Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Harmony Cedar Rapids during CMS and state inspections, most recent first.
Staff failed to follow infection control policies for glucometer use when an RN, working her first shift in the facility, performed blood glucose checks on two residents with diabetes and other comorbidities, including an autoimmune disorder. The RN retrieved a shared glucometer from the top of the med cart without a barrier, placed it directly on a resident’s blanket and later on a dining table, and conducted fingerstick testing for each resident. On both occasions, she returned the glucometer to the med cart without a barrier and without disinfecting it, despite facility policies and the DON’s expectation that glucometers be cleaned with EPA-approved wipes before and after each use and prior to storage with other clean equipment.
Delayed call light response was identified for three residents with BIMS scores showing intact cognition for two residents and moderately impaired cognition for one resident. Residents reported waits of up to an hour, and one resident described a call light left unanswered for about 45 minutes total. During observation, two room call lights remained on for 20 and 29 minutes while staff walked past without stopping, and the Nurse Manager, CNA, and DON all stated the expectation was for call lights to be answered within about 5 to 10 minutes.
Failure to maintain clean and sanitary resident rooms and bedding. A resident with moderate cognitive impairment and frequent urinary incontinence was repeatedly observed with soiled linens, dried feces, foul odors, and periods where the bed had no linens and the mattress was not cleaned or sanitized. Two other residents reported delayed or incomplete bedding changes, and one resident was observed with sheets and a bed pad soaked and stained with urine because staff had not changed them.
A resident with traumatic spinal cord dysfunction, paraplegia, DM, and renal disease had repeated documentation of mouth and tooth pain, cracked and decayed teeth, and antibiotic treatment for possible gum infection, but the quarterly and annual MDS assessments did not code any dental concerns in the mouth/facial pain/discomfort section despite intact cognition.
The facility failed to include key needs in care plans for two residents. One resident with ESRD and dialysis dependence had a care plan that did not direct staff to send the required transfer sling for dialysis chair transfers, and the resident reported missing dialysis when staff did not place the sling. Another resident with intact cognition had repeated dental pain and mouth infection documented in progress notes, but the care plan did not address the teeth pain or related infections, despite ongoing complaints and treatment with antibiotics.
A facility failed to follow medication administration standards when a CMA returned refused medications to the cart and an LPN later took the cup with the intent to offer them again instead of disposing of them per policy. The facility also gave another resident’s medications crushed by mouth in pudding even though the physician orders still directed administration via G-tube; staff acknowledged the route had not been changed in the orders before oral administration began.
A resident with severe cognitive impairment and wheelchair use was observed being pushed down a hallway by an Activities Assistant without footrests in place. The resident’s feet scuffled on the floor during transport, and the staff member stated they knew foot pedals were required but had not intended to push the resident that far. The DON and other staff stated footrests must be in place before a resident is pushed in a wheelchair.
A resident with ESRD and dependence on renal dialysis was sent to dialysis without the required transfer sling in place. Dialysis staff sent the resident back because the proper lift equipment was missing, and the resident reported the treatment could not be completed that day. The DON said staff had missed placing the sling on the chair before transfer, and the facility’s dialysis transfer agreement stated it was responsible for assuring timely dialysis services.
Medication Error Rate Exceeded Allowed Threshold: A CMA prepared medications for a resident with heart disease and diabetes and was observed to place incorrect doses in the medication cup. The potassium dose was 10 mEq instead of the ordered 20 mEq, and primidone was 50 mg instead of the ordered 150 mg. These errors contributed to a 6.45% medication error rate, above the required threshold, during the medication pass observation.
The facility failed to coordinate ongoing dental services for two residents with intact cognition and documented dental pain, cracked teeth, and abscesses. One resident had repeated complaints of tooth pain with antibiotics, pain meds, and multiple notes showing difficulty arranging dental care because of Medicaid, client participation, and transportation barriers; the other resident was treated with cephalexin for a dental abscess while staff continued searching for a provider after prior referrals were declined.
A resident dependent on staff for transfers, with diagnoses including MS and anxiety, was being moved using a stand lift by two CNAs who failed to secure the required safety belt and leg straps. During the transfer, the resident reported dizziness, released her grip, and fell backward, resulting in a femur fracture that required surgery. Staff statements conflicted regarding whether the resident refused safety features, but documentation and interviews indicated no prior refusals. Both CNAs had completed training but did not follow protocols, leading to the incident.
The facility failed to provide adequate staffing, particularly on weekends, as indicated by the PBJ Staffing Data Report. A resident reported being left on a bedpan for 45 minutes due to staffing issues. Staff interviews confirmed that while essential needs were met, not all care-planned needs could be addressed. The facility's staffing matrix did not account for resident acuity, and the assessment was not updated to reflect the actual census.
A facility failed to re-screen a resident with intellectual disability who exceeded the 60-day convalescent care approval without the required re-evaluation. The resident had multiple diagnoses, including quadriplegia and seizure disorder, and was unable to complete the BIMS. The care plan included PASRR recommendations, but a status change was not submitted as required. The Social Services staff responsible for PASRR follow-up was new to the process and acknowledged the oversight. The facility did not have a specific policy on PASRR completion.
A facility failed to ensure consistent documentation of a resident's code status, resulting in a discrepancy between the electronic medical record and the IPOST form. The resident, with intact cognition and multiple medical diagnoses, had a DNR status in the electronic record but a CPR directive on the IPOST form. The DON acknowledged the inconsistency and noted the absence of a policy to guide the advance directive process, leading to the failure to ensure the resident's wishes were consistently documented.
A facility failed to submit a discharge MDS within the required time frame for a resident who was discharged to another facility. The MDS was completed and signed but not marked as submitted due to an error by the MDS Coordinator. The facility lacked a specific policy for MDS assessments, relying on the RAI Manual.
The facility failed to accurately code the MDS for two residents, leading to deficiencies in documenting their medical conditions. One resident's intellectual disability was not recorded as required by the PASRR form, while another resident's MDS inaccurately indicated they were receiving hospice care despite being discharged. The MDS Coordinator acknowledged these oversights, and the facility lacked a specific policy on MDS completion.
Two residents were not treated with dignity and privacy during care. One resident was exposed during incontinence care, visible to her roommate and hallway, as staff failed to pull the privacy curtain. Another resident was returned to her wheelchair in wet pants after toileting, contrary to facility policy. The DON expects staff to ensure privacy and change wet clothing.
A resident with multiple diagnoses, including benign prostatic hyperplasia and hemiplegia, returned from the ER with testicular pain and was supposed to have a follow-up urology appointment. The facility failed to schedule this appointment promptly, despite the resident experiencing pain. The DON admitted the appointment should have been made sooner, but it was delayed, and the facility was still waiting for a response from the urology department.
A CNA at the facility failed to follow safe transfer techniques by using a mechanical stand lift to transfer a resident without the required assistance of a second staff member, as specified in the resident's care plan and facility policy. The DON confirmed the expectation for two staff members to be present during such transfers.
The facility failed to provide proper incontinence and catheter care for three residents, with staff not following hand hygiene and PPE protocols. A resident was not adequately cleaned during care, and staff did not perform hand hygiene after glove removal. Another resident's care was initiated by one staff member instead of two, and a staff member removed her mask during a COVID outbreak. The Director of Nursing confirmed these actions were against facility policies.
The facility failed to administer medications as ordered for three residents, leading to deficiencies in medication management. A resident with diabetes did not receive prescribed doses of Humalog insulin and Atorvastatin due to unavailability. Another resident missed doses of Humalog and Trulicity, while a third resident did not receive Januvia and Mirabegron as prescribed. These lapses were identified through clinical record reviews and staff interviews, highlighting issues in medication availability and administration.
A resident with severe cognitive impairment and multiple diagnoses was discharged from skilled services without notice due to a misunderstanding about Hospice placement. The facility failed to obtain a physician's order or provide the required discharge notice, preventing the resident from appealing the decision.
The facility failed to lock medication carts when not in use and left EHRs open and unattended, allowing unauthorized access. Additionally, a nurse did not ensure a resident took their medications, leaving the room before administration was complete.
The facility failed to provide and document non-pharmacological interventions before administering as-needed anti-anxiety medications for a resident with moderate cognitive loss. Staff interviews and documentation revealed inconsistencies in following the facility's policy, leading to the identified deficiency.
Failure to Disinfect Glucometer Between Resident Uses
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control practices for glucometer use during blood glucose monitoring for two residents. Resident #2, who had diagnoses including Type 2 diabetes mellitus, congestive heart failure, and dementia, had physician orders and a care plan directing blood sugar checks by fingerstick four times daily. During an observation, Staff A, an RN working at the facility for the first time, retrieved a glucometer stored on top of the medication cart without a barrier, brought it into the resident’s room, placed it directly on the resident’s blanket, and performed the blood glucose test. After completing the test, Staff A removed her gloves, exited the room, and placed the glucometer back on the medication cart without a barrier and without sanitizing it, contrary to facility policy requiring cleaning and disinfection of the glucometer before and after each resident use. The same glucometer was then used for Resident #3, who had diagnoses including polymyalgia rheumatica, an autoimmune disorder, and diabetes mellitus, with orders and a care plan directing blood sugar checks four times daily and monitoring for signs and symptoms of infection. Staff A retrieved the glucometer from the top of the medication cart, where it had remained since use with Resident #2, and brought it to the dining room table where Resident #3 was seated. She donned gloves, placed the glucometer directly on the dining room table without a barrier, and performed the blood glucose test. Afterward, she again placed the glucometer on the medication cart without a barrier and without sanitizing it. The DON later reported that staff were supposed to sanitize glucometers between uses with specific disinfectant wipes, and facility policies required cleaning and disinfecting glucometers before and after each resident use and before storing them with other clean equipment.
Delayed Call Light Response
Penalty
Summary
The facility failed to provide enough nursing staff every day to meet resident needs and to have a licensed nurse in charge on each shift as evidenced by delayed responses to call lights for 3 of 3 residents reviewed. Resident #12, who had a BIMS score of 15 out of 15 indicating intact cognition, reported that call light response had taken up to an hour and said the timing was tracked with a phone or clock. Resident #14, whose BIMS score was 9 out of 15 indicating moderately impaired cognition, reported that response times varied and could also take up to an hour, with timing tracked by phone or clock. Resident #27, who had a BIMS score of 14 out of 15 indicating intact cognition, reported that when staff were not visible in the hall, call lights had to wait; the resident described an incident in which a roommate activated the call light, no staff were found in the hall or break room after 10 minutes, and the light was not answered for about 35 more minutes. During continuous observation on 2/26/26, two room call lights were observed on for 20 minutes and 29 minutes before being answered, while several staff walked by without stopping and others were seen going in and out of the staff break room. Staff K, the Nurse Manager, stated the hall was not really short staffed but many residents and staff were sick and it was a busy time of day, so call lights were taking awhile to answer; she said the expectation was 5 to 10 minutes. Staff H, a CNA, stated call lights should be answered within a couple minutes or at least checked on, but there were times they could not be answered timely. The DON stated call lights should be answered as soon as possible, between 5 and 10 minutes, and staff should not walk past call lights without seeing if they could assist. The facility Call Light Policy stated the purpose was prompt response to resident calls for assistance and that call lights shall be answered in a timely manner.
Failure to Maintain Clean and Sanitary Resident Rooms and Bedding
Penalty
Summary
The facility failed to ensure a safe, clean, and sanitary environment for residents, including Resident #38, who had a BIMS score of 12 out of 15 and required partial to moderate assistance with toileting and was frequently incontinent of urine. Resident #38 was repeatedly observed with soiled linens and bedding that remained on the bed for extended periods, including sheets with a dried brown substance, a foul odor in the room, and later soiled linens with dried feces. At times the bed had no linens on it after the dirty sheets were removed, and the mattress was not cleaned or sanitized. The resident stated staff usually did not make the bed until she yelled at them to do it and that staff sometimes made the bed later in the day. Resident #27, who had a BIMS score of 15 out of 15, reported not recalling when the bedding was last done and believed it may have been several weeks or more, stating it was supposed to be done when the resident had a shower. The resident also reported requesting a new pillow cover and that only part of the bedding had been changed. Resident #10, who also had a BIMS score of 15 out of 15, was reported in a confidential interview to have sheets and a bed pad soaked and stained with wet and dry urine because nursing facility staff had not changed the sheets.
MDS Dental Coding Not Completed for Resident With Ongoing Tooth Pain
Penalty
Summary
The facility failed to code dental concerns appropriately on the quarterly and annual MDS assessments for Resident #10. The resident’s quarterly MDS dated [DATE] documented diagnoses of traumatic spinal cord dysfunction, paraplegia, diabetes, and renal disease, and the BIMS score was 15 out of 15, indicating intact cognition. However, the dental section of both the quarterly and annual MDS assessments contained no coding for mouth, facial pain, or discomfort. Clinical records showed repeated documentation of dental pain and oral problems. A progress note dated 8/28/25 stated the resident said, “My mouth hurts,” had a history of cracked teeth, presented with dental pain, had caries on the left upper teeth, and was started on antibiotic therapy due to concern for a potential gum infection. Additional progress notes documented tooth pain involving multiple cracked teeth with significant decay, persistent pain despite antibiotics, continued antibiotics for mouth pain and teeth infection, pain in the left upper and right lower teeth with several decayed and cracked teeth noted, and later reports of dental pain in the upper and lower teeth described as “zingers” and requests for pain medication, primarily for the lower teeth.
Incomplete Care Plans for Dialysis Transfer Needs and Dental Pain
Penalty
Summary
The facility failed to develop complete care plans that reflected residents’ identified needs and treatment requirements. For Resident #4, whose MDS documented end stage renal disease and dependence on renal dialysis, the care plan initiated 4/17/25 stated dialysis was required on Monday, Wednesday, and Friday, but it did not direct staff to ensure a transfer sling was sent so the resident could be transferred to the dialysis chair. The resident stated on 2/23/26 that dialysis could not be completed that day because staff did not place the required sling under the resident on the chair, and the resident said not all staff knew about the requirement. The Administrator and DON acknowledged the care plan should direct the resident’s care and needs. The dialysis transfer agreement and dialysis off-site document also stated coordination of care between the facility and dialysis center was to be documented in the patient care plan. For Resident #10, whose MDS documented traumatic spinal cord dysfunction, paraplegia, diabetes, renal disease, and intact cognition with a BIMS score of 15, the care plan focused on pain related to obesity, gout, spinal cord injury, substance abuse history, kidney disease, diverticulitis, abdominal distention, and stercoral colitis. However, the care plan did not address repeated complaints of teeth pain or the related infections, despite progress notes documenting ongoing mouth and dental pain, continued antibiotics for mouth pain and teeth infection, decayed and cracked teeth, and repeated reports of dental pain described as zingers and requests for pain medication. The facility policy directed that person-centered care plans be reviewed and revised after MDS assessments when applicable and with changes that warrant revision.
Medication Refusal Handling and Incorrect Medication Route
Penalty
Summary
The facility failed to follow professional standards during medication administration for a resident who refused morning medications. The resident had diagnoses including high blood pressure, anxiety, depression, and a seizure disorder, and the February 2026 MAR listed multiple morning medications, including antihypertensives, an antipsychotic, an antidepressant, an anticonvulsant, and pain medication. During observation, a CMA counted 12 pills, took them to the resident, and after the resident refused, returned to the medication cart and placed tape over the medication cup with the resident’s name and room number written on it. The CMA stated the nurse would try to give the medications if the CMA was not able to. Later, the CMA informed an LPN that the resident had refused the medications, and the LPN took the medication cup and walked away with it, stating she planned to offer the medications to the resident. The facility policy directed that refused medications be disposed of appropriately, documented, and reported. The facility also failed to provide medications by the ordered route for a resident with a feeding tube history and moderate cognitive impairment. The resident’s MDS documented a BIMS score of 11, a feeding tube, dysphagia, schizophrenia, pneumonia, and use of psychotropic, opioid, antibiotic, and anticonvulsant medications. The care plan noted altered nutritional status and a history of G-tube feedings, with tube feedings discontinued in February 2026 for comfort measures and oral diet resumed at the resident’s request. However, the physician orders dated 2/3/26 still directed multiple medications to be given via G-tube, including acetaminophen, amitriptyline, calcium, guaifenesin, lamotrigine, lansoprazole, magnesium hydroxide, melatonin, midodrine, polyethylene glycol, prednisone, multivitamin, and Zyprexa Zydis. Despite those orders, an LPN reported administering the resident’s morning medications crushed orally in pudding, and the resident stated she took medications orally with pudding and had been receiving them that way for about a month. An ARNP stated that because the resident was comfort focused, medications could be provided orally, but also said she did not know when the order changed from G-tube to oral. The DON stated the facility did not have an order to provide medications orally prior to the morning of the observation, and the ARNP later entered a progress note giving an oral medication order. Staff acknowledged the route change had not been transcribed, and the MAR showed multiple nurses administered the medications orally before the order was changed.
Unsafe Wheelchair Transport Without Footrests
Penalty
Summary
The facility failed to ensure safe transport of a resident in a wheelchair for 1 of 5 residents reviewed for accidents. Resident #60 had severe cognitive impairment with a BIMS score of 4 out of 15, used a wheelchair for mobility, and was documented in the care plan as an assist of two staff for transfers and non-ambulatory. The resident was observed being pushed in the wheelchair by an Activities Assistant while the wheelchair did not have foot pedals applied. During the observation, the staff member approached the resident from behind, told the resident they would be pushed to the activity area, and swiftly pushed the resident approximately 125 feet down the hallway. The resident’s feet scuffled rapidly on the floor in front of the wheelchair as the resident was accustomed to propelling themselves. In interview, the staff member stated they had not intended to push the resident all the way, but continued after assisting because the resident had blocked another resident in the hall, and acknowledged awareness that foot pedals must be on a wheelchair when pushing a resident. Other staff and leadership stated it was their expectation that residents are only pushed in wheelchairs when foot pedals are in place, and the DON stated the facility did not have a specific wheelchair policy but followed standards of care.
Missed Dialysis Transport Due to Missing Transfer Sling
Penalty
Summary
The facility failed to ensure a resident who required dialysis had the proper transfer sling in place before leaving for a dialysis appointment. Resident #4 had diagnoses of end stage renal disease and dependence on renal dialysis, and the care plan documented dialysis treatments on Monday, Wednesday, and Friday. On 2/23/26, the resident reported that dialysis could not be completed because staff did not place the required transfer sling under the resident on the chair before transport, and dialysis clinic staff told the resident to return to the facility. The progress note documented that the resident was transported to dialysis without the proper [Brand Name Lift] sling in place, and dialysis staff notified transportation and the facility that the required transfer equipment was not present. The resident was offered the option to return to the facility to retrieve the sling and then return to dialysis, but was told the session would be shortened because of time constraints. The Administrator stated awareness that the resident did not receive dialysis that day, and the DON stated staff had missed putting the required sling on the chair before the resident transferred to it. The facility’s dialysis transfer agreement stated it was responsible for assuring the availability and timeliness of dialysis treatments for residents with ESRD.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent when two medication errors were observed during 31 opportunities, resulting in a 6.45% error rate for one of five residents observed during medication administration. Resident #9’s MDS documented diagnoses including heart disease and diabetes, and that the resident took medications including hypoglycemic agents for diabetes control and diuretics. During the medication pass observation, Staff A, a CMA, prepared 17 medications for Resident #9. The medications included methocarbamol 500 mg, primidone 50 mg, furosemide 40 mg, atenolol 50 mg, Jardiance 10 mg, potassium 10 mEq, omeprazole 20 mg, senna 8.6 mg, metformin 1000 mg, ezetimibe 10 mg, iron 325 mg, fish oil 1000 mg, aspirin 81 mg, cetirizine 10 mg, pregabalin 200 mg, and two acetaminophen 500 mg tablets. When Staff A was ready to deliver the medications, the pills were counted and it was confirmed there were 17 pills in the cup. The potassium capsule was 10 mEq even though the order was for 20 mEq, and the primidone tablet was 50 mg even though the physician ordered 150 mg. Staff A confirmed only one of each of those medications was in the cup. The facility policy titled Medication Administration-Medication Pass stated the five rights of medication administration included patient, medication, dose, route, and time.
Failure to Coordinate Dental Services for Two Residents
Penalty
Summary
The facility failed to ensure ongoing coordination of dental services for 2 of 2 residents reviewed for dental services, including a resident with traumatic spinal cord dysfunction, paraplegia, diabetes, renal disease, and intact cognition, and another resident with heart and lung disease, anxiety, depression, and intact cognition. The first resident had repeated complaints of tooth pain, cracked teeth, and abscesses documented across multiple progress notes, with ongoing reports of pain in the upper and lower teeth, use of antibiotics, mouthwash, and pain medication, and repeated statements that dental care was needed. The care plan did not address the repeated tooth pain, abscesses, or related treatments, despite the resident’s ongoing complaints and documented dental concerns. For the first resident, staff documentation showed repeated difficulty arranging dental care. The resident was noted to be in agreement for dental services due to two abscesses, but staff discussed barriers related to Medicaid, client participation, and transportation. The contracted dental provider reported the resident had been eligible since October 2025 and that the application had been received in September 2025, but the facility had held the process because the resident had no client participation. Staff later stated the resident did not qualify for the contracted provider and would need a local dentist that accepted Medicaid. The resident stated he had not refused dental care and wanted treatment, but had been told he would not fit in the van. The record also documented that the resident had a prior dental appointment that could not be attended because of transportation issues. For the second resident, the care plan documented chronic pain but did not address tooth pain or abscesses. The resident was started on cephalexin for a dental abscess, and the medication record showed the antibiotic was given for five days. The resident stated that the social worker was looking into a dental appointment, and staff documented they were still searching for a provider willing to accept the resident after another provider declined because the resident could only pay ten dollars a month. The facility assessment listed dental services through two providers, but the record showed ongoing difficulty obtaining dental care for this resident as well.
Failure to Use Stand Lift Safety Features Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when staff failed to transfer a resident with multiple sclerosis, multidrug-resistant organism, and anxiety diagnoses in a safe manner using a stand lift. The resident was dependent on staff for all transfers and had no prior history of falls. During a transfer from wheelchair to bed, two CNAs attempted to use a stand lift but did not secure the resident with the required safety belt and leg straps, as directed by both the care plan and manufacturer’s instructions. The resident reported feeling dizzy during the transfer, released her grip from the lift handles, and subsequently fell backward to the floor, striking her head and experiencing severe hip pain. Staff statements revealed confusion and inconsistency regarding the use of safety features on the stand lift. One CNA stated that the resident typically declined the use of the safety belt and leg straps, while the other CNA reported being told not to use the safety belt. However, the resident and another CNA both stated that the resident had never refused the use of safety straps, although she had commented that the straps were tight. Documentation in the clinical record did not indicate any refusals by the resident to use the safety belt during transfers prior to the incident. The fall resulted in a significant injury, with the resident sustaining a displaced femur fracture that required surgical intervention. Both involved staff had previously completed training and skills validation for safe transfers but failed to follow established protocols and manufacturer guidelines during the incident. The facility’s investigation and staff interviews confirmed that the safety features of the stand lift were not used as required, directly leading to the resident’s fall and injury.
Inadequate Staffing Leads to Resident Care Deficiency
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of its residents, as evidenced by the Payroll Based Journal (PBJ) Staffing Data Report, which indicated excessively low weekend staffing. The facility's assessment, which was not updated during the period of the PBJ report, documented staffing levels based on an average daily census of 67 residents, while the actual average daily census was 76.8. Interviews with staff and residents revealed that the facility's staffing matrix did not account for resident acuity, and weekend staffing was the same as weekdays, despite the increased use of agency staff on weekends. A resident with intact cognition reported being left on a bedpan for 45 minutes, attributing the delay to staffing issues. Staff interviews confirmed that while the most important resident needs were met, not all care-planned needs could be addressed due to insufficient staffing. The Director of Nursing believed the facility had enough staff on weekends, but the Administrator acknowledged the low weekend staffing indicated by the PBJ data. The facility's failure to update its assessment and consider resident acuity in staffing decisions contributed to the deficiency.
Failure to Re-Screen Resident for PASRR Condition
Penalty
Summary
The facility failed to ensure a re-screening for a resident with a PASRR condition, specifically intellectual disability, who exceeded the 60-day convalescent care approval without the required re-evaluation. The resident, diagnosed with quadriplegia, seizure disorder, malnutrition, pressure ulcers, and unspecified intellectual disabilities, was unable to complete the Brief Interview for Mental Status (BIMS). The care plan indicated a focus on PASRR recommendations, but the necessary status change was not submitted before the 60th day as required. The Director of Nurses identified Social Services, Staff A, as responsible for PASRR follow-up, who admitted to being new to the process and acknowledged the oversight. The facility lacked a specific policy on PASRR completion, relying instead on general regulations.
Inconsistent Documentation of Code Status for a Resident
Penalty
Summary
The facility failed to ensure consistent documentation of code status for a resident, leading to a discrepancy between the electronic medical record and the IPOST form. The resident, who had intact cognition as indicated by a BIMS score of 15 out of 15, had medical diagnoses including heart disease, anemia, acquired absence of parts of the digestive tract, and discitis. The electronic medical record and care plan indicated a Do Not Resuscitate (DNR) status, while the IPOST form, signed by the resident and provider, directed Cardiopulmonary Resuscitation (CPR). During an interview, the Director of Nurses (DON) acknowledged the inconsistency between the electronic medical record and the IPOST form for the resident's code status. The DON stated that nursing staff could access the resident's code status through either the electronic medical record or the IPOST document in the code status book, and expected them to match. However, there was no policy in place to guide the advance directive process, and the staff followed standard procedures based on physician orders or the IPOST form. This lack of policy contributed to the failure to ensure the resident's wishes were consistently documented and accessible in the event of a cardiac arrest.
Failure to Submit Discharge MDS Timely
Penalty
Summary
The facility failed to submit a discharge Minimum Data Set (MDS) within the required time frame for one resident. The MDS for the resident, who was discharged to another facility, was completed and signed by the MDS Coordinator but was not marked as submitted. The discharge was planned, and the return was not anticipated. The MDS Coordinator acknowledged that the document was mistakenly marked as 'do not submit' in the electronic health record, which was likely an error on her part. The facility did not have a specific policy for MDS assessments, and the staff followed the Resident Assessment Instrument (RAI) Manual for processing MDS data.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the documentation of their medical conditions. For one resident, the MDS did not reflect the diagnosis of intellectual disability as required by the Preadmission Screening and Resident Review (PASRR) form. The PASRR form had clearly indicated the need to document the intellectual disability on the MDS, but this was not completed. The MDS Coordinator acknowledged the oversight, noting that the resident should have been coded for intellectual deficit. Additionally, the facility lacked a specific policy on MDS completion, relying instead on the federally mandated process. Another resident's MDS inaccurately indicated that they were receiving hospice care, despite being discharged from hospice services prior to the MDS completion. The resident had been admitted to hospice care due to Lewy Body Dementia but was discharged when they no longer met the criteria for hospice care. The MDS Coordinator admitted that the Significant Change MDS was completed inaccurately, as it still showed the resident as receiving hospice care. This discrepancy was identified during a review of the MDS, highlighting the need for accurate and timely updates to resident records.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to uphold the dignity and privacy of residents during care, as observed in two separate incidents involving two residents. In the first incident, a resident was receiving incontinence care from two CNAs while being exposed from the waist to the knees, in full view of her roommate, as the privacy curtain was not pulled. During this time, a Guest Services Aide entered the room without knocking, and a Licensed Practical Nurse (LPN) entered after knocking but not waiting for a response, further exposing the resident to the hallway. The facility's policy on incontinence and perineal care, as well as mechanical lift transfer, requires staff to provide privacy and avoid unnecessary exposure, which was not adhered to in this case. In the second incident, a CNA assisted another resident to the restroom, who had a strong odor of urine and wet pants. After assisting the resident to use the toilet and applying a clean brief, the CNA pulled up the resident's wet pants and returned her to her wheelchair without changing them. This action was contrary to the facility's policy, which directs staff to make residents comfortable and change wet clothing. The Director of Nursing (DON) stated that staff are expected to knock and wait for a response before entering a resident's room and to ensure residents' privacy and comfort during care.
Failure to Follow Physician's Orders for Resident Care
Penalty
Summary
The facility failed to ensure services provided to residents met professional standards of quality by not following a physician's order for a resident. The resident, who had diagnoses including benign prostatic hyperplasia, hemiplegia, and non-Alzheimer's dementia, was brought back to the facility from the emergency room with testicular pain. The hospital notes indicated that the resident was to have a follow-up appointment with a urologist, but this appointment was not scheduled in a timely manner. The Director of Nursing (DON) acknowledged that the appointment should have been made the day after the resident returned from the hospital. However, it was not until eight days later that a call was made to the urology department, and the facility was still awaiting a return call. The resident expressed that the cysts were causing pain, and there was a lack of clarity about when the appointment would occur. The facility's policy required that all resident care be in accordance with physician's orders, which was not adhered to in this case.
Failure to Follow Safe Transfer Techniques
Penalty
Summary
The facility failed to follow safe transfer techniques for a resident, leading to a deficiency. The Minimum Data Set (MDS) for the resident documented frequent urinary incontinence, and the care plan specified that transfers should be assisted by two staff members. However, during an observation, a Certified Nursing Assistant (CNA) attempted to transfer the resident using a mechanical stand lift without the required assistance of a second staff member. The CNA acknowledged the need for a second person but proceeded with the transfer alone until another CNA arrived to assist. The facility's policy on mechanical lift transfers, revised in February 2024, advised that two staff members should be present for such transfers, and each resident's care plan should be adhered to. The Director of Nursing (DON) confirmed the expectation for two staff members to be present during the use of the mechanical stand lift. This incident highlights a failure to adhere to established safety protocols and care plans, resulting in a deficiency being noted by the surveyors.
Inadequate Incontinence and Catheter Care During COVID Outbreak
Penalty
Summary
The facility failed to provide proper incontinence and catheter care for three residents, as observed by surveyors. Staff members did not follow the facility's policies and procedures for hand hygiene and the use of personal protective equipment (PPE) during care. For Resident #13, staff members did not perform adequate cleaning of the resident's buttocks, hips, or legs during incontinence care. Additionally, they failed to perform hand hygiene after glove removal and before handling the resident's clothing and catheter drainage bag. In the case of Resident #14, a staff member removed her mask while in close proximity to residents during a COVID outbreak, which is against infection control protocols. The resident required assistance from two staff members, but care was initiated by only one staff member. The staff members did not adequately clean the resident's thighs, buttocks, and hips during perineal care, and hand hygiene was not performed appropriately after glove removal. For Resident #12, the staff member did not clean the resident's hips and buttocks during incontinence care and used the same wipe surface for multiple wipes, which is against the facility's policy. The staff member also failed to perform hand hygiene after glove removal. These actions indicate a lack of adherence to the facility's policies on catheter care, handwashing, and incontinence care, as confirmed by the Director of Nursing during an interview.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to follow physician orders for three residents, leading to deficiencies in medication administration. Resident #3, with moderate cognitive impairment and diabetes, did not receive prescribed doses of Humalog insulin on multiple occasions in April 2024, and Atorvastatin was not administered on one occasion. The progress notes indicated that the Humalog was unavailable, causing delays in administration. Resident #4, also with moderate cognitive impairment and diabetes, missed doses of Humalog and Trulicity due to unavailability, as noted in the March and April 2024 MARs. Resident #5, with diabetes and BPH, did not receive Januvia and Mirabegron on specified dates, with nurse's notes indicating the medications were not available. The facility's failure to administer medications as ordered by physicians was identified through clinical record reviews, facility policy reviews, and staff interviews. The deficiencies were attributed to the unavailability of medications, as documented in the MARs and nurse's notes. The facility's medication administration policy, revised in May 2023, aimed to ensure safe and accurate medication preparation and administration, but the lapses in following physician orders for these residents highlighted a significant issue in medication management and availability within the facility.
Failure to Provide Notice of Discharge from Skilled Services
Penalty
Summary
The facility failed to provide a notice of discharge from skilled services for one resident, leading to a deficiency. The resident, who had severe cognitive impairment and required extensive assistance for activities of daily living, was admitted to the facility with diagnoses including non-traumatic brain dysfunction, seizures, and lung disease. After experiencing a fall that required hospital treatment, the resident returned to the facility, and a Primary Care Physician directed staff to provide skilled nursing therapies due to impaired mobility and activities of daily living. However, the Director of Physical Therapy discharged the resident from skilled services, mistakenly believing the resident was placed on Hospice, without obtaining a physician's order or providing the required notice of discharge. The facility's administrator confirmed that there was a discussion with the resident's family regarding Hospice services, but no physician's order or documentation was found in the resident's clinical record to support the initiation of Hospice services. Consequently, the facility did not provide the resident with a notice of discharge from skilled services, nor did they offer the resident the right to appeal the discharge. This oversight resulted in a failure to comply with the requirement to notify residents of changes in their skilled service status and potential liability for services not covered by Medicaid/Medicare.
Medication Cart Security and EHR Privacy Violations
Penalty
Summary
The facility failed to ensure medication carts were locked at all times when not in use and did not secure resident medical records on the Electronic Health Record (EHR) system. During a continuous observation, a medication cart on Legacy Hall was found unlocked and unattended for several minutes, with a resident in a wheelchair close enough to access the cart. The cart was eventually locked by a registered nurse after being left unsecured for approximately 15 minutes. Additionally, a registered nurse left the EHR open and unattended on two separate occasions, each time for several minutes, allowing unauthorized access to resident information. Furthermore, the facility did not adhere to professional standards of practice during medication administration. A registered nurse left nine oral medications in a resident's room without ensuring the resident took them, leaving the room before the administration was complete. The nurse acknowledged the expectation to close the EHR screen and to stay with the resident until the medication was taken. The Director of Nursing confirmed these expectations and the facility's policy, which mandates securing the medication cart and ensuring the completion of medication administration before leaving the resident.
Failure to Implement Non-Pharmacological Interventions Before Administering Anti-Anxiety Medication
Penalty
Summary
The facility failed to provide and document the implementation of non-pharmacological interventions prior to administering as-needed anti-anxiety medications for a resident with moderate cognitive loss. The resident's care plan did not include non-pharmacological interventions to address agitation or restlessness before administering the medication. The facility's records showed multiple instances where the medication was administered without documented attempts of non-pharmacological interventions, contrary to the facility's policy and the Behavior Management Guide revised in July 2023. Staff interviews revealed that while nursing interventions should be tried and documented before administering as-needed anti-anxiety medication, this was not consistently done. Staff members admitted that due to being busy, interventions might not get documented, and if it wasn't documented, it didn't get done. Additionally, there were inconsistencies in accessing and utilizing the resident's care plan and Kardex, especially for agency staff who did not have computer logins to access these documents. The facility's documentation survey reports for February and March 2024 indicated that the resident had no documented behaviors or interventions on most days, despite the frequent administration of anti-anxiety medication. The Director of Nursing confirmed that there should be a nursing order to monitor resident behaviors and provide three interventions before administering as-needed anti-anxiety medications, which was not observed in the resident's orders. This lack of adherence to the facility's policy and proper documentation led to the identified deficiency.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 189 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cedar Rapids
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cottage Grove Place | 0.3 mi | ★★★★★ | 2 | 1 |
| Living Center West | 1.2 mi | ★★★★★ | 2 | 0 |
| St Luke's Helen G Nassif Transitional Care Center | 2.3 mi | ★★★★★ | 4 | 0 |
| Linn Manor Care Center | 2.7 mi | ★★★★★ | 10 | 0 |
| Meth-wick Health Center | 2.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.