Maquoketa Care Center

In the surveyor’s words

From the most serious findings on record at Maquoketa Care Center, in the surveyor’s own words.

• Actual harm, isolatedF600Jul 2, 2026

  Based on observation, clinical record review, document review, policy review, resident and staff interviews, the facility failed to protect and provide a safe environment for 1 of 3 residents reviewed from resident-to-resident abuse (Resident #32). On 6/14/26 at 7:44 AM Resident #42 walked from his dining room chair over to Resident #32 who sat in a Broda wheelchair (specialty wheelchair) and struck Resident #32 on the left side of the head with his cane. This deficient practice resulted in a 5 Centimeter (CM) bump with a 1 CM lesion to Resident #32's head and facial bruising. The facility reported a census of 33 residents. The concern was identified and corrected June 16, 2026 with an all staff huddle to provide resident safety education, prior to surveyor entrance on June 29, 2026. […]

• Actual harm, isolatedF600May 13, 2026

  Based on observation, clinical record review, resident and staff interviews, and facility policy, the facility failed to provide a safe environment and protect one of seven residents reviewed from resident to resident abuse (Resident #2). On 4/19/26, Resident #1 stood over Resident #2 while Resident #2 was in a reclined wheelchair, and Resident #1 hit Resident #2 in the face with the handle of his cane 3 to 4 times. This deficient practice resulted in a slightly swollen eye for Resident #2 with bruising to the left cheek under Resident #2's eye. […]

• No harm, potential for more than minimal, patternF880Jul 2, 2026

  Based on observation, clinical record review, policy review and staff interviews, the facility failed to maintain a safe, sanitary, and infection-controlled environment to prevent the potential development and transmission of disease and pathogenic organisms. Specifically, the facility failed to ensure proper hand hygiene protocols were executed during wound care dressing changes for 2 of 2 residents observed (#6 and #24); failed to utilize a gown as part of Enhanced Barrier Precautions (EBP) for 1 of 2 residents observed with indwelling medical devices (Resident #5); and failed to ensure medications were administered free from significant contamination and errors for 2 of 7 residents observed during oral medication administration passes (Resident #18 and Resident #43). […]

• No harm, potential for more than minimal, patternF725Dec 5, 2024

  Based on record review, Facility Assessment review, resident and staff interviews, and policy review the facility failed to employ sufficient numbers of staff to meet resident needs, and failed to answer call lights in a timely manner for 3 of 4 residents reviewed (Resident #1, Resident #3, and Anonymous). The facility reported a census of 31 residents. Findings include: 1. A review of the facility staff schedules from November 2nd through December 7th, 2024 revealed Certified Nursing Aides (CNAs) were not present in the required ratios during the day shifts as follows: ~ Missing one CNA- 14 days ~ Missing two CNAs- 3 days In an interview on 12/02/24 at 1:12 PM a resident who wished to remain anonymous explained staff were not coming in often enough to toilet them. […]

• No harm, potential for more than minimal, patternF761Dec 5, 2024

  Based on observation, staff interviews, and policy review the facility failed to keep all medication locked in the medication cart as required. The facility reported a census of 31 residents. Findings include: In an observation on 12/02/24 at 8:00 AM the bottom drawer of a medication cart in the back hall was found open with medications exposed. This surveyor was able to approach the cart and access medications in the drawer. No nurse or staff were visualized next to the cart or down the hallway. In an interview on 12/03/24 at 1:40 PM Staff A, Registered Nurse (RN) explained the expectation for the medication cart was for it to be kept locked, the laptop screen to be locked out, and any personal health information to be covered when not directly at it. […]