Harmony Cedar Rapids

In the surveyor’s words

From the most serious findings on record at Harmony Cedar Rapids, in the surveyor’s own words.

• Immediate jeopardy, isolatedF690Aug 2, 2023

  Based on clinical record review, observations, resident and staff interviews and policy review, the facility failed to ensure appropriate care and treatment to prevent urinary tract infections (UTI) leading to a resident suffering from septic shock and deep tissue pressure injury to the urethral meatus (tip of the penis) for 1 of 3 residents reviewed for catheter care (Resident #1). The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of May 28, 2023 on July 26, 2023 at 12:15 p.m. The facility staff removed the Immediate Jeopardy on July 27, 2023 by implementing the following actions: a. Resident #1 resides in the center, head to toe assessment was completed and pain evaluation with interventions. b. […]

• Immediate jeopardy, isolatedF880Aug 2, 2023

  Based on observations, clinical record review, resident and staff interviews and policy review, the facility failed to implement their infection control policy to ensure MRSA (a contagious staph bacteria infection) was contained. Staff interviews revealed Resident #1 had a suprapubic catheter leaking urine onto clothes and sheets; staff were unaware Resident #1 was positive for MRSA due to a Nurse not reporting Lab Results and the facility did not provide personal protective equipment for staff use for 4 days. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of July 21, 2023 on July 26, 2023 at 4:30 p.m. The facility staff removed the Immediate Jeopardy on July 27, 2023 by implementing the following actions: a. […]

• Immediate jeopardy, isolatedF684May 31, 2023

  Based on Pre-Admission Hospital Record review, facility clinical record review, State of Iowa Certificate of Death review, Medical Director and staff interviews, and facility document review, the facility failed to complete a thorough assessment, contact the resident's physician timely to request transport to the hospital for provision of treatment for 1 of 5 residents reviewed (Resident #2), when a serious change in condition noted for the resident. This failure resulted in the resident not being transported to the emergency room (ER) in a timely manner to receive medical interventions/treatment and subsequently the resident found in bed at the facility without a pulse or respirations, therefore causing an Immediate Jeopardy to the health and welfare of the resident. […]

• Actual harm, isolatedF689Dec 23, 2025

  Based on clinical record review, staff and resident interviews, manufacturer's recommendation and facility policy review the facility failed to transfer one of four residents reviewed in a safe manner (Resident #1). On 11/13/25, Resident #1 fell backwards from the stand lift, reported pain 9 out of 10 to the left hip, was sent to the hospital, and had a femur fracture which required surgical repair. The facility reported a census of 83 residents.The facility corrected the deficient practice per past noncompliance on 11/28/25 through the following actions:*Nursing staff re-educated on the proper use of mechanical lifts*Facility wide audit of mechanical lift equipement.*Nursing staff completed a skills check-off for standing lift and full body mechanical lift.*Audits of resident transfers… […]

• Actual harm, isolatedF697Aug 2, 2023

  Based on resident and staff interviews, observation and record review, the facility failed to manage pain for 1 of 3 residents reviewed for dressing changes (Resident #1). Resident #1 stated he had experienced pain during daily dressing changes for 6 weeks. The facility reported a census of 72 residents. The MDS dated [DATE] revealed Resident #1 had a diagnosis of renal insufficiency, obstructive uropathy, urinary tract infection (UTI) septicemia (blood poisoning by bacteria) and required extensive assistance of 1 person for personal hygiene. Resident #1 had a brief Interview for mental status (BMI) score of 12 indicating a slight impairment of cognition. […]