Elma, IA

Colonial Manor of Elma

4-star overall rating with 4-star inspections with $8,018 in total fines with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

407 9th Street, Elma, IA

(641) 393-2134

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

40

Certified beds

Average residents

32

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Legacy Healthcare

Operator or chain grouping

Approved since

1998-06-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

90 facilities

Chain averages 3 overall / 3 health / 3 staffing / 3 quality stars

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.42

Registered nurse staffing · state 0.73 · national 0.68

LPN hours / resident day

0.72

Licensed practical nurse staffing · state 0.57 · national 0.87

Aide hours / resident day

2.54

Nurse aide staffing · state 2.53 · national 2.35

Total nurse hours

3.68

All reported nurse hours · state 3.83 · national 3.89

Licensed hours

1.14

RN + LPN hours · state 1.30 · national 1.54

Weekend hours

3.29

Weekend nurse staffing · state 3.35 · national 3.43

Weekend RN hours

0.38

Weekend registered nurse coverage · state 0.50 · national 0.47

Physical therapist

0.01

Reported PT staffing · state 0.04 · national 0.07

Adjusted RN hours

0.48

CMS adjusted RN staffing hours

Adjusted total hours

4.18

CMS adjusted total nurse staffing hours

Case-mix index

1.20

Higher values indicate more complex resident acuity

RN turnover

75%

Annual RN turnover · state 44% · national 45%

Total nurse turnover

64%

Annual nurse turnover · state 44% · national 46%

SNF VBP

Value-based purchasing

Program rank

6,579

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

32.37

Composite VBP score used to determine payment impact.

Payment multiplier

0.9870

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

3.70

Baseline 39.47% · Performance 48.57% · Measure score 3.70 · Achievement 3.70 · Improvement 0

Adjusted total nurse staffing

2.78

Baseline 3.95 hours · Performance 3.87 hours · Measure score 2.78 · Achievement 2.78 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.15%	10.72% 0.6 pts better	No Different than the National Rate · Eligible stays 51 · Observed rate 7.84% · Lower 95% interval 6.53%
Discharge to community	50.6%	50.57% About the same	No Different than the National Rate · Eligible stays 39 · Observed rate 43.59% · Lower 95% interval 36.44%
Medicare spending per beneficiary	0.7	1.02 0.3 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 33 · Denominator 33
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 33
Discharge self-care score	50%	53.69% 3.7 pts worse	Numerator 14 · Denominator 28
Discharge mobility score	28.57%	50.94% 22.4 pts worse	Numerator 8 · Denominator 28
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 33 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 56
Staff flu vaccination coverage	26.32%	42% 15.7 pts worse	Numerator 20 · Denominator 76
Discharge function score	46.43%	56.45% 10 pts worse	Numerator 13 · Denominator 28
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.4	1.5 0.1 pts better	1.9 0.5 pts better	Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.2 · Expected 1.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	2.7	2.1 0.6 pts worse	1.8 0.9 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.6 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.1%	94.0% 5.1 pts better	93.4% 5.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 96.2% · Q4 100.0% · 4Q avg 99.1%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	95.2% 4.8 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	7.2%	3.7% 3.5 pts worse	3.3% 3.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 6.9% · Q3 7.7% · Q4 7.7% · 4Q avg 7.2% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.0%	4.0% 4 pts better	11.4% 11.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents who lose too much weight	3.4%	4.9% 1.5 pts better	5.4% 2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 0.0% · Q3 4.8% · Q4 5.0% · 4Q avg 3.4%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	39.1%	20.6% 18.5 pts worse	19.6% 19.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 42.3% · Q2 41.7% · Q3 38.1% · Q4 33.3% · 4Q avg 39.1%
Percentage of long-stay residents who received an antipsychotic medication	34.7%	19.8% 14.9 pts worse	16.7% 18 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 38.1% · Q2 35.0% · 4Q avg 34.7% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.2% 0.2 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	19.0%	18.5% 0.5 pts worse	16.3% 2.7 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 19.0% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	21.7%	18.3% 3.4 pts worse	14.9% 6.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 38.5% · Q2 12.5% · Q3 14.3% · Q4 19.0% · 4Q avg 21.7% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.2%	1.7% 0.5 pts better	1.0% 0.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 5.0% · 4Q avg 1.2% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	2.8%	2.5% 0.3 pts worse	1.7% 1.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 0.0% · Q3 0.0% · Q4 4.0% · 4Q avg 2.8% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	35.2%	26.0% 9.2 pts worse	19.8% 15.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 29.6% · Q3 34.7% · Q4 52.2% · 4Q avg 35.2%
Percentage of long-stay residents with pressure ulcers	7.8%	4.3% 3.5 pts worse	5.1% 2.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 9.8% · Q3 4.8% · Q4 7.1% · 4Q avg 7.8% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	80.6%	84.3% 3.7 pts worse	81.7% 1.1 pts worse	Short Stay · 2024Q4-2025Q3 · Q4 76.0% · 4Q avg 80.6%
Percentage of short-stay residents who had an outpatient emergency department visit	22.5%	13.1% 9.4 pts worse	12.0% 10.5 pts worse	Short Stay · 20240701-20250630 · Adjusted 22.5% · Observed 24.0% · Expected 11.9% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.9% 1.9 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were rehospitalized after a nursing home admission	33.6%	21.3% 12.3 pts worse	23.9% 9.7 pts worse	Short Stay · 20240701-20250630 · Adjusted 33.6% · Observed 36.0% · Expected 25.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-02-13 · Fire 2025-02-13

4 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

2 fire-safety deficiencies

Top issue: Services (1 deficiency)

Cycle 2 Health 2024-05-02 · Fire 2024-05-02

4 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

2 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 3 Health 2023-03-02 · Fire 2023-03-02

0 health deficiencies

No concentrated health issue counts in this cycle.

3 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2025-02-13

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-03-05

D · Potential for more than minimal harm 2025-02-13

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2025-02-13

E · Potential for more than minimal harm 2024-05-02

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2024-05-14

D · Potential for more than minimal harm 2024-05-02

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-05-14

F · Potential for more than minimal harm 2023-03-02

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2023-03-14

F · Potential for more than minimal harm 2023-03-02

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-03-08

E · Potential for more than minimal harm 2023-03-02

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2023-03-08

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-08-28

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2025-09-27

D · Potential for more than minimal harm 2025-02-13

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2025-03-15

D · Potential for more than minimal harm 2025-02-13

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-03-15

B · Minimal harm 2025-02-13

F637 · Resident Assessment and Care Planning Deficiencies

Health

Assess the resident when there is a significant change in condition

Corrected 2025-03-15

G · Actual harm 2024-12-05

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-10-17

E · Potential for more than minimal harm 2024-05-02

F801 · Nutrition and Dietary Deficiencies

Health

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Corrected 2024-06-02

D · Potential for more than minimal harm 2024-05-02

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2024-06-02

D · Potential for more than minimal harm 2024-05-02

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2024-06-02

Penalties and ownership

What sits behind the stars

$8,018 2024-12-05

Fine

Fine · fine $8,018

Fine

Ownership

Iowa Portfolio Opco Holdings LLC

5% Or Greater Direct Ownership Interest · Organization

100% 20 facilities 2024-08-15

Chaim Rajchenbach Descendants Tr Ua 04282008

5% Or Greater Indirect Ownership Interest · Organization

68% 83 facilities 2024-08-15

Oakway Operations LLC

5% Or Greater Indirect Ownership Interest · Organization

23% 48 facilities 2024-08-15

Doros Generation Trust U/A/D 1/3/12

5% Or Greater Indirect Ownership Interest · Organization

5% 78 facilities 2024-08-15

Andera, Calee