A northeast Iowa nursing home repeatedly cited for medication errors has been added to the federal list of the nation’s worst care facilities.
Northgate Care Center of Waukon has been added to the Centers for Medicare and Medicaid Services’ list of candidates for special-focus status, indicating a history of serious, recurring resident-care issues.
At any given time, no more than two nursing homes per state appear on the list of federally designated Special-Focus Facilities, although the list also includes hundreds of other nursing homes — typically, 10 per state — where ongoing quality-of-care violations have made them eligible for that status.
On May 27, 2026, the Arbor Court care facility in Mount Pleasant, recently renamed the Woodland Health and Rehabilitation Center, was deemed to have “graduated” from the list of designated special-focus facilities after 26 months. At the same time, Northgate Care Center was added to the list of Iowa’s 10 eligible candidates for special-focus status.
Northgate’s addition to the candidate list appears to stem from regulatory violations related to staffing and medication issues. In late 2025, Northgate Care Center was cited by the Iowa Department of Inspections, Appeals and Licensing for medication errors and failing to properly assess and treat a resident who was given the wrong medication and subsequently died.
The home was also cited for failing to employ a sufficient number of staff to meet residents’ needs, with residents reporting wait times of up to 2 ½ hours to have their call lights answered.
According to state inspectors, the female resident who died last year had been given medications intended for another resident — including melatonin to encourage sleep, an antidepressant, an antianxiety medication and an anticoagulant.
Video surveillance footage recorded a short time later showed the resident sitting in a recliner, standing up and immediately falling to the floor. The woman later complained of pain. An ambulance crew arrived and took her to a hospital, where an X-ray indicated she’d sustained a broken leg.
According to inspectors, the resident’s family chose to forgo surgical intervention, which led to hospice care and, at some unspecified point over the next few days, the resident’s death.
‘I knew I was wrong.’
According to the inspectors’ report, a licensed practical nurse at the home admitted that after the resident was taken to the hospital, she called the emergency room to report the resident had been given only one incorrect medication — not four — shortly before the fall.
“When asked why she had not told the truth in the beginning, the nurse responded by stating, ‘Because I knew I was wrong,’” the inspectors’ report states.
Four months later, in March 2026, the home was cited again for medication issues, with inspectors noting that four of seven nurses on staff were knowingly violating protocols for dispensing medications.
Inspectors said the nursing staff was aware that in order to avoid confusion and minimize the risk of dispensing the wrong medications to residents, they should not set up, in advance, various cups of medication to be administered to the residents hours later.
A certified nurse aide told inspectors that when she recently reported for work one day she saw the staff setting up, in advance, the residents’ medications to be distributed later. The CNA reportedly stated she “could not believe they were doing exactly what the facility just got in trouble for” days earlier during the first day of the state inspectors’ visit.
One registered nurse told inspectors she “knew it was wrong,” having been trained on the issue five days earlier, but the process saved time. A licensed practical nurse at the home reportedly told inspectors that because the home was always short on staff, she set up morning medications in advance to “get the job done.”
The nurse allegedly added that she had worked at the home for eight years, had always set up medications in advance, and “could not get (her work) done if she had to actually do it the right way.”
The home’s medical director reportedly told inspectors that “economics only allows the facility to staff a certain way,” and that while the system of setting up medications in advance did “kind of bother” him, he was unsure how to solve the issue “and meet the expectation with efficiency.”
Last year, the Northgate facility was among several Iowa nursing homes included in a staffing-shortages report published by the nonprofit Long Term Care Community Coalition. The coalition’s analysis concluded Northgate was among the 12 lowest-ranked homes in Iowa with regard to staffing levels, indicating the home’s staffing was 39.9% below expected levels.
