Northgate Care Center
960 4th Street NW, Waukon, IA 52172 · Allamakee County · 50 certified beds · avg 41 residents/day · certified since Aug 1, 1997 · Medicare and Medicaid certified
Certified for both programmes. Certification means the facility can bill Medicaid — it does not mean a Medicaid-funded bed is free right now, so ask directly. Who pays for nursing home care →
SFF Candidate
Part of chain: LEGACY HEALTHCARE (89 facilities, chain avg rating 2.9★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, facility-wide · Mar 4, 2026 · F-0760 · triggered by a complaint
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (L): A life-threatening or extremely dangerous situation existed throughout the facility. The single most serious citation CMS can issue.
Corrected: Mar 25, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Nov 14, 2025 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Nov 24, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (20)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Mar 4, 2026 | ▲ L · Immediate jeopardy, facility-wide | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Mar 4, 2026 | F · Potential for harm, facility-wide | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Mar 4, 2026 | F · Potential for harm, facility-wide | The facility did not have a written plan describing how it runs its quality improvement program — the ongoing process of finding problems in care and fixing them. |
| Mar 4, 2026 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Mar 4, 2026 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Mar 4, 2026 | D · Potential for harm, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| Mar 4, 2026 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Mar 4, 2026 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Mar 4, 2026 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Mar 4, 2026 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Nov 14, 2025 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Nov 14, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Nov 14, 2025 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Nov 14, 2025 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Nov 14, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Nov 14, 2025 | D · Potential for harm, one-off | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Nov 14, 2025 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Nov 14, 2025 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Sep 22, 2024 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Apr 25, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
Inspection trend by year
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2024 | 2 | 0 | E |
| 2025 | 8 | 1 | G ▲ |
| 2026 | 10 | 1 | L ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $87,160.
| Date | Type | Amount / length |
|---|---|---|
| Mar 4, 2026 | Fine | $87,160 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Iowa avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.58 | 4.37 | 3.95 | bottom 12% in Iowa; bottom 41% in the U.S. |
| Registered Nurse hours | 0.48 | 0.85 | 0.69 | bottom 10% in Iowa; bottom 34% in the U.S. |
| Weekend total nurse staffing | 3.16 | 3.86 | 3.50 | bottom 13% in Iowa; bottom 40% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.31 | 0.51 | 0.48 | bottom 18% in Iowa; bottom 33% in the U.S. |
| Total nursing staff turnover (%) | 34.3 | 44.0 | 45.8 | top 27% in Iowa; top 22% in the U.S. |
| RN turnover (%) | 0.0 | 42.1 | 42.9 | — |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 2.97, RN 0.40, weekend 2.62. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 4/5 · short-stay residents: 2/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Beasley, Karla | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/15/2024 |
| Beasley, Karla | Individual | ADP of the SNF | NOT APPLICABLE | 08/15/2024 |
| Behounek, Linsey | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/15/2024 |
| Behounek, Linsey | Individual | ADP of the SNF | NOT APPLICABLE | 08/15/2024 |
| Borcherding, Jenny | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/15/2024 |
| Borcherding, Jenny | Individual | ADP of the SNF | NOT APPLICABLE | 08/15/2024 |
| Burken, Sheri | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/15/2024 |
| Burken, Sheri | Individual | ADP of the SNF | NOT APPLICABLE | 08/15/2024 |
| Cascade Capital Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/15/2024 |
| Cascade Capital Partners LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/15/2024 |
| CCG Gorgona LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/15/2024 |
| Friedenberg, Laura | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/15/2024 |
| Friedenberg, Laura | Individual | ADP of the SNF | NOT APPLICABLE | 08/15/2024 |
| Friedman, Brian | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 03/11/2025 |
| Gorgona Holdco LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/15/2024 |
| Gorgona Propco Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/15/2024 |
| Gorgona Sub Holdco LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/15/2024 |
| Hedberg, Jennifer | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/15/2024 |
| Hedberg, Jennifer | Individual | ADP of the SNF | NOT APPLICABLE | 08/15/2024 |
| Hennager, Christina | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/15/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "How does your quality improvement program work, and can you share a recent example of a problem you found and fixed?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "How do you explain health changes and treatment options to residents and their families?"
- "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Good Samaritan - Waukon | 0.8 mi | Waukon, IA | ★★☆☆☆ | 2/5 | |
| Wellington Place | 13.3 mi | Decorah, IA | ★★★☆☆ | 4/5 | |
| Thornton Manor Nursing and Care Center | 13.6 mi | Lansing, IA | ★★★★☆ | 3/5 | |
| The Highlands | 15.8 mi | Decorah, IA | ★★☆☆☆ | 2/5 | |
| Ossian Care Center | 17.1 mi | Ossian, IA | ★★☆☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 165338.