Inspection Reports for
Harmony Utica Ridge
3800 Commerce Blvd, Davenport, IA, 528073495
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
15.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
248% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Routine
Census: 88
Deficiencies: 12
Date: Apr 21, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident care, medication management, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to notify providers of significant weight changes, untimely completion and accuracy of Minimum Data Set (MDS) assessments, incomplete care plans, failure to follow physician orders for wound care, inadequate fall prevention measures, improper catheter care, delayed pain medication administration, expired food storage, inaccurate staffing reports, failure to implement enhanced barrier precautions, and incomplete documentation of pneumococcal vaccinations.
Deficiencies (12)
Failed to notify provider of weight change of 3 pounds or more in one day for Resident #67.
Failed to ensure timely completion of quarterly MDS assessments for 4 residents.
Failed to ensure accuracy of Section N, Medications, on MDS assessments for 2 residents.
Failed to include dialysis services and anticoagulant use in care plans for 2 residents.
Failed to follow physician orders for treatment of surgical wound for Resident #87.
Failed to ensure foot pedals were utilized when residents transported in wheelchairs and inconsistent fall interventions for 3 residents.
Failed to maintain indwelling catheter bag and tubing off the floor for Resident #43.
Failed to ensure availability of scheduled and as needed pain medications for Resident #104.
Failed to discard expired lettuce and failed to record evening meal temperatures for 3 days.
Failed to ensure accurate reporting of weekend staffing hours in Payroll Based Journal.
Failed to implement Enhanced Barrier Precautions for Resident #43 with indwelling catheter.
Failed to provide documentation of residents' refusal or acceptance of pneumococcal vaccine for 3 residents.
Report Facts
Residents affected: 1
Residents affected: 4
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 1
Days: 3
Quarter: 1
Residents affected: 1
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff L | Licensed Practical Nurse | Mentioned in weight change notification deficiency |
| Staff M | Licensed Practical Nurse | Mentioned in weight change notification deficiency |
| Staff O | Registered Nurse Unit Manager | Mentioned in weight change notification deficiency |
| Director of Nursing | Interviewed regarding multiple deficiencies including weight notification, MDS timeliness, care plans, wound care, fall prevention, catheter care, pain management, staffing, infection control, and vaccination documentation | |
| Staff J | MDS Coordinator | Mentioned in MDS timeliness and accuracy deficiencies and vaccination documentation |
| Staff C | Registered Nurse | Mentioned in care plan and catheter care deficiencies |
| Staff Q | Registered Nurse | Mentioned in wound care deficiency |
| Staff I | Licensed Practical Nurse | Mentioned in fall incident and fall prevention deficiency |
| Staff A | Certified Nursing Assistant | Mentioned in fall prevention deficiency |
| Staff B | Registered Nurse | Mentioned in fall prevention deficiency |
| Staff D | Certified Nursing Assistant | Mentioned in catheter care and infection control deficiencies |
| Staff R | Licensed Practical Nurse | Mentioned in pain medication management deficiency |
| Staff AK | Certified Nursing Assistant | Mentioned in fall prevention deficiency |
Inspection Report
Routine
Census: 88
Deficiencies: 3
Date: Apr 21, 2025
Visit Reason
The inspection was conducted to evaluate compliance with physician orders, pain management, and infection prevention and control practices at the facility.
Findings
The facility failed to follow physician orders for wound care treatment for one resident, failed to ensure timely availability of scheduled and as-needed pain medications for another resident, and failed to implement Enhanced Barrier Precautions for a resident with an indwelling catheter. The facility reported a census of 88 residents.
Deficiencies (3)
Failed to follow physician orders for treatment of left lower leg surgical site for Resident #87, including use of alternate treatment application without proper documentation or provider notification.
Failed to ensure availability of scheduled medications and timely availability of as-needed pain medication for Resident #104.
Failed to implement Enhanced Barrier Precautions by not wearing isolation gown when emptying catheter bag for Resident #43 with an indwelling catheter.
Report Facts
Residents Affected: 1
Residents Affected: 1
Residents Affected: 1
Census: 88
Hydrocodone-Acetaminophen tablets: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Q | Registered Nurse (RN) | Performed wound care and reported treatment order changes for Resident #87 |
| Staff R | Licensed Practical Nurse (LPN) | Worked overnight shift and administered pain medication to Resident #104 |
| Staff N | Certified Nursing Assistant (CNA) | Observed not wearing isolation gown during catheter care for Resident #43 |
| Staff D | Certified Nursing Assistant (CNA) | Interviewed about Enhanced Barrier Precautions for catheter care |
| Director of Nursing | Director of Nursing (DON) | Provided information on nursing expectations and facility policies related to deficiencies |
Inspection Report
Routine
Census: 84
Deficiencies: 1
Date: Jul 25, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with infection prevention and control standards during wound care.
Findings
The facility failed to implement proper infection control practices during wound care, including failure to remove isolation gowns before exiting a resident's room and not changing gloves between wound care tasks. Observations and staff interviews confirmed these lapses.
Deficiencies (1)
Failure to implement infection prevention and control program during wound care, including not removing isolation gown before exiting resident's room and not changing gloves between wound care tasks.
Report Facts
Census: 84
Wound measurement length: 3.8
Wound measurement width: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Registered Nurse (RN) | Observed failing to remove isolation gown and change gloves appropriately during wound care |
| Staff L | Certified Nursing Assistant (CNA) | Observed assisting with wound care and involved in infection control observation |
| Staff M | Nurse Practitioner (NP) | Observed during wound care and interviewed regarding infection control practices |
| Staff E | Licensed Practical Nurse (LPN) | Interviewed regarding wound care and infection control practices |
| Staff G | Registered Nurse (RN) | Interviewed regarding wound care and infection control practices |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding expectations for wound care and infection control |
Inspection Report
Census: 89
Deficiencies: 3
Date: Jun 13, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, including mental health assessments, pressure ulcer care, and dialysis care.
Findings
The facility failed to submit a Change in Status PASRR assessment for a resident with new mental health diagnoses, failed to provide appropriate pressure ulcer care resulting in immediate jeopardy and resident death, and failed to complete nursing assessments before and after dialysis for a resident. The facility reported a census of 89 residents.
Deficiencies (3)
Failed to submit a Change in Status PASRR assessment after new mental health diagnoses were determined for Resident #38.
Failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for Resident #16, resulting in immediate jeopardy and resident death.
Failed to complete nursing assessments and monitoring before and after outpatient dialysis for Resident #72.
Report Facts
Residents Affected: 1
Residents Affected: 1
Residents Affected: 1
Census: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Licensed Practical Nurse (LPN) | Named in wound care deficiency related to Resident #16 |
| Staff F | Licensed Practical Nurse (LPN) | Named in wound care deficiency related to Resident #16 |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding wound care and dialysis care deficiencies |
| Staff H | Wound Nurse | Named in wound care deficiency related to Resident #16 |
Inspection Report
Routine
Census: 89
Deficiencies: 2
Date: Jun 13, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including wound care and dialysis services, following concerns about pressure ulcer care and dialysis assessments.
Findings
The facility failed to provide appropriate wound assessment and intervention for Resident #16, resulting in immediate jeopardy and the resident's subsequent hospitalization and death. Additionally, the facility failed to complete nursing assessments before and after dialysis for Resident #72, indicating lapses in monitoring and documentation.
Deficiencies (2)
Failure to provide wound assessment and intervention for Resident #16, leading to infected pressure ulcers and sepsis.
Failure to complete nursing assessments and monitoring before and after outpatient dialysis for Resident #72.
Report Facts
Residents affected: 1
Residents affected: 1
Facility census: 89
Wound measurement: 4.5
Wound measurement: 3
Wound measurement: 0.5
Wound measurement: 5
Wound measurement: 1.5
Wound measurement: 1.5
Wound measurement: 1.5
Wound measurement: 2
Wound measurement: 0.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Licensed Practical Nurse | Named in wound care deficiency and interview regarding Resident #16 |
| Staff F | Licensed Practical Nurse | Named in wound care deficiency and interview regarding Resident #16 |
| Staff H | Wound Nurse | Named in wound care assessment for Resident #16 |
| Director of Nursing | Director of Nursing | Interviewed regarding wound care expectations and dialysis care for Residents #16 and #72 |
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 5
Date: Mar 5, 2024
Visit Reason
The inspection was conducted following complaints regarding resident care, dignity, and safety concerns involving multiple residents, including allegations of staff mistreatment and failure to provide adequate care.
Complaint Details
The investigation was complaint-driven, triggered by allegations of mistreatment, inadequate care, and safety concerns involving multiple residents. The facility could not substantiate some claims but found other quality of care issues. Immediate jeopardy was identified related to a resident fall resulting in death.
Findings
The facility failed to ensure residents were treated with dignity and respect, failed to update care plans appropriately, failed to provide adequate nail and shower care, failed to document complete assessments, and failed to supervise a resident properly resulting in a fall with serious injury and death. Several incidents involved staff roughness, inadequate care planning, and lack of proper follow-up.
Deficiencies (5)
Failure to honor residents' rights to dignity and respect, including an incident where a CNA slapped a resident's hand.
Failure to update the care plan for skin tear and related interventions for a resident.
Failure to provide nail care to feet of residents and failure to provide showers twice weekly as scheduled.
Failure to document complete assessment and follow-up for residents with infections and wounds.
Failure to supervise a resident with left-sided weakness during bed mobility resulting in a fall, subdural hematoma, and death.
Report Facts
Residents census: 99
Skin tear measurement: 5.5
Fall incident date: Feb 20, 2024
Blood pressure: 241
Blood pressure: 102
Glucose level: 59
Subdural hematoma size: 5.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | CNA | Named in allegation of slapping Resident #4's hand and terminated after investigation |
| Staff D | CNA | Witness to incident involving Resident #4 |
| Staff E | CNA | Reported on Staff C's conduct and Resident #7's transfer incident |
| Staff B | CNA | Reported on proper use of Sara lift and shower frequency |
| Staff F | LPN | Reported on catheter insertion documentation and fall incident |
| Staff G | LPN | Responded to Resident #14 fall, witnessed seizure, and reported incident details |
| Staff Q | CNA | Provided incontinent care to Resident #14 alone, involved in fall incident |
| Staff S | CMA/CNA | Observed Resident #14 post-fall and reported seizure |
| Staff H | RN | Reported on podiatrist visits and Resident #13 care |
| Staff I | LPN/Unit Manager | Reported on podiatrist scheduling and expectations for nail care |
| Staff M | DO | Could not recall details of Resident #5 hospital transfer |
| Staff O | LPN | Reported on catheter insertion and hematuria documentation |
| Director of Nursing | DON | Provided multiple interviews regarding incidents, care expectations, and fall investigation |
| Administrator | Provided interviews regarding facility policies and incident expectations |
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 10
Date: Apr 18, 2023
Visit Reason
The inspection was conducted due to complaints and concerns regarding medication self-administration, misappropriation of narcotic medications, timely reporting of suspected abuse or theft, medication administration errors, shower frequency, catheter care, oxygen tubing changes, and infection control practices.
Complaint Details
The complaint investigation involved allegations of medication misappropriation, failure to provide care, delayed reporting of abuse and theft, medication administration errors, and infection control breaches. The facility reported a census of 91 residents. Multiple residents were involved in the narcotic diversion and medication administration concerns. The investigation included interviews with staff and residents, record reviews, and observations.
Findings
The facility failed to ensure residents were properly assessed for self-administration of medications, failed to prevent misappropriation of narcotic medications for multiple residents, delayed reporting suspected abuse and theft, failed to conduct thorough investigations of drug diversion, failed to administer medications per physician orders, failed to provide showers twice weekly for a resident, failed to provide consistent and proper catheter care, failed to change oxygen tubing weekly, and failed to ensure proper infection control practices related to COVID-19 precautions.
Deficiencies (10)
Failed to ensure residents were assessed to self-administer medications prior to medications being left at bedside (Resident #402).
Failed to protect residents from misappropriation of narcotic pain medications including fentanyl patch and opioids for multiple residents (#18, #59, #87, #247).
Failed to timely report suspected abuse, neglect, or theft and report investigation results to proper authorities.
Failed to respond appropriately to all alleged violations including thorough investigation of drug diversion involving multiple residents.
Failed to ensure medications were administered per physician orders and failed to clarify conflicting medication administration instructions for seven residents.
Failed to provide showers twice weekly for Resident #30 as per care plan and resident report.
Failed to ensure catheter care was consistently performed and proper technique followed for Residents #27 and #71.
Failed to change oxygen tubing weekly for Resident #29 as ordered.
Failed to safeguard against potential loss and/or diversion of controlled substances due to lack of complete documentation when administering narcotics for 12 residents.
Failed to ensure staff perform proper infection control techniques to protect against potential exposure of COVID-19 virus for 3 residents.
Report Facts
Residents affected: 91
Deficiencies cited: 10
Medication doses signed out but not documented: 64
Medication doses signed out but not documented: 20
Oxygen tubing date: Mar 13, 2023
Medication doses administered: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff K | Licensed Practical Nurse (LPN) | Named in multiple findings related to narcotic medication misappropriation and documentation discrepancies |
| Staff N | Registered Nurse (RN)/Unit Manager | Conducted investigation of drug diversion and identified documentation issues |
| Staff M | Licensed Practical Nurse (LPN) | Interviewed regarding narcotic medication discrepancies and medication cart management |
| Staff L | Registered Nurse (RN) | Involved in narcotic patch diversion incident and medication administration |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding reporting, investigation, and medication administration practices |
| Administrator | Facility Administrator | Interviewed regarding reporting delays and investigation of drug diversion |
| Staff E | Certified Nurse Aide (CNA) | Observed failing to use PPE during COVID isolation care |
| Staff F | Registered Nurse (RN)/Agency | Observed failing to verify isolation status before providing care |
| Staff B | Certified Nursing Assistant (CNA) | Observed performing catheter care with improper technique |
| Staff C | Certified Nursing Assistant (CNA) | Observed performing catheter care with improper technique |
Inspection Report
Routine
Census: 91
Deficiencies: 10
Date: Apr 18, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including medication administration, resident care, infection control, and other standards.
Findings
The facility was found deficient in multiple areas including failure to assess residents for self-administration of medications, misappropriation and diversion of narcotic medications, failure to timely report suspected abuse and theft, failure to conduct thorough investigations of drug diversion, failure to administer medications as ordered, failure to provide showers twice weekly for a resident, inconsistent catheter care, failure to change oxygen tubing weekly, and incomplete documentation of narcotic administration.
Deficiencies (10)
Failure to ensure residents were assessed to self-administer medications prior to medications being left at bedside (Resident #402).
Failure to protect residents from misappropriation of narcotic medications including fentanyl patch and opioids for multiple residents (#18, #59, #87, #247).
Failure to timely report suspected abuse, neglect, or theft and report investigation results to proper authorities.
Failure to conduct thorough investigation of drug diversion involving multiple residents and staff.
Failure to administer medications per physician orders and failure to clarify conflicting medication administration instructions for seven residents.
Failure to provide showers twice weekly for Resident #30 as per care plan and resident report.
Failure to ensure proper catheter care and use of securement device for residents with indwelling catheters (#27 and #71).
Failure to change oxygen tubing weekly for Resident #29 as ordered.
Failure to safeguard against potential loss or diversion of controlled substances due to lack of complete documentation of narcotic administration for 12 residents.
Failure to implement infection prevention and control program to ensure staff perform proper infection control techniques to prevent COVID-19 exposure for residents.
Report Facts
Residents affected: 91
Deficiency count: 10
Narcotic administration discrepancies: 64
Medication doses not documented: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff K | Licensed Practical Nurse (LPN) | Named in multiple findings related to narcotic medication diversion and documentation discrepancies |
| Staff N | Registered Nurse (RN)/Unit Manager | Conducted investigation of narcotic diversion and identified documentation issues |
| Staff L | Registered Nurse (RN) | Discovered fentanyl patch diversion and reported incident |
| Staff M | Licensed Practical Nurse (LPN) | Interviewed regarding narcotic diversion and medication administration |
| Staff J | Licensed Practical Nurse (LPN) | Interviewed regarding medication administration and narcotic diversion |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding multiple deficiencies including reporting, investigations, and medication administration |
| Administrator | Facility Administrator | Interviewed regarding narcotic diversion investigation and reporting |
| Regional Nurse Consultant (RNC) | Regional Nurse Consultant | Provided guidance during narcotic diversion investigation |
| Staff B | Certified Nursing Assistant (CNA) | Observed performing catheter care with improper technique |
| Staff C | Certified Nursing Assistant (CNA) | Observed performing catheter care with improper technique |
| Staff E | Certified Nursing Assistant (CNA) | Observed failing to use PPE during care of resident in isolation |
| Staff F | Registered Nurse (RN)/Agency | Interviewed regarding isolation precautions and PPE use |
| Staff D | Registered Nurse (RN) | Observed administering medication late and interviewed about medication administration practices |
| Staff G | Registered Nurse (RN) | Interviewed regarding oxygen tubing change frequency |
| Staff H | Certified Nursing Assistant (CNA) | Interviewed regarding shower frequency and documentation |
| Staff I | Certified Nursing Assistant (CNA) | Interviewed regarding shower frequency and documentation |
| Staff R | Agency Licensed Practical Nurse (LPN) | Interviewed regarding medication cart sharing and narcotic administration |
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