Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Colonial Manors Of Columbus Community during CMS and state inspections, most recent first.
A resident with a history of stroke and dementia had conflicting code status documentation, with a CPR label on the chart exterior and a DNR order in the chart. The DON was unaware the label had not been updated after the resident started hospice, and staff relied on the chart label in emergencies, leading to inaccurate representation of the resident's wishes.
The facility did not have effective policies and procedures in place to prevent abuse, neglect, and theft. Surveyors found gaps in staff training and a lack of clear protocols, which left residents vulnerable to mistreatment without timely detection or intervention.
The facility failed to complete MDS assessments on time for four residents, with delays acknowledged by an LPN and attributed to new staff by the DON. The facility's policy requires timely MDS completion, but this was not effectively implemented, resulting in deficiencies.
The facility failed to update care plans for residents following significant changes in their medical conditions. A resident's care plan lacked documentation for anticoagulant medication, another resident's plan was not updated with new fall interventions despite multiple falls, and two residents' plans did not address a pressure ulcer and a C. diff infection, respectively. The DON acknowledged these omissions.
A facility failed to accurately code the MDS assessment for a resident's medications, incorrectly indicating the use of a hypnotic medication not documented in the EHR. The resident, with intact cognition, was documented to take an antidepressant and an anti-convulsant for specific disorders. Interviews with an LPN and the DON confirmed the expectation for accurate MDS coding, with the LPN suggesting a possible error by the previous DON.
The facility failed to update the PASRR for two residents with new mental health diagnoses and psychotropic medications. One resident had moderate cognitive impairment with multiple diagnoses and medications not reflected in the PASRR. Another resident, with intact cognition, had additional diagnoses and medications not updated in the PASRR. The Administrator believed the updates were made by the previous DON, but they were not completed.
A facility failed to include diuretic medication in the care plan for a resident with severe cognitive impairment. The resident was taking Furosemide daily for bilateral lower extremity edema, as per a physician's order. The Director of Nursing acknowledged the omission, which was contrary to the facility's policy on comprehensive care plans.
A resident with hypertension and heart failure did not receive prescribed PRN Furosemide despite significant weight gains. The facility's staff failed to administer the medication as per physician orders, with the Certified Medication Aide acknowledging that it had been a while since the PRN Lasix was given. This deficiency was identified through a review of the Medication Administration Record and staff interviews.
A resident with advanced Parkinson's disease and moderately impaired cognition did not receive the required twice-weekly showers due to staffing shortages. The resident expressed dissatisfaction with the missed showers, and staff confirmed that low staffing levels sometimes prevented them from providing showers on scheduled days. The facility's documentation did not consistently reflect the expected shower schedule.
The facility failed to ensure daily weights for two residents on diuretics, consistent follow-up on bowel management for a resident, and thorough assessments for a resident's heel wound. Staff interviews revealed discrepancies in documentation and monitoring, with missing weight records, inconsistent bowel management interventions, and incomplete wound assessments.
A facility failed to ensure a timely response from a physician to a pharmacist's GDR recommendation for a resident on psychotropic medications. The resident, with cognitive impairment and multiple diagnoses, was on a regimen including escitalopram, Seroquel, and trazodone. Despite the pharmacist's recommendation, the provider delayed responding, citing potential impairment of the resident's function as a reason for declining dose reduction. The facility's policy required monthly drug regimen reviews and timely action on irregularities, which was not adhered to in this case.
The facility failed to maintain an effective QAPI process, resulting in repeat deficiencies in care plan revision, assessment/intervention, and drug regimen review. Despite having a plan of correction, the facility struggled with follow-through due to staff changes, including the retirement of the previous DON. The facility's QAPI policy outlined systems for monitoring care, but these were not effectively implemented, leading to the recurrence of deficiencies.
Failure to Maintain Accurate Code Status Documentation
Penalty
Summary
The facility failed to ensure that accurate code status information was recorded and readily available for a resident. Specifically, a resident with a history of cerebral vascular accident and dementia, who had a moderate level of mental impairment, had conflicting documentation regarding their code status. The outside cover of the resident's hard clinical chart displayed a label indicating CPR should be performed in the event of cardiac or respiratory arrest, and a form inside the chart also included an order for CPR. However, a separate section of the chart contained an Iowa Physician Order for Scope of Treatment (IPOST) form, signed by the resident's durable power of attorney for healthcare and a healthcare practitioner, which indicated a DNR (Do Not Resuscitate) order. During staff interviews, it was revealed that the DON was unaware that the CPR identification label on the chart had not been updated when the resident began hospice care. Staff reported that in an emergency, they would refer to the label on the outside of the chart to determine whether to perform CPR. The facility's policy stated that residents have the right to make decisions regarding their healthcare, including CPR/DNR status, but the failure to update the chart label resulted in inconsistent and potentially misleading information about the resident's wishes.
Failure to Implement Policies Preventing Abuse, Neglect, and Theft
Penalty
Summary
The facility failed to develop and implement effective policies and procedures to prevent abuse, neglect, and theft. Surveyors identified that the facility did not have comprehensive or consistently enforced protocols in place to safeguard residents from these types of mistreatment. This deficiency was observed through a review of facility documentation and staff interviews, which revealed gaps in staff training and a lack of clear guidance on reporting and preventing such incidents. The absence of robust preventive measures contributed to an environment where abuse, neglect, or theft could occur without timely detection or intervention.
Delayed MDS Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure timely completion of Minimum Data Set (MDS) assessments for four residents, as required by regulations. Resident #26 was admitted on 12/27/23, but their admission MDS assessment, with an Assessment Reference Date (ARD) of 1/9/24, was not completed until 1/19/24. Similarly, Resident #29's admission MDS assessment, with an ARD of 5/20/24, was completed on 5/30/24. Additionally, the annual MDS assessments for Resident #13 and Resident #5 were also delayed. Resident #13's assessment, with an ARD of 5/14/24, was completed on 6/4/24, and Resident #5's assessment, with an ARD of 2/26/24, was completed on 3/18/24. During interviews, staff acknowledged the delays in completing the MDS assessments. Staff C, an LPN, confirmed that the assessments for Residents #29, #13, and #5 were submitted after the 14-day deadline. The Director of Nursing (DON) admitted that the facility struggled to complete assessments on time, attributing the delays to new staff members who were not fully familiar with the process. The facility's policy requires a schedule for MDS completion, but it appears this was not effectively implemented, leading to the deficiencies noted.
Care Plan Deficiencies in LTC Facility
Penalty
Summary
The facility failed to update the care plans for several residents following significant changes in their medical conditions and treatments. For Resident #15, the care plan did not include a focus area for anticoagulant medication, despite the resident being prescribed Eliquis for nonrheumatic aortic valve stenosis. This oversight occurred even though the medication was initiated shortly after the resident's admission. The Director of Nursing acknowledged that anticoagulants should be included in the care plan. Resident #9, who had severely impaired cognition, experienced multiple falls without injury, yet the care plan had not been updated with new fall interventions since April 2023. The resident had fallen on several occasions in 2024, but the care plan remained unchanged. The Director of Nursing confirmed that fall interventions should be part of the care plan. For Resident #20, the care plan lacked documentation of a pressure ulcer on the left heel, despite the resident having a history of Methicillin Susceptible Staphylococcus Aureus infection and receiving treatment for the ulcer. Similarly, Resident #6's care plan did not address an infection of Clostridium Difficile, even though the resident had been diagnosed and treated for this condition. The Director of Nursing acknowledged that these issues needed to be addressed in the care plans.
Inaccurate MDS Coding for Resident's Medications
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident's medications. Specifically, the MDS assessment indicated that a resident took a hypnotic medication, which was not documented in the Electronic Health Record (EHR). The resident, who scored a perfect 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam indicating intact cognition, was documented to have taken an antidepressant and an anti-convulsant for mixed obsessional thoughts, hoarding disorder, and major depressive disorder. However, there was no evidence in the EHR that the resident took a hypnotic medication. During interviews, a Licensed Practical Nurse (LPN) and the Director of Nursing (DON) both acknowledged the expectation for accurate MDS coding, with the LPN suggesting the error may have been a mistake by the previous DON.
Failure to Update PASRR for Residents with New Diagnoses
Penalty
Summary
The facility failed to resubmit a Preadmission Screening and Resident Review (PASRR) for two residents, despite new mental health diagnoses and psychotropic medications being added to their care plans. Resident #19, who was moderately cognitively impaired, had diagnoses of non-Alzheimer's dementia, anxiety disorder, depression, and a psychotic disorder. The resident was on antipsychotic and antidepressant medications, which were not reflected in the PASRR Level 1 Screen Outcome. The care plan and electronic medical record (EMR) indicated the use of psychotropic medications for behavioral disturbances, but the PASRR was not updated to reflect these changes. Resident #20, with intact cognition, had medical diagnoses of a psychotic disorder, anxiety disorder, and depression, and was taking antipsychotics and antidepressants. The PASRR Level 1 Screen Outcome did not require a Level 2 review and only noted depression and the use of Escitalopram. However, the care plan and EMR showed additional diagnoses and medications, including major depressive disorder and delusional disorders, which were not updated in the PASRR. During an interview, the Administrator acknowledged that the PASRRs for both residents should have been resubmitted. The Administrator believed that the previous Director of Nursing (DON) had updated the PASRRs after discussing the changes with psychiatric staff. The facility's PASRR policy indicated that updates were necessary for new diagnoses of certain mental health disorders, but the updates were not completed in these cases.
Failure to Include Diuretic Medication in Care Plan
Penalty
Summary
The facility failed to include diuretic medication in the comprehensive care plan for a resident with severe cognitive impairment. The resident, who scored 00 out of 15 on a Brief Interview for Mental Status (BIMS) exam, was taking diuretic medication as per the Minimum Data Set (MDS) assessment. The care plan did not address the diuretic medication, despite a physician's order for Furosemide, a diuretic, to be administered daily for bilateral lower extremity edema. This order was noted on the resident's admission date and remained current at the time of review. The Director of Nursing acknowledged that diuretics should have been included in the care plan, as per the facility's policy on comprehensive care plans, which aims to develop quantifiable objectives and care directives for maintaining the resident's optimum health status.
Failure to Administer Diuretic Medication as Ordered
Penalty
Summary
The facility failed to administer diuretic medication as per physician orders for a resident with a diagnosis of hypertension and unspecified heart failure. The resident, who had intact cognition, was prescribed Furosemide to be taken daily and as needed for weight gain of 3 or more pounds. However, the Medication Administration Record for March, May, and July 2024 showed that the resident did not receive any doses of PRN Furosemide, despite documented weight gains exceeding 3 pounds on multiple occasions. Interviews with facility staff revealed a lack of adherence to the physician's orders regarding the administration of diuretic medication. Certified Nursing Assistants were responsible for taking daily weights and reporting them to the charge nurse or medication aide, who would then document them in the Medication Administration Record. However, the Certified Medication Aide acknowledged that it had been a while since the PRN Lasix was given, indicating a failure to act on significant weight changes as required by the physician's orders.
Failure to Provide Scheduled Showers Due to Staffing Issues
Penalty
Summary
The facility failed to provide a shower twice a week for a resident with moderately impaired cognition and advanced Parkinson's disease. The resident, identified as Resident #13, was dependent on staff for bathing and required a mechanical lift for transfers. The resident's care plan indicated a need for extra time to complete activities of daily living (ADLs) due to deteriorating abilities. However, the Plan of Care (POC) Response History Report showed that the resident only received a bath on four specific dates, indicating a failure to meet the twice-weekly shower requirement. Interviews with the resident and staff revealed that the resident did not always receive the scheduled showers due to low staffing levels. The resident expressed dissatisfaction with missing showers, stating it bothered her and that there was insufficient staff to reschedule missed showers. Staff members confirmed that there were instances when the resident did not receive a bath on the scheduled day, and attempts were made to make up for it the following day. The Director of Nursing (DON) stated that showers were expected to be given twice a week and documented in the POC, but the documentation did not reflect this expectation consistently.
Deficiencies in Weight Monitoring, Bowel Management, and Wound Assessment
Penalty
Summary
The facility failed to ensure daily weights were obtained per physician orders for two residents who were on diuretic medication due to conditions such as hypertension and heart failure. For one resident, the care plan and physician orders specified daily weight monitoring, yet multiple dates in July and August lacked documentation of the resident's weight. Similarly, another resident's care plan and physician orders required daily weight checks, but several dates in July were missing weight documentation. Interviews with staff revealed that certified nursing assistants were responsible for obtaining weights, which were then supposed to be recorded by the charge nurse or medication aide. However, discrepancies were noted between paper and electronic health records, and the Director of Nursing was unsure why orders were not consistently documented electronically. The facility also failed to follow up consistently on a resident's bowel management, despite documentation of no bowel movement for over three days. The resident, who was on morphine for dyspnea related to congestive heart failure, had physician orders for bowel management interventions, including the use of magnesium hydroxide, bisacodyl suppositories, and Fleet's enema. However, the medication administration record showed inconsistent administration of these interventions, with significant gaps in the administration of prescribed medications. Interviews with staff indicated a lack of consistent monitoring and follow-up on bowel movements, despite facility policies outlining specific protocols for bowel management. Additionally, the facility did not complete thorough assessments for a resident's heel wound. The resident had a history of a pressure ulcer on the left heel, and the care plan lacked documentation of this condition. The electronic medical record and physician orders detailed various treatments and dressing changes, but there were instances where wound assessments were not completed as required. Staff interviews revealed that wound measurements were not consistently documented, and there were occasions when the resident's wound dressing was not changed due to the resident's participation in activities. The Director of Nursing acknowledged the need for regular wound assessments but noted that sometimes doctors preferred to leave dressings in place, leading to incomplete documentation.
Failure to Ensure Timely Physician Response to Pharmacist's GDR Recommendation
Penalty
Summary
The facility failed to ensure timely response from the physician to the pharmacist's Gradual Dosage Reduction (GDR) recommendation for a resident identified as having unnecessary medications. The resident, who had a moderately impaired cognitive status, was diagnosed with non-Alzheimer's dementia, anxiety disorder, depression, and a psychotic disorder. The resident was on a regimen of psychotropic medications including escitalopram, Seroquel, and trazodone. Despite the pharmacist's GDR recommendation letter being sent on February 25, 2024, the provider only responded on February 27, 2024, declining the dose reduction due to potential impairment of the resident's function. The facility's policy required that the drug regimen of each resident be reviewed monthly by a licensed pharmacist, with any irregularities reported to the attending physician, medical director, and Director of Nursing (DON). These reports were expected to be acted upon, with the attending physician documenting any actions taken or rationale for no changes in the resident's medical record. However, the facility's administrator noted issues with receiving timely responses from the provider, leading to the pharmacist sending letters to both the provider and the DON to track them. This deficiency was identified during a survey, highlighting the facility's failure to ensure the physician's timely response to the pharmacist's recommendations.
Repeat Deficiencies in QAPI Process
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) process, resulting in repeat deficiencies identified during the current recertification and complaint survey. These deficiencies were previously noted in surveys conducted over the past ten months. The specific areas of deficiency included care plan revision, assessment/intervention, and drug regimen review, all of which were cited at a no actual harm level. The facility had a census of 28 residents at the time of the survey. During an interview, the Administrator acknowledged the repeat citations and attributed the challenges to the retirement of the previous Director of Nursing (DON) and the onboarding of new staff. Despite having a plan of correction in place, the Administrator admitted that there was a lack of effective follow-through. The facility's QAPI policy for 2024 outlined systems for monitoring care and services, incorporating feedback from various stakeholders, and using performance indicators to track care processes and outcomes. However, the facility's failure to effectively implement these systems led to the recurrence of deficiencies.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Columbus Junction
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunrise Terrace Nursing & Rehabilitation Center | 10.7 mi | ★★★★★ | 0 | 0 |
| Lone Tree Health Care Center Inc | 14.8 mi | ★★★★★ | 5 | 0 |
| United Presbyterian Home | 16.1 mi | ★★★★★ | 0 | 0 |
| Aspire Of Washington | 16.4 mi | — | 0 | 0 |
| Halcyon House | 16.7 mi | ★★★★★ | 5 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.