Northgate Care Center
960 4th Street Nw · Waukon, IA · 52172 · 5635683493
50 certified beds For profit - Corporation Chain: Legacy Healthcare
Why this verdict
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (1 citation).
- Inspection record is far worse than the national median (deficiency count and severity).
- Inspection results are getting worse cycle over cycle, not better.
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Red flags
Special Focus Facility candidate
CMS lists this facility as a candidate for its Special Focus program for persistently poor inspection performance.
1 immediate-jeopardy citation in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
$71,110 in federal fines in the last 24 months
1 fine — CMS fines are reserved for verified, serious non-compliance.
Total nurse staffing below 3.0 hours per resident-day
2.92 reported hours vs the 3.48 minimum CMS's own staffing study recommends.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 3 of 5 Quality measures: 2 of 5
| Total nurse hours / resident-day | 2.92 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.40 | 0.55–0.75 |
| Weekend hours / resident-day | 2.56 | ≈ weekday level |
| Nursing turnover / year | 26% | median 45% |
| Fines (3-yr window) | 1 · $71,110 |
Inspection citations (20 in the current record)
-
Immediate jeopardy · L March 4, 2026 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected March 25, 2026 · Pharmacy Service
-
Potential for harm · D March 4, 2026
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected April 2, 2026 · Resident Rights
-
Potential for harm · D March 4, 2026
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected April 2, 2026 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · D March 4, 2026
Ensure each resident receives an accurate assessment.
Corrected April 2, 2026 · Resident Assessment and Care Planning
-
Potential for harm · D March 4, 2026
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected April 2, 2026 · Quality of Life and Care
-
Potential for harm · D March 4, 2026
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected April 2, 2026 · Quality of Life and Care
-
Potential for harm · D March 4, 2026
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected April 2, 2026 · Quality of Life and Care
-
Potential for harm · F March 4, 2026
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected April 2, 2026 · Administration
-
Potential for harm · E March 4, 2026
Provide and implement an infection prevention and control program.
Corrected April 2, 2026 · Infection Control
-
Potential for harm · F March 4, 2026 · found via complaint
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected April 2, 2026 · Pharmacy Service
-
Actual harm · G November 14, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected November 24, 2025 · Quality of Life and Care
-
Potential for harm · D November 14, 2025 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected December 8, 2025 · Resident Rights
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Potential for harm · D November 14, 2025 · found via complaint
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected December 8, 2025 · Resident Rights
-
Potential for harm · D November 14, 2025 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected December 8, 2025 · Resident Assessment and Care Planning
-
Potential for harm · D November 14, 2025 · found via complaint
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected December 8, 2025 · Nursing and Physician Services
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Potential for harm · D November 14, 2025 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected December 8, 2025 · Pharmacy Service
-
Potential for harm · D November 14, 2025 · found via complaint
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected December 8, 2025 · Resident Assessment and Care Planning
-
Potential for harm · E November 14, 2025 · found via complaint
Provide and implement an infection prevention and control program.
Corrected December 8, 2025 · Infection Control
-
Potential for harm · D September 22, 2024 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected October 10, 2024 · Pharmacy Service
-
Potential for harm · E April 25, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected May 25, 2024 · Nutrition and Dietary
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| March 4, 2026 | Fine | $71,110 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 165338 · certified since August 1, 1997. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.