Inspection Reports for Colonial Manors of Columbus Community
814 Springer Avenue, IA, 527380266
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 25, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction related to a survey ending July 24, 2025, with acceptance of a credible allegation of substantial compliance and plan of correction.
Findings
The facility was found to be in substantial compliance based on the accepted plan of correction, and certification in compliance is effective August 23, 2025. No specific deficiencies are detailed in this document.
Report Facts
Survey end date: Jul 24, 2025
Certification effective date: Aug 23, 2025
Inspection Report
Annual Inspection
Census: 30
Deficiencies: 2
Jul 24, 2025
Visit Reason
The inspection was conducted as the facility's annual recertification survey from July 21 to July 24, 2025.
Findings
The facility was found deficient in ensuring accurate resident code status documentation for cardiopulmonary resuscitation (CPR) and do not resuscitate (DNR) orders, and in developing and implementing abuse and neglect policies. There was a substantiated allegation of abuse involving a resident, with failures in reporting and investigation procedures.
Complaint Details
The complaint related to abuse allegations involving Resident #17 was substantiated based on family member reports, staff interviews, and review of incident reports. The facility failed to ensure proper reporting and investigation of the abuse allegation.
Severity Breakdown
Level D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure accurate resident code status documentation for CPR/DNR for 1 of 16 residents reviewed. | Level D |
| Failure to develop and implement abuse and neglect policies, including investigation and reporting of allegations of abuse. | Level D |
Report Facts
Residents reviewed for code status: 16
Residents reviewed for abuse allegation: 1
Census: 30
Dates of survey: 2025-07-21 to 2025-07-24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurses Aide (CNA) | Named in abuse allegation involving Resident #17 |
| Staff B | Licensed Practical Nurse (LPN) | Named in abuse allegation involving Resident #17 |
| Director of Nursing | Director of Nursing (DON) | Reported on CPR identification label and abuse investigation |
| Administrator | Administrator | Denied reports of abuse, involved in abuse investigation and reporting |
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 16, 2024
Visit Reason
The document serves as a statement of deficiencies and plan of correction following a survey, indicating acceptance of credible allegation of substantial compliance and certification of the facility.
Findings
The facility was found to be in substantial compliance based on the credible allegation and plan of correction, resulting in certification effective September 13, 2024.
Inspection Report
Annual Inspection
Census: 28
Deficiencies: 11
Aug 15, 2024
Visit Reason
The inspection was the facility's annual recertification survey conducted from August 12 to August 15, 2024.
Findings
The survey identified multiple deficiencies related to comprehensive assessments, accuracy of assessments, coordination of PASARR and assessments, development and implementation of comprehensive care plans, quality of care, drug regimen review, and QAPI program effectiveness. The facility submitted plans of correction for all deficiencies.
Severity Breakdown
Level D: 3
Level C: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to conduct timely and comprehensive Minimum Data Set (MDS) assessments for residents. | — |
| Failure to accurately code assessments, including medication assessments, for residents. | Level D |
| Failure to coordinate PASARR assessments and resubmit with changes related to psychiatric diagnoses and medications. | Level D |
| Failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes. | Level D |
| Failure to include diuretic medications in care plans and ensure timely updates. | — |
| Failure to update care plans to reflect interventions for falls, pressure/diabetic ulcers, skin issues, and C-diff. | — |
| Failure to review and follow physician orders for diuretic medications. | — |
| Failure to update care plans to reflect resident choice to refuse bathing and ensure bathing is offered twice weekly. | — |
| Failure to audit daily weights, bowel movements, and wound assessments, and to follow physician orders related to these. | — |
| Failure to timely follow up on medication regimen review recommendations for unnecessary medications. | — |
| Failure to maintain an effective QAPI program addressing care plan revisions, assessments/interventions, and drug regimen reviews. | Level C |
Report Facts
Census: 28
Deficiency count: 11
Audit period: 4
Audit period: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Licensed Practical Nurse | Acknowledged late submission of MDS assessments and medication coding issues |
| Staff B | Certified Medication Aide | Provided information on daily weights and wound care documentation |
| Staff E | Licensed Practical Nurse | Discussed wound dressing documentation and medication administration |
| Director of Nursing | DON | Provided statements on facility compliance, audit plans, and expectations |
| Administrator | Discussed QAPI program and communication with pharmacy consultants |
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 14, 2023
Visit Reason
The document serves as a Statement of Deficiencies and Plan of Correction following a survey, indicating acceptance of the facility's credible allegation of substantial compliance and plan of correction.
Findings
The facility was found to be in substantial compliance based on the accepted plan of correction, resulting in certification of compliance effective November 12, 2023.
Inspection Report
Annual Inspection
Census: 24
Deficiencies: 7
Oct 12, 2023
Visit Reason
The inspection was an annual recertification survey conducted from October 9, 2023 to October 12, 2023, to assess compliance with federal and state regulations.
Findings
The facility was found deficient in multiple areas including care plan timing and revision, quality of care, free of accident hazards, drug regimen review, routine/emergency dental services, infection prevention and control, antibiotic stewardship, and immunizations. Deficiencies were noted in documentation, resident care plans, medication administration, and resident safety interventions.
Severity Breakdown
SS=D: 6
SS=E: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Care Plans were not revised to include use of anticoagulant medications, updated interventions for falls, and use of opioid medication for two residents. | SS=D |
| Facility failed to carry out assessments and interventions when a resident did not have a bowel movement for multiple days. | SS=D |
| Facility failed to implement resident specific interventions for elopement and failed to ensure elopement alert devices were consistently checked. | SS=D |
| Drug regimen review was not timely and did not include review of the resident's medical chart. | SS=D |
| Facility failed to provide routine dental services for 3 of 3 residents reviewed. | SS=D |
| Facility failed to ensure adherence to antibiotic stewardship practices. | SS=D |
| Facility failed to ensure influenza and pneumococcal immunizations were offered and documented for residents. | SS=E |
Report Facts
Census: 24
Deficiencies cited: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Acknowledged care plan issues and interventions during inspection |
| Staff A | Certified Nursing Assistant (CNA) | Identified residents at risk for wandering/elopement |
| Staff B | Certified Nursing Assistant (CNA) | Provided information about resident behaviors and elopement alert devices |
| Staff C | Certified Medication Aide | Explained resident use of wheelchair and attempts to leave facility |
| Staff D | Registered Nurse (RN) | Explained resident wandering and elopement incidents |
| Administrator | Facility Administrator | Responded to resident elopement incidents and provided statements during inspection |
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 8, 2022
Visit Reason
The document serves as a statement of deficiencies and plan of correction following health recertification and federal comparative surveys conducted earlier in the year.
Findings
The facility was certified in compliance effective 2022-08-06 based on acceptance of the credible allegation of compliance and plan of correction for prior surveys ending 2022-05-12 and 2022-06-28.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Jun 28, 2022
Visit Reason
The Centers for Medicare and Medicaid Services (CMS) conducted an abbreviated Federal Oversight Support Survey (FOSS)/Focused Concern Survey (FCS) on 6/27-6/28/22 to assess compliance with COVID-19 vaccination requirements for facility staff.
Findings
One deficiency was found related to the facility's failure to develop and implement a comprehensive COVID-19 staff vaccination policy and waiver process, including the lack of a documented waiver review process and incomplete vaccination waiver packets for staff.
Deficiencies (1)
| Description |
|---|
| Failure to develop and implement a comprehensive COVID-19 staff vaccination policy and waiver process, including lack of documented waiver review and incomplete waiver packets. |
Report Facts
Staff vaccination waiver packets reviewed: 9
Staff with unvaccinated waivers: 9
Correction date: Aug 6, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Cutter Hand | Administrator | Signed the report and plan of correction; mentioned in relation to waiver packet completion and facility policy. |
Inspection Report
Renewal
Census: 29
Deficiencies: 8
May 12, 2022
Visit Reason
The inspection was a recertification survey and investigation of complaint #98561 conducted May 9-12, 2022, to assess compliance with federal regulations and facility policies.
Findings
The facility was found deficient in multiple areas including coordination of PASARR assessments, comprehensive care planning, free of accident hazards related to oxygen tank transport, treatment and services for dementia, antibiotic stewardship program, infection preventionist qualifications, and immunization policies. Complaint #98561-C was not substantiated.
Complaint Details
Complaint #98561-C was investigated and found not substantiated.
Severity Breakdown
SS=D: 6
SS=F: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Facility failed to coordinate PASARR assessments and resident reviews for psychotic disorder diagnoses. | SS=D |
| Comprehensive care plans were not developed or revised timely for residents, including failure to address surgical wounds, antipsychotic medication, and oxygen use. | SS=D |
| Facility failed to ensure safe transport of portable oxygen tanks, posing accident hazards. | SS=D |
| Failed to implement an individualized plan of care to address dementia and cognition for a resident. | SS=D |
| Antibiotic stewardship program was not implemented facility-wide, lacking monitoring and protocols. | SS=F |
| Facility failed to ensure infection preventionist had completed required specialized training. | SS=D |
| Facility failed to ensure infection preventionist had taken required courses and training. | SS=D |
| Facility failed to ensure residents were offered pneumococcal immunization and education as required. | SS=D |
Report Facts
Census: 29
Deficiencies cited: 7
Inspection Report
Routine
Census: 32
Deficiencies: 0
Dec 30, 2020
Visit Reason
A Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on December 29 - 30, 2020 to assess compliance with CMS and CDC recommended practices for COVID-19.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices for COVID-19.
Report Facts
Total residents: 32
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 0
Oct 26, 2020
Visit Reason
An investigation of Complaint #94049-C was conducted along with a COVID-19 Focused Infection Control Survey from 10/22 to 10/26/2020.
Findings
The complaint was not substantiated and no deficiencies were found. The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 preparation.
Complaint Details
Complaint #94049-C was investigated and found not substantiated.
Inspection Report
Routine
Census: 42
Deficiencies: 0
Jun 16, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Annual Inspection
Census: 38
Deficiencies: 7
Jan 15, 2020
Visit Reason
The inspection was conducted as an annual health survey to assess compliance with federal regulations including privacy, care planning, quality of care, pain management, pharmacy services, nutrition, food safety, and infection control.
Findings
The facility was found deficient in multiple areas including failure to maintain resident privacy during care, incomplete and untimely care plan revisions, inadequate pain management, failure to ensure availability of ordered medications, improper food portioning and handling, and lapses in infection control practices including wound care and laundry handling.
Severity Breakdown
SS=D: 5
SS=E: 3
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to maintain privacy for Resident #28 during perineal care and transfer, leaving resident exposed. | SS=D |
| Failed to review and revise care plans timely for 5 of 12 sampled residents, including failure to address pain and medication side effects. | SS=E |
| Failed to ensure residents received treatment and care consistent with professional standards for 4 of 5 sampled residents, including pain management and wound care. | SS=E |
| Failed to ensure availability of physician ordered medication (Beano) for Resident #18 during medication pass. | SS=D |
| Failed to serve pureed food portions according to planned menu and portion size guidelines. | SS=D |
| Failed to handle food in accordance with professional standards for food service safety, including improper glove use by dietary staff. | SS=D |
| Failed to maintain infection control with wound care equipment, laundry delivery and storage, and housekeeping cart placement; Medical Director did not review infection control policies annually. | SS=E |
Report Facts
Resident census: 38
Medication omissions: 5
Pureed ham servings: 2
Pureed ham volume: 1.5
Pressure ulcer measurement: 2.1
Pressure ulcer measurement: 2.4
Pressure ulcer depth: 0.1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Nurse Aide | Named in privacy deficiency for Resident #28 |
| Staff H | Nurse Aide | Named in privacy deficiency for Resident #28 |
| Director of Nursing | Provided statements on staff expectations and deficiencies | |
| Staff K | Licensed Practical Nurse | Commented on pain reporting for Resident #28 |
| Staff E | Medication Aide | Reported Resident #28 had pain during care |
| Staff I | Medication Aide | Reported Resident #28 expressed pain during lift |
| Staff F | Certified Medication Aide | Reported Resident #28 had pain during care |
| Staff B | Cook | Observed preparing and serving pureed food |
| Dietary Manager | Provided statements on dietary expectations | |
| Dietitian | Provided statements on dietary expectations and food handling | |
| Staff A | Registered Nurse | Observed performing wound care |
| Staff D | Laundry | Observed delivering laundry with improper covering |
| Administrator | Provided statements on infection control and housekeeping | |
| Infection Preventionist | Provided statements on infection control expectations |
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