Good Samaritan Waukon: Immediate Jeopardy Safety Violation - IA
The citation, issued September 11, 2025 following a complaint investigation, carries the most serious designation available under the federal inspection system: Scope/Severity Level J, immediate jeopardy to resident health or safety. It means inspectors concluded that the facility's failures had placed, or were placing, one or more residents at risk of serious injury, serious harm, serious impairment, or death.
Good Samaritan Society - Waukon is part of one of the largest nonprofit nursing home chains in the country. The Good Samaritan Society, affiliated with Sanford Health, operates facilities across more than a dozen states. The Waukon location sits in Allamakee County, a rural stretch of Iowa near the Wisconsin border, where long-term care options are limited and residents often have few alternatives.
The deficiency was cited under federal tag F0689, which covers accident hazards and supervision. Inspectors found the facility failed to ensure that a nursing home area was free from accident hazards and failed to provide adequate supervision to prevent accidents. That standard exists because nursing home residents, many of whom have dementia, limited mobility, or both, cannot reliably protect themselves from environmental dangers. The burden falls on the facility.
Immediate jeopardy citations are not handed out routinely. They represent a finding that harm was not merely possible but that the situation warranted urgent correction. Inspectors do not apply that label to a loose handrail or a wet floor sign left out too long. The standard requires that the deficient practice has caused, or is likely to cause, serious injury, harm, impairment, or death.
The inspection was triggered by a complaint, not a routine survey. That matters. Complaint investigations begin when someone, a resident, a family member, a staff member, or a member of the public, contacts state or federal authorities to report a specific concern. Inspectors then go in to determine whether the complaint is substantiated. In this case, they found not just a deficiency but an immediate jeopardy situation.
The facility's correction status is listed as past non-compliance, with the correction reported as of August 21, 2025, more than three weeks before the September 11 inspection date. That sequence is worth pausing on. The facility reported correcting the problem on August 21. Federal inspectors arrived on September 11. The citation was still issued, which means inspectors reviewed what happened and determined that, whatever correction the facility claimed, there had been a genuine immediate jeopardy violation in the period before that reported correction date.
Past non-compliance is a specific regulatory finding. It means the deficiency is no longer ongoing at the time of the inspection, but it existed in the past. The facility does not get credit for fixing something simply because it fixed it before inspectors walked through the door. The violation still goes on the record. It still carries the immediate jeopardy designation. It still affects the facility's quality ratings.
What the inspection report does not say, at least in the narrative provided, is exactly what the accident hazard was, which resident or residents were affected, how the situation came to light, or what specific corrective steps the facility took. Federal inspection reports at the full detail level typically include those specifics, the room where something happened, the date, the resident's coded identifier, what staff said when interviewed, what records showed. What is available here establishes that the violation happened, that it reached the highest severity threshold, and that someone cared enough to file a complaint.
The F0689 tag covers a broad range of accident scenarios. Falls are the most common category in nursing homes. So are incidents involving equipment left in unsafe condition, chemicals or medications accessible to residents with cognitive impairment, sharp objects, hot liquids, and physical plant hazards like broken flooring or unsecured furniture. Supervision failures under the same tag can include leaving a high-fall-risk resident unattended, failing to respond to a call light or an alarm, or not following a care plan that required one-to-one monitoring.
Any of those could produce an immediate jeopardy finding if the circumstances were serious enough. The label does not require that harm actually occurred, only that the potential for serious harm was present and that the facility's practices created that risk.
Waukon has a population of roughly 3,600 people. Good Samaritan Society - Waukon is one of the area's significant employers and one of the few local options for residents who need skilled nursing care or long-term placement. For families in Allamakee County, moving a parent or spouse to a facility farther away is not always financially or practically possible. That geography shapes what accountability looks like in a place like this. A family that is unhappy with care at the only nearby nursing home faces a different set of choices than a family in a city with a dozen options within driving distance.
The complaint that triggered this investigation came from someone who believed the situation was serious enough to report. Complaints to state health departments and to CMS can be filed anonymously, and they frequently are. Staff members file complaints. Family members file complaints. Residents themselves sometimes file complaints. Whoever made the call in this case prompted an investigation that ended with an immediate jeopardy citation, which is, by any measure, a significant outcome.
Facilities that receive immediate jeopardy citations are required to submit plans of correction to the state survey agency. Those plans must describe what happened, what the facility did to protect residents during the jeopardy period, and what systemic changes the facility put in place to prevent recurrence. The state agency reviews those plans and determines whether the jeopardy has been lifted. In this case, the jeopardy was considered resolved, which is why the correction status reads as past non-compliance rather than ongoing.
Resolved does not mean forgotten, and it does not mean the underlying conditions that produced the violation have been permanently addressed. Nursing homes that receive immediate jeopardy citations sometimes receive them again. The inspection record for any facility is public, searchable through the CMS Care Compare database, and families researching placement options can see this citation when they look up Good Samaritan Society - Waukon.
The Good Samaritan Society has faced regulatory scrutiny at various locations over the years, as most large nursing home operators have. The Waukon facility's specific history before this citation is a matter of public record available through CMS. What this inspection added to that record is a Level J deficiency under F0689, issued following a complaint, covering the period before August 21, 2025.
What it does not yet show, because the full inspection record with detailed findings has not been published in complete narrative form, is the name of the resident who was placed in jeopardy, the exact nature of the hazard or supervision failure, how long the dangerous condition existed before it was corrected, and whether anyone was hurt.
Those details matter. They are the difference between a regulatory label and an actual account of what a person experienced inside a building where they lived and where they depended on staff to keep them safe. The inspection system captures the label. The full story of what happened to one resident, in one room, on some date before August 21 in Waukon, Iowa, remains incomplete in the public record.
Someone filed a complaint because they believed a person was in danger. Federal inspectors agreed, at the highest level of agreement the system allows. The facility said it fixed the problem three weeks before inspectors arrived.
Whether the fix holds is a question the next inspection will answer.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Good Samaritan - Waukon from 2025-09-11 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 21, 2026 · Our methodology
Good Samaritan - Waukon in Waukon, IA was cited for immediate jeopardy violations during a health inspection on September 11, 2025.
Good Samaritan Society - Waukon is part of one of the largest nonprofit nursing home chains in the country.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.