Harmony House Health Care Center
2950 West Shaulis Road, Waterloo, IA 50701 · Black Hawk County · 65 certified beds · avg 43 residents/day · certified since Mar 30, 1989
SFF Candidate
Part of chain: LEGACY HEALTHCARE (89 facilities, chain avg rating 2.9★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Aug 6, 2025 · F-0609
The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
Why it matters: When incidents aren't reported promptly, abusers may continue harming residents and outside authorities can't step in.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Sep 9, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Aug 6, 2025 · F-0610
The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do.
Why it matters: When allegations aren't investigated, harm to residents can continue unchecked.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Sep 9, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Mar 25, 2026 · F-0692 · triggered by a complaint
The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Why it matters: Malnutrition and dehydration can quickly weaken a resident and lead to serious complications.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 16, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jan 24, 2024 · F-0550 · triggered by a complaint
The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Why it matters: Being treated without dignity harms a resident's self-worth, mental health, and overall quality of life.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jan 30, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (38)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jun 30, 2026 | E · Potential for harm, repeated | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. · from a complaint |
| Jun 30, 2026 | E · Potential for harm, repeated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint |
| Jun 30, 2026 | D · Potential for harm, one-off | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. · from a complaint |
| Jun 30, 2026 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Jun 30, 2026 | D · Potential for harm, one-off | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| May 18, 2026 | D · Potential for harm, one-off | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · from a complaint |
| May 18, 2026 | D · Potential for harm, one-off | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| May 18, 2026 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Mar 25, 2026 | ▲ G · Actual harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint |
| Mar 25, 2026 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Mar 25, 2026 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Mar 25, 2026 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Mar 25, 2026 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Mar 25, 2026 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Mar 25, 2026 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Mar 25, 2026 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Mar 25, 2026 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. · from a complaint |
| Mar 25, 2026 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Mar 25, 2026 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Aug 6, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Aug 6, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. |
| Aug 6, 2025 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Aug 6, 2025 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint |
| Aug 6, 2025 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. · from a complaint |
| Aug 6, 2025 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| Aug 6, 2025 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Aug 6, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Aug 6, 2025 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Aug 6, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Aug 6, 2025 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Aug 6, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Aug 6, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Apr 16, 2025 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Sep 12, 2024 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Sep 12, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Sep 12, 2024 | E · Potential for harm, repeated | The facility employed staff who were not licensed, certified, or registered as required by state law. · from a complaint |
| Sep 12, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jan 24, 2024 | ▲ G · Actual harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (4 → 13).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2024 | 5 | 1 | G ▲ |
| 2025 | 14 | 2 | J ▲ |
| 2026 | 19 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $48,825.
| Date | Type | Amount / length |
|---|---|---|
| Mar 25, 2026 | Fine | $48,825 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Iowa avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.51 | 4.37 | 3.95 | bottom 8% in Iowa; bottom 37% in the U.S. |
| Registered Nurse hours | 0.52 | 0.85 | 0.69 | bottom 13% in Iowa; bottom 40% in the U.S. |
| Weekend total nurse staffing | 3.28 | 3.86 | 3.50 | bottom 22% in Iowa; bottom 46% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.32 | 0.51 | 0.48 | bottom 20% in Iowa; bottom 35% in the U.S. |
| Total nursing staff turnover (%) | 61.5 | 44.0 | 45.8 | bottom 10% in Iowa; bottom 14% in the U.S. |
| RN turnover (%) | 33.3 | 42.1 | 42.9 | top 38% in Iowa; top 33% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.84, RN 0.57, weekend 3.58. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 3/5 · short-stay residents: —/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Rajchenbach, Chaim | Individual | 5% or Greater Direct Ownership Interest | 50% | 08/15/2024 |
| Beasley, Karla | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/15/2024 |
| Behounek, Linsey | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/15/2024 |
| Borcherding, Jenny | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/15/2024 |
| Burken, Sheri | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/15/2024 |
| Cascade Capital Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/15/2024 |
| Cascade Capital Partners LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/15/2024 |
| CCG Gorgona LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/15/2024 |
| Cutler, Darron | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/15/2024 |
| Elwick, Lisa | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/15/2024 |
| Friedenberg, Laura | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/15/2024 |
| Friedman, Brian | Individual | Trustee of the SNF | NOT APPLICABLE | 01/03/2012 |
| Geiger, Mary | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/15/2024 |
| Gorgona Holdco LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/15/2024 |
| Gorgona Propco Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/15/2024 |
| Gorgona Sub Holdco LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/15/2024 |
| Hedberg, Jennifer | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/15/2024 |
| Hennager, Christina | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/15/2024 |
| Heying, Larina | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/15/2024 |
| Houston, Mindy | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/15/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "What do you do daily to keep residents moving, and how do you help residents at risk of losing mobility?"
- "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
- "What choices do residents have over their daily schedule, like meal times, bathing, and activities?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Pinnacle Specialty Care | 3.4 mi | Cedar Falls, IA | ★★☆☆☆ | 2/5 | |
| Harmony Waterloo | 3.5 mi | Waterloo, IA | ★☆☆☆☆ | 1/5 | abuse |
| The Suites at Western Home Communities | 3.5 mi | Cedar Falls, IA | ★★★★★ | 5/5 | |
| Friendship Village Retirement | 3.6 mi | Waterloo, IA | ★★★★★ | 4/5 | |
| Ravenwood Specialty Care | 3.9 mi | Waterloo, IA | ★☆☆☆☆ | 1/5 | |
| Newaldaya Lifescapes | 5.1 mi | Cedar Falls, IA | ★★☆☆☆ | 2/5 | |
| Martin Health Center, INC | 6.1 mi | Cedar Falls, IA | ★★★★★ | 4/5 | |
| Cedar Falls Health Care Center | 6.6 mi | Cedar Falls, IA | ★★☆☆☆ | 2/5 | |
| Northcrest Specialty Care | 7.0 mi | Waterloo, IA | ★★☆☆☆ | 2/5 | |
| Pillar of Cedar Valley | 9.2 mi | Waterloo, IA | ★☆☆☆☆ | 2/5 | |
| Parkview Manor Care Center | 12.7 mi | Reinbeck, IA | ★☆☆☆☆ | 1/5 | |
| Laporte City Specialty Care | 15.1 mi | La Porte City, IA | ★★★★☆ | 4/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 165152.