Harmony Dubuque

In the surveyor’s words

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

• Actual harm, isolatedF697Mar 12, 2026

  Based on clinical record review, facility policy review, staff interview, Nurse Practitioner (NP) interview, physician office staff interview, resident interview, and resident family member interview, the facility failed to ensure a resident received effective pain management interventions that included the administration of analgesic and other medications that enhanced pain control as ordered and directed by the physician for 1 of 4 residents reviewed for pain management (Resident #9). This deficient practice resulted in the resident experiencing sleep disturbance due to pain. On 2/16/26 Resident #9 called 911 themselves for transfer to the hospital for pain management when the resident experienced pain at level 10 out of 10. […]

• Actual harm, isolatedF689Nov 7, 2023

  Based on clinical record review, facility policy review, and staff interviews the facility failed to provide the assistance required to prevent falls for 2 of 5 residents reviewed for falls (Resident #8, and Resident #223). The facility reported a census of 72 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 8/30/23 , listed diagnoses for Resident #8 that included: Type 2 diabetes, dysphagia (difficulty swallowing), severe intellectual disability, and fracture of lower right leg. The MDS assessed the resident required extensive assistance of one staff for: bed mobility, transfers, and walking in the room and the corridor; and supervision with set up help only for eating. […]

• Actual harm, isolatedF689Jul 10, 2023

  Based on observation, clinical record review, document review, resident and staff interviews, the facility failed to prevent an injury of unknown origin on 6/10/23 which resulted in a hematoma and facial bruising for 1 of 3 resident's sampled (Resident #6) and failed to utilize a gait belt per the therapy recommendations for safety for 1 of 3 residents reviewed (Resident #20). The facility completed an investigation for injury of unknown origin to assure resident safety from abuse from 6/10/23 - 6/15/23. The facility reported a census of 65 residents. Findings include: 1. Resident #6's MDS dated [DATE] showed Resident #6 with long/short term memory impairment and severely impaired decision making. […]

• No harm, potential for more than minimal, widespreadF865Jan 14, 2026

  Based on staff interviews, facility record review and facility policy review the facility failed to ensure an effective Quality Assurance Performance Improvement (QAPI) process to address previously identified quality deficiencies, resulting in repeated deficiencies cited on the current survey that were cited in previous surveys. The facility reported a census of 57 residents.Findings include: The Centers for Medicare and Medicaid Services (CMS) 2567 form dated 10/24/24 reflected deficiencies identified for the QAPI program (F865), and infection control (F880) . The current survey conduction 1/5/26 though 1/14/26 also identified the above concerns. […]

• No harm, potential for more than minimal, widespreadF851Oct 24, 2024

  Based on Payroll Based Journal (PBJ) Data, schedule review, and staff interview the facility failed to submit complete and accurate payroll data to CMS during the third quarter of the 2024 fiscal year. The facility reported a census of 52 residents. Findings include: A document titled PBJ Staffing Data Report for Fiscal Year 2024 Quarter 3 (April 1-June 30) documented the facility triggered for excessively low weekend staffing. On 10/22/24 at 8:12 PM the Administrator stated she became aware there was an issue with the PBJ data the day before. She had already reached out to their main office for a report of what was submitted and to try to learn what caused the facility to trigger for low staffing. […]