Colonial Manor of Elma

Name: Colonial Manor of Elma
Address: 407 9th Street, Elma, IA, 50628, US
Telephone: 6413932134

407 9th Street, Elma, IA 50628 · Howard County · 40 certified beds · avg 34 residents/day · certified since Jun 1, 1998

Abuse citation flag (CMS)

Part of chain: LEGACY HEALTHCARE (89 facilities, chain avg rating 2.9★)

The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.

2/5

Health inspection rating (on-site)

Serious findings on record

$44,768

Fines, last 3 years

4.06

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5

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)

▲ Actual harm, one-off · Apr 9, 2026 · F-0600 · triggered by a complaint

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.

Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.

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 24, 2026 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Dec 5, 2024 · 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: Oct 17, 2024 (Past Non-Compliance)

All citations in the current public record (16)

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
Apr 9, 2026	▲ G · Actual 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. · from a complaint
Feb 19, 2026	D · Potential for harm, one-off	The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint
Feb 19, 2026	D · Potential for harm, one-off	The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function.
Feb 19, 2026	D · Potential for harm, one-off	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Feb 19, 2026	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.
Feb 19, 2026	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.
Feb 19, 2026	D · Potential for harm, one-off	The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Feb 19, 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 28, 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. · from a complaint
Feb 13, 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
Feb 13, 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. · from a complaint
Feb 13, 2025	B · Minimal risk, repeated	The facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way.
Dec 5, 2024	▲ 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
May 2, 2024	E · Potential for harm, repeated	The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service.
May 2, 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.
May 2, 2024	D · Potential for harm, one-off	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.

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (3 → 7).

Year	Citations	Serious (G–L)	Worst severity that year
2024	4	1	G ▲
2025	4	0	D
2026	8	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)

2 fines totaling $44,768.

Date	Type	Amount / length
Apr 9, 2026	Fine	$36,750
Dec 5, 2024	Fine	$8,018

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)	4.06	4.37	3.95	bottom 41% in Iowa; top 37% in the U.S.
Registered Nurse hours	0.65	0.85	0.69	bottom 29% in Iowa; top 41% in the U.S.
Weekend total nurse staffing	3.58	3.86	3.50	bottom 41% in Iowa; top 38% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.38	0.51	0.48	bottom 34% in Iowa; bottom 49% in the U.S.
Total nursing staff turnover (%)	62.2	44.0	45.8	bottom 10% in Iowa; bottom 13% in the U.S.
RN turnover (%)	85.7	42.1	42.9	bottom 5% in Iowa; bottom 3% 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 3.56, RN 0.57, weekend 3.14. 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: 2/5 · long-stay residents: 1/5 · short-stay residents: 3/5

Who owns this facility

For profit - Limited Liability company

Owner / manager	Type	Role	Stake	Since
Andera, Calee	Individual	Operational/Managerial Control	NOT APPLICABLE	08/15/2024
Andera, Calee	Individual	ADP of the SNF	NOT APPLICABLE	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
Deford, Colin	Individual	Operational/Managerial Control	NOT APPLICABLE	06/01/2025
Deford, Colin	Individual	ADP of the SNF	NOT APPLICABLE	06/01/2025
Friedenberg, Laura	Individual	Operational/Managerial Control	NOT APPLICABLE	08/15/2024
Friedman, Brian	Individual	Trustee of the SNF	NOT APPLICABLE	01/03/2012
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
Heying, Larina	Individual	Operational/Managerial Control	NOT APPLICABLE	08/15/2024
Houston, Mindy	Individual	Operational/Managerial Control	NOT APPLICABLE	08/15/2024
Jaeger, Krystle	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.

"Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"What safeguards do you have to protect residents' money and belongings, and what happens when something goes missing?"
"What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
"Who completes resident assessments here, and how do you check them for accuracy?"
"How do you identify and arrange specialized services for residents with mental health conditions or disabilities?"
"How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
"How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
"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
Riceville Family Care and Therapy Center	9.4 mi	Riceville, IA	★★★★★	4/5
New Hampton Nursing & Rehab Center	14.8 mi	New Hampton, IA	★★★★☆	4/5
Accura Healthcare of New Hampton	14.8 mi	New Hampton, IA	★★★★☆	3/5
Chautauqua Guest Home #3	17.4 mi	Charles City, IA	★★★★★	5/5
Chautauqua Guest Home #2	17.6 mi	Charles City, IA	★★★★★	4/5
Faith Lutheran Home	18.4 mi	Osage, IA	★★★★☆	4/5
Osage Rehab and Health Care Center	18.7 mi	Osage, IA	★☆☆☆☆	1/5
Evans Senior Living Community	19.3 mi	Cresco, IA	★★★★★	5/5

Compare this facility with the 3 closest →

All facilities in Elma →

Facility data as of CMS processing date 2026-08-01. CCN 165386.

The Care File

Visit checklist — Colonial Manor of Elma

407 9th Street, Elma, IA 50628 · 6413932134

Health inspection rating 2/5 · CMS overall 2/5 · ▲ FEDERAL ABUSE CITATION FLAG· Fines (3y): $44,768

Most serious findings on record:

▲ Apr 9, 2026 (F-0600, Actual 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.
▲ Dec 5, 2024 (F-0689, 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.

Questions for the administrator:

☐ "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "What safeguards do you have to protect residents' money and belongings, and what happens when something goes missing?"
☐ "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
☐ "Who completes resident assessments here, and how do you check them for accuracy?"
☐ "How do you identify and arrange specialized services for residents with mental health conditions or disabilities?"
☐ "How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
☐ "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
☐ "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?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 165386 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)