Harmony Marshalltown
910 East Olive, Marshalltown, IA 50158 · Marshall County · 72 certified beds · avg 51 residents/day · certified since Feb 1, 1998
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 5, 2025 · F-0627 · triggered by a complaint
The facility did not make sure a transfer or discharge met the resident's needs and preferences, or did not properly prepare the resident to leave safely.
Why it matters: A rushed or poorly planned move can leave a resident somewhere that can't meet their needs.
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 5, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Aug 5, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
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 5, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Aug 5, 2025 · F-0686 · triggered by a complaint
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.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
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: Sep 5, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Sep 18, 2023 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
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: Sep 21, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (46)
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 |
|---|---|---|
| May 20, 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 |
| Jan 14, 2026 | F · Potential for harm, facility-wide | 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. |
| Jan 14, 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. |
| Jan 14, 2026 | D · Potential for harm, one-off | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| Jan 14, 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. |
| Aug 5, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not make sure a transfer or discharge met the resident's needs and preferences, or did not properly prepare the resident to leave safely. · from a complaint |
| Aug 5, 2025 | ▲ J · Immediate jeopardy, 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 |
| Aug 5, 2025 | ▲ G · Actual 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. · from a complaint |
| Aug 5, 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 |
| Aug 5, 2025 | E · Potential for harm, repeated | The facility did not have policies on smoking. · from a complaint |
| Aug 5, 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. · from a complaint |
| Aug 5, 2025 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Aug 5, 2025 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Apr 10, 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. · from a complaint |
| Apr 10, 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. · from a complaint |
| Apr 10, 2025 | D · Potential for harm, one-off | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint |
| Apr 10, 2025 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Dec 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. |
| Dec 12, 2024 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. · from a complaint |
| Dec 12, 2024 | 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. |
| Dec 12, 2024 | 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. |
| Dec 12, 2024 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Dec 12, 2024 | D · Potential for harm, one-off | 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 |
| Dec 12, 2024 | D · Potential for harm, one-off | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. |
| Dec 12, 2024 | 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. |
| Dec 12, 2024 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Dec 12, 2024 | D · Potential for harm, one-off | The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status. |
| Sep 25, 2024 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Sep 12, 2024 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Sep 12, 2024 | 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 |
| Sep 12, 2024 | 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 |
| Sep 12, 2024 | D · Potential for harm, one-off | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. · from a complaint |
| Sep 12, 2024 | 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 |
| Sep 12, 2024 | 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 |
| Sep 12, 2024 | 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 |
| Feb 1, 2024 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Feb 1, 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. |
| Feb 1, 2024 | 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 |
| Feb 1, 2024 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. |
| Feb 1, 2024 | 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. |
| Feb 1, 2024 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Feb 1, 2024 | 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 |
| Feb 1, 2024 | D · Potential for harm, one-off | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. · from a complaint |
| Feb 1, 2024 | B · Minimal risk, repeated | The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. |
| Sep 18, 2023 | ▲ G · Actual 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 |
| Sep 18, 2023 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (9 → 4).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 2 | 1 | G ▲ |
| 2024 | 27 | 0 | E |
| 2025 | 12 | 3 | J ▲ |
| 2026 | 5 | 0 | F |
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 $78,878.
| Date | Type | Amount / length |
|---|---|---|
| Aug 5, 2025 | Fine | $78,878 |
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) | 4.64 | 4.37 | 3.95 | top 34% in Iowa; top 20% in the U.S. |
| Registered Nurse hours | 0.51 | 0.85 | 0.69 | bottom 13% in Iowa; bottom 39% in the U.S. |
| Weekend total nurse staffing | 4.22 | 3.86 | 3.50 | top 29% in Iowa; top 17% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.36 | 0.51 | 0.48 | bottom 27% in Iowa; bottom 44% in the U.S. |
| Total nursing staff turnover (%) | 50.7 | 44.0 | 45.8 | bottom 29% in Iowa; bottom 35% in the U.S. |
| RN turnover (%) | 90.9 | 42.1 | 42.9 | bottom 3% in Iowa; bottom 2% 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 4.01, RN 0.44, weekend 3.65. Staffing rating: 3/5.
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: 4/5 · short-stay residents: 2/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Burken, Sheri | Individual | 5% or Greater Indirect Ownership Interest | — | 08/15/2024 |
| Garden, Daniel | Individual | Indirect Ownership Interest | NOT APPLICABLE | 08/15/2024 |
| Ninio, Mordechay | Individual | Indirect Ownership Interest | NOT APPLICABLE | 08/15/2024 |
| Beasley, Karla | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/17/2025 |
| Behounek, Linsey | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/17/2025 |
| Borcherding, Jenny | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/17/2025 |
| Cascade Capital Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/17/2025 |
| Cascade Capital Partners LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/17/2025 |
| CCG Gorgona LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/17/2025 |
| Dhondt, Justina | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/17/2025 |
| Friedenberg, Laura | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/17/2025 |
| Gorgona Holdco LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/17/2025 |
| Gorgona Propco Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/17/2025 |
| Gorgona Sub Holdco LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/17/2025 |
| Hedberg, Jennifer | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/17/2025 |
| Hennager, Christina | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/17/2025 |
| Heying, Larina | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/17/2025 |
| Houston, Mindy | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/17/2025 |
| Jaeger, Krystle | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/17/2025 |
| Knutson, Michele | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/17/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Before a resident is discharged or transferred, how do you make sure the new place can actually meet their needs?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "Where do you post your daily staffing numbers, and can I see today's?"
- "What is your nurse and aide staffing ratio on each shift, including nights and weekends?"
- "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 |
|---|---|---|---|---|---|
| Accura Healthcare of Marshalltown | 1.2 mi | Marshalltown, IA | ★☆☆☆☆ | 1/5 | abuse |
| Southridge Specialty Care | 1.4 mi | Marshalltown, IA | ★★☆☆☆ | 2/5 | |
| Iowa Veterans Home | 2.5 mi | Marshalltown, IA | ★★★★★ | 5/5 | |
| Oakview Nursing Home | 13.6 mi | Conrad, IA | ★★★★☆ | 4/5 | |
| Westbrook Acres | 14.1 mi | Gladbrook, IA | ★★☆☆☆ | 3/5 | |
| State Center Specialty Care | 14.1 mi | State Center, IA | ★★★★★ | 3/5 | |
| Accura Healthcare of Toledo | 16.2 mi | Toledo, IA | ★★★☆☆ | 4/5 | |
| Sunny Hill Care Center | 16.6 mi | Tama, IA | ★☆☆☆☆ | 1/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 165385.