctor and the Director of Nursing (DON) were informed. The resident was subsequently sent to the hospital for evaluation and observation.
Sanitary Conditions Not Maintained During Meal Service
Penalty
Summary
The facility failed to maintain sanitary conditions during meal service, as observed during the noon meal on 4/22/24. Staff A, a cook, was seen serving 28 glasses to 19 residents while touching the drinking rim surfaces with her bare hands. Additionally, Staff A pushed the beverage cart throughout the dining room without sanitizing the cart handle and did not perform hand hygiene during the meal service. The Dietary Manager, Staff B, confirmed that staff are trained to avoid touching the drinking rims of glasses and the tines of silverware, and to hold plates by the edge and base. However, the facility lacked a policy regarding dining services and appropriate hand placement during food service. Further observations on 4/23/24 revealed multiple staff members handling milk jugs by the handle without performing hand hygiene prior to touching the jugs.
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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) |
|---|---|---|---|---|
| Good Samaritan - Waukon | 0.8 mi | — | 1 | 1 |
| Wellington Place | 13.3 mi | — | 0 | 0 |
| Thornton Manor Nursing And Care Center | 13.6 mi | — | 0 | 0 |
| The Highlands | 15.8 mi | — | 2 | 0 |
| Ossian Care Center | 17.1 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.