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Complaint Investigation

Colonial Manor Of Elma

August 28, 2025 · Elma, IA · 407 9th Street
Citations 1
CMS Rating 4/5
Beds 40
Provider ID 165386
Healthcare Facility
Colonial Manor Of Elma
Elma, IA  ·  View full profile →
Inspection Summary

Colonial Manor of Elma in Elma, IA — inspection on August 28, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0656
Resident Assessment and Care Planning Deficiencies
Potential for More Than Minimal Harm

Review of the Witness Statement for Staff A License Practical Nurse (LPN) dated 4/30/25 at 11:45 AM documented on 4/25/25 she watched Resident #3 stand up impulsively from the wheelchair and immediately fall over.

The statement lacked if the chair alarm was in place.

During an interview on 8/26/25 at 3:12 PM with Staff C, Staffing Coordinator and Activities Director revealed she helped with Resident #3 fall on 4/25/25 and did not recall seeing the chair alarm in his wheelchair.

During an interview on 8/26/25 and 4:14 PM with Staff D, Social Services Designee revealed she did not recall a wheelchair in alarm in place during Resident #3 fall on 4/25/25.

During an interview on 8/28/25 at 12:59 PM with the Director of Nursing (DON) revealed if he had a chair alarm on his Care Plan that should of been in place at the time of the fall.

She revealed she was not the Director of Nursing at the facility when the fall occurred.

During an interview on 8/28/25 at 2:44 PM the Administrator revealed she would of expected the chair alarm to be used when Resident #3 fell, however it would of not of changed the outcome because it was an observed fall.

Review of the facilities policy and procedure for Alarms, Voice Activated Devices, Monitoring Devices, last revised 4/25/25 instructed: The use of any type of alarming device, including audio devices (such as personal alarms, monitors and voice activated chair commands), used to alert staff of a change in position, will be assessed for appropriateness and continued effectiveness. (Alarming devices do not generally prevent a resident from falling but may alter staff of position changes with residents who have diminished cognition related to self-safety.)

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

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Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Elma, IA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Colonial Manor of Elma or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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