Harmony Marshalltown

In the surveyor’s words

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

• Immediate jeopardy, isolatedF627Aug 5, 2025

  Based on clinical record review, resident interview, and staff interviews, the facility failed to provide a safe discharge for 1 out of 1 resident reviewed (Resident #2). On 7/3/25 at approximately 6:15 PM, Resident #2 exited the building to go see his support animal without staff knowledge. On 7/4/25 around 3:00 AM, Resident #2 requested to return to the facility. Due to the frustration of not being able to get a ride back to the facility, Resident #2 used his electric wheelchair and transported himself to a convenience store at 3:00 AM. At 5:30 AM the police notified the Administrator they found Resident #2. On 7/4/25 at 5:50 AM, the Administrator went to the convenience store and had Resident #2 sign a form indicating he left the facility against medical advice (AMA). […]

• Immediate jeopardy, isolatedF689Aug 5, 2025

  Based on observation, clinical record review, staff and resident interviews, and facility policy, the facility failed to ensure residents safely returned to the building from smoking for 3 of 5 residents reviewed (Residents #1, #2, and #5). On 7/7/25 around 8:00 PM Resident #1 went outside to smoke. After smoking, she couldn't get back into the to the building and remained outside on 7/7/25 at 8:00 PM until 7/8/25 at 6:00 AM. The staff failed to do visual checks on Resident #1 for 10 hours. During the time Resident #1 couldn't get back into the building, the weather had a forecast of heavy rain shower with thunder and lightning. The rain began at 5:00 AM to 6:00 AM, this resulted in a temperature drop from 90 degrees Fahrenheit (F) to 72 degrees F. […]

• Immediate jeopardy, isolatedF689May 10, 2022

  Based on observation, record review, staff interviews, and facility policy review the facility failed to provide adequate nursing supervision to ensure the environment was as free of hazards as possible for a resident with a history of wandering and identified at risk for elopement (when a resident leaves the building without staff knowledge or consent). Resident #1 was identified with cognitive impairment, periods of increased confusion and disorientation, impaired safety awareness, wandering behaviors, and Care Planned for a Wander Management Alarm Bracelet (wander guard). […]

• Actual harm, isolatedF686Aug 5, 2025

  Based on staff interviews, clinical record review and policy review the facility failed to provide interventions to prevent a deep tissue injury (a type of pressure injury that occurs when underlying soft tissue is damaged due to prolonged pressure, often over bony prominence.) from performing for 1 of 2 residents reviewed (Resident #3). The facility identified a census of 51 residents. Findings include: Determining the Stage of Pressure Injury:Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. […]

• Actual harm, isolatedF689Sep 18, 2023

  Based on interviews, observations, and record review, the facility failed to provide appropriate nursing supervision to ensure safety for 1 of 3 residents sampled (Resident #1). Resident #1 required assist of 1 for transfers and ambulation. The facility failed to provide the assist of 1 resulting in Resident #1 falling in her room and fracturing her hip. The facility reported a census of 51 residents. Findings include: A Minimum Data Set (MDS) dated [DATE], documented that diagnoses for Resident #1 included: malignant neoplasm of right breast (breast cancer) and age related cognitive decline. A Brief Interview for Mental Status (BIMS) was not assessed. Resident #1 required extensive assist of 1 for transfers, toilet use, and ambulation. […]