Federal inspectors found that Harmony Dubuque violated residents' rights to communicate with family members during a November complaint investigation. The facility's own policies promised to treat residents with dignity and respect, but staff made unilateral decisions about whether residents could speak with loved ones.
Resident #3, who scored 14 out of 15 on a cognitive assessment indicating intact mental function, told inspectors on November 13 that family visits and phone calls were very important to her. She had lived at the facility since January 2020 and was on medication for depression and anxiety.
The resident revealed that one family member had told her multiple times about failed attempts to reach her by phone. Another family member reported being unable to speak with the resident for two weeks despite repeated calls, mostly in the evening.
"Staff told the family member the resident was eating or sleeping and could not come to the phone," according to the inspection report.
But the resident said she was never informed about these calls. "If that family member called for her, no one told her and she would have taken the call," inspectors documented.
Even more troubling, the resident had no idea she could use the facility phone to call her family. When asked if she called them herself, "Resident #3 stated no one had ever told her she could use the facility phone to do that."
Staff B, the office manager, explained the facility's phone system to inspectors. All calls came through one line until 8:00 PM, then went directly to nurses stations. To connect calls to residents, callers were placed on hold while staff announced the call over the speaker system.
Two cordless phones were available at each nurses station. "Any staff should take the phone to the resident, take it off of hold, and let the resident talk in private," Staff B said. Residents could also be brought to the nurses station if they preferred.
The office manager described her standard practice when residents were eating or sleeping: tell the caller and let them decide whether to wake the resident, interrupt their meal, call back, or have the resident return the call later.
But when inspectors asked if residents were always given a choice about taking calls, Staff B revealed a crucial exception. "It depended on if the caller was the Power of Attorney."
This admission showed staff were making decisions based on who was calling rather than respecting the resident's right to communicate.
Staff E, a licensed practical nurse, told inspectors that "99 percent of the time residents took calls from loved ones if they knew they were on the phone." This statement underscored how rarely residents were actually informed about incoming calls.
The administrator, who had been at the facility for only a month, said she wasn't aware of concerns about family calls getting through. She told inspectors she expected all staff to ensure residents could speak with their loved ones.
The facility's own policy, revised in April 2024, promised to treat residents with dignity and respect while maintaining their self-esteem and self-worth. The policy specifically guaranteed residents' rights to "considerate and respectful care" and to "have access to visitors."
The policy also affirmed residents' rights to "be free from involuntary seclusion" and "to manage their own care" — rights that were violated when staff decided unilaterally whether residents could take phone calls from family.
For Resident #3, who struggled with anxiety and depression and whose care plan noted she was unable to discharge to the community, these blocked communications represented more than administrative oversight. Family contact was described as "very important to her," yet staff had systematically prevented these connections for weeks.
The inspection found the facility failed to ensure residents could exercise their basic rights as citizens. While staff claimed to follow procedures for managing phone calls, the reality was that residents weren't informed about calls from family members and weren't told they could make outgoing calls themselves.
The violation affected the fundamental relationship between residents and their families. In a setting where residents depend on staff for basic communication with the outside world, the facility's practices created an involuntary barrier between people who needed each other most.
Federal inspectors classified this as a violation causing minimal harm or potential for actual harm affecting few residents. But for those residents cut off from family contact, the impact was far from minimal.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Harmony Dubuque from 2025-11-13 including all violations, facility responses, and corrective action plans.