Harmony Cedar Rapids: Preventable Fall Fracture Violation - IA
The administrator went further. She called it 100% preventable.
Federal inspectors cited the facility on December 23, 2025, for failing to protect Resident 1 from a fall that resulted in an actual fracture. The deficiency was tagged at a level of actual harm. Two certified nursing assistants, identified in the inspection report as Staff A and Staff B, were transferring the resident without using the required mechanical stand lift. The lift, along with a sling and support belt designed to hold a resident securely during the move from seated to standing, was the facility's required method for that resident's transfers. Neither aide used it.
The facility's own instructions for the standing sling describe exactly what the equipment is supposed to do: position the sling around the patient's lower back, wrap the leg flaps around the legs, fasten the support belt securely by pressing the buckles together. The belt, according to the instructions, should be tight but comfortable. The skills check-off sheet the facility provided to inspectors, dated July 2018, directed staff to fasten the safety belt around the resident's waist before any lift transfer began.
None of that happened.
The director of nursing told inspectors that if a resident refused to use safety equipment, she expected staff to stop and notify a nurse. Not to proceed without it. To stop and get a nurse. The director said the fall and fracture were preventable.
The administrator, speaking to inspectors at 2:20 in the afternoon on the day of the inspection, said she expected CNAs to transfer Resident 1 with the stand lift and with the belt and straps in place, every time. She reported that both Staff A and Staff B had been terminated as a result of their failure to follow that expectation. Then she said the fall and the fracture were 100% preventable.
Two people independently said the same thing: this did not have to happen.
What the inspection report does not resolve is what Resident 1 experienced in the moments between the transfer beginning without the lift and the fall itself, or what the fracture has meant for that person's recovery, mobility, or daily life since. Fractures in nursing home residents, depending on location and severity, can mean weeks of restricted movement, surgical intervention, or a permanent change in what a person can do independently. The report notes the harm as actual. It does not describe what comes next for the person who was dropped.
The facility's mechanical lift program has been in place since at least 2018, when the skills check-off sheet was last dated. The sling instructions provided to inspectors carried no date at all. Whether Staff A and Staff B had been trained on that equipment, how recently, and what that training looked like are questions the inspection summary does not answer.
What it does answer is simpler and harder to set aside. The equipment existed. The instructions existed. The expectation from both the director of nursing and the administrator was unambiguous. A resident who needed a mechanical lift to transfer safely did not get one. That resident fell. That resident fractured a bone.
Both aides lost their jobs. The facility called it preventable.
Resident 1 still has the fracture.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Harmony Cedar Rapids from 2025-12-23 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 19, 2026 · Our methodology
Harmony Cedar Rapids in Cedar Rapids, IA was cited for violations during a health inspection on December 23, 2025.
The administrator went further.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.