Columbia Manor Health & Rehabilitation

Inspectors wroteBased on interview, and record review facility, staff failed to administer medications as ordered and failed to document a reason medication was on hold for one resident (Resident #30). The facility census was 44. 1. Review of the facility's Administering Medications policy, revised April 2019, showed the facility will ensure medications are administered in a safe and timely manner and as prescribed. Medication is administered in accordance with prescribers' orders, including any required time frame. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure residents remained free of significant medication errors when staff administered Resident #2's medication to Resident #1. The facility census was 44.1. Review of the facility Administering Medications policy, revised April 2019, showed the facility will ensure medications are administered in a safe and timely manner and as prescribed. The individual administering the medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include checking the identification band, checking photograph attached to the medical record and if necessary, verifying the resident's identification with other facility personnel. Medication errors are documented, reported and reviewed by QUAPI committee to inform process changes and the need for additional staff training. [...]

Inspectors wroteBased on interview and record review, facility staff failed to notify the physician and resident representative for one resident (Resident #1) out of one sampled resident, when staff assessed the resident with a lump to his/her forehead, and when the resident refused all his/her scheduled medications. The facility census was 41.1. Review of the facility's Change in a Resident's Condition or Status policy, revised 02/2021, showed staff are directed to promptly notify the resident, his or her attending physician, and the resident's representative of changes in the resident's medical/mental condition, and/or status. The nurse will notify the attending physician or physician on call when there has been a: -Discovery of injuries of unknown source;-Significant change in the resident's physical/emotional/mental condition;-Refusal of treatment or medications two or more consecutive times. 2. [...]

Inspectors wroteBased on interviews and record review, facility staff failed to report an allegation of bruises and injury of unknown origin for one resident (Resident #1) to the Department of Health and Senior Services (DHSS) within the 24-hour required timeframe. The facility's census was 41. The administrator was notified on 2/27/26 of past Non-Compliance, which occurred on 02/25/26, when the resident representative called the facility and made a follow-up report of the allegations. Staff immediately started an investigation, contacted the resident's Hospice Provider, Regional Staff, in-serviced facility staff on the abuse and neglect policy which included to report injury of unknown origin within 24 hours, and reported the allegations to DHSS on 02/26/26. [...]

Inspectors wroteBased on interview and record review, facility staff failed to meet professional standards of care when staff failed to document a skin assessment for one resident (Resident #1) out of one sampled resident, when staff assessed the resident with a lump to his/her forehead. The facility census was 411. Review of the facility's admission Assessment and Follow up: Role of the Nurse policy, revised 09/2012, showed staff are directed to conduct a physical assessment on admission, including the eyes, ears, nose, throat, head, neck, and skin. Conduct supplemental assessments (following facility forms and protocol) including skin assessment. The policy did not specify the frequency for which staff should complete a skin assessment. 2. [...]

Inspectors wroteBased on interview and record review, facility staff failed to notify the facility attending physician following a change in condition of one resident (Resident #1) out of nine sampled residents when the resident fell and received a head injury. The facility census was 44.1. [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide a discharge notice for one resident (Resident #1) and failed to allow Resident #1 to return to the facility when the hospital was unable to admit him/her and told the facility the resident was ready to return. The facility's census was 38.1. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to allow sanitized dishes to air dry prior to stacking in storage to prevent the growth of food-borne pathogens. This failure has the potential to affect all residents. The facility census was 38.1. Review of the facility's policy titled Cleaning Dishes/Dish Machine, dated 2021, showed the policy directed staff to air dry washed dishes on dish racks and to inspect the dishes for cleanliness and dryness before they are put away. Review showed Dishes should not be nested unless they are completely dry. Observation on 08/05/25 at 10:10 A.M., showed wet six plates stacked together on a service cart in the mechanical dishwashing area. During an interview on 08/05/25 at 10:10 A.M., the Certified Dietary Manager (CDM) said he/she washed the plates that morning. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure residents had complete, accurate and individualized care plans, to address the care needs for four residents (Residents #3, #7, #32, and #34) out of 12 sampled. The facility census was 38.1. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated December 2016, showed the interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The care plan will incorporate identified problem areas. The care plan will incorporate risk factors associated with identified problems. The care plan will reflect currently recognized standards of practice for problem areas and conditions. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to follow infection control protocols for COVID-19 (an infectious disease caused by severe acute respiratory syndrome coronavirus2 (SARS-CoV-2) when staff did not wear eye protection while inside the room of two residents (Resident #10 and #24) of three sampled residents who tested positive for COVID-19. Facility staff failed to use appropriate hand hygiene during wound care for two residents (Residents #38 and #41) of two sampled residents. The facility census was 38. 1. Review of the facility's COVID-19 policies and procedures guide, dated 09/26/25, showed symptomatic residents, regardless of vaccination status, suspected or confirmed with COVID-19, are encouraged to stay restricted to their rooms and cared for by staff using a respirator, eye protection, gloves and a gown. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure the wireless call light system was fully operational twenty-four hours per day, seven days a week, and failed to ensure direct care staff always carried and utilized the wireless nurse call pagers for three residents (Resident #3, #10, and #24) out of five sampled residents when the call-light response time was greater than 30 minutes. The facility census was 38.1. Review of the facility's policy titled, Answering the Call Light, dated March 2021, showed be sure the light is plugged in and functioning at all times. The policy did not contain direction or guidance for the use of paging devices to audibly alert staff of a residents call for assistance.2. [...]

Inspectors wroteBased on interview and record review, facility staff failed to maintain professional standards of practice when staff failed to provide access for qualified staff to the facility's emergency medication kit (E-Kit), in order to administer medications to three newly admitted residents (Residents #1, #2, and #3). The facility census was 38. 1. Review of the facility's Medication Pass Policy, undated, did not contain information related to administration of medications from the E-Kit. 2. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 4/15/25, showed an admission date of 4/09/25. Review showed staff assessed the resident as cognitively intact, with diagnoses of high cholesterol and depression. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to implement the Enhanced Barrier Precautions (EBP) policy when they did not educate, or alert staff of residents who required EBP, and failed to place appropriate personal protective equipment (PPE) in close proximity for two residents (Resident #1 and #2) of two sampled residents. The facility's census was 37. 1. Review of the facility policies showed it did not contain a Enhanced Barrier Precaution policy. Review of the Centers for Medicare and Medicaid Services, New CDC Guidance: Enhanced Barrier Precautions, dated 03/20/2024 showed: -Educate all staff on enhanced barrier precautions and use during high-contact resident care activities to include dressing, bathing, transferring, providing hygiene, changing linens and briefs, assisting with toileting, device care or use: [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD- a serious type of pneumonia (lung infection) caused by Legionella bacteria. Facility staff failure to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems has the potential for the failure of staff to identify and mitigate the presence of waterborne pathogens, which places all residents of the facility at risk of exposure which could lead to illness. The facility census was 37 with a capacity of 52. 1. [...]

Inspectors wroteBased on observation, interviews, and record review, facility staff failed to maintain a clean comfortable, and maintained homelike environment. The facility census was 37. 1. Review of the facility's Work Orders, Maintenance policy, dated April 2010, showed maintenance work orders shall be completed in order to establish a priority of maintenance, work orders must be filled out and forwarded to the maintenance director and emergency requests will be given priority in making necessary repairs. Review of the facility's Cleaning and Disinfection of Environmental Surfaces, dated August 2019, showed environmental surfaces will be cleaned and disinfected according to current Centers for Disease Control and Prevention (CDC) recommendations for disinfection of healthcare facilities and the Occupational Safety and Health Administration (OSHA) bloodborne pathogens standard. 2. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to develop and implement a comprehensive person-centered care plan for three (Resident #9, #33 and #143) out of ten sampled residents The facility census was 37. 1. Review of the facility's Care Plans, Comprehensive Person-Centered policy, dated December 2016 showed: -The care plan interventions are derived from a thorough analysis of information gathered as part of the comprehensive assessment; -The care planning process will include an assessment of the resident's strengths and needs and incorporate the resident's personal and cultural preferences in developing the goals of care; -The comprehensive, person centered care plan will: [...]

Inspectors wroteBased on interview and record review, facility staff failed to meet professional standards of care when nursing staff failed to obtain and document weights for five (Resident #1, #12, #17, #33 and #142) of nine sampled residents and failed to follow up on dietician recommendations for one (Resident #142) of one sampled residents with a weight loss. The facility census was 37. 1. Review of the facility's Weighing and Measuring the Resident policy, dated March 2011, showed: -The purpose to determine the weight, to provide a baseline and ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident; -Weight is measured on admission and monthly during the resident's stay; -The following should be recorded in the resident's record: [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to safely propel two (Resident #17 and #8) out of 15 sampled residents while in a wheelchair. The facility census was 37. 1. Review of the facility's polices showed staff did not provide a wheelchair propulsion policy. 2. Review of Resident #17's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 03/28/24, showed staff assessed the resident as follows: -Cognition not assessed; -Uses a wheelchair for mobility; -Diagnosis of Alzheimers, and Parkinson disease. Observation on 05/30/24 at 11:40 A.M., showed Certified Nurse Aid (CNA) L propelled the resident from the hall to the dinning area without the resident's foot pedals. Observation showed the residents feet made contact on the floor. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to obtain a consent for the use of side rails for six of six sampled residents (Resident #3, #9, #10, #13, and #141). The facility census was 37. 1. Review of the facility's Proper Use of Side Rails Policy, dated December 2016, showed staff are to obtain consent for side rail use from the resident or legal representative 2. Review of Resident #3's Quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 03/28/24, showed staff assessed the resident as follows: -Required moderate assistance with bed mobility; -Totally dependent for assistance with transfers, and toileting; -Impairment in all four extremities. Review of the resident's medical record showed the record did not contain a signed consent for the use of side rails. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure ten out of ten nurse aides ((NA) NA A, NA B, NA C, NA D, NA E, NA F, NA G, NA H, NA I, and NA J) out of ten sampled NA , completed the nurse aide training program within four months of their employment in the facility. The facility census was 37. 1. Review of the facility's Nurse Aide Qualifications and Training Requirements, dated May 2019, showed the facility will not employ any individual as a nurse aide for more than four months full-time, temporary, per diem, or otherwise, unless: -That individual is competent to provide designated nursing care and nursing related services; and -That individual has completed a training program and competency evaluation program, or a competency evaluation program approved by the state; or that individual has been deemed competent as provided in the requirements of participation; [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure residents with psychotropic and anti-psychotic medications were monitored for adverse reactions or efficacy of these medications for five of seven sampled residents (Resident #1, #9, #13, #23 and #143) and failed to obtain and document an appropriate diagnosis for medication use for three of five sampled residents. (Resident #1, #9, #143). The facility census was 37. 1. Review of the facility's Antipsychotic Medication use policy, dated December 2016 showed: -Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective; -The physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others; [...]

Inspectors wroteBased on interview, and record review, facility staff failed to comply with federal, state,and local laws and professional standards by not providing financial payment for Certified Nurse Aid (CNA) training and certification expenses for two Nurse Aids (NA) out of two sampled staff. The facility census was 37. 1. Review of the Missouri Department of Health and Senior Services On Site Visit Evaluation Instrument for Nurse Aid Training form (DA-603), dated 05/30/24, showed the facility charged Nurse Aids (NA) 850.00 dollars by paycheck deduction to complete a CNA training course and certification test. 2. Review of the facility's Sponsorship Plan Reimbursement Agreement, undated, showed NA staff were required to sign an agreement to pay for half of the cost of CNA training through payroll deduction. [...]

Inspectors wroteBased on interview and record review, facility staff failed to document the administration or refusal of the pneumococcal (lung inflammation caused by bacterial or viral infection) vaccine for three (Resident #1, #142 and #143) out of seven sampled residents. The facility census was 37. 1. Review of the facility's Pneumococcal Vaccine Policy, dated August 2016, showed: -Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty days of admission to the facility unless medically contraindicated or the resident has already been vaccinated; -Assessments of pneumococcal vaccine status will be conducted within 5 working days of the resident's admission if not conducted prior to admission; [...]

Inspectors wroteBased on interview and record review, facility staff failed to document residents' code status consistently, Do Not Resuscitate (DNR) or Full Code (Resuscitate refers to cardiopulmonary resuscitation-CPR) for two (Resident #39 and #137) of four sampled residents. The facility census was 37. 1. Review of the facility's Advance Directives policy, revised [DATE], showed staff are directed to: -Inquire if the resident, his/her family members and/or his or her and/or his or her legal representative, about the existence of any written advance directives; -Prominently display information about whether or not the resident has executed an advance directive in the resident's medical record; -The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive; [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure one (Resident #141) out of one sampled resident received care and services for the provision of hemodialysis (the clinical cleansing of blood by dialysis, as a substitute for the normal function of the kidney) when staff failed to provide ongoing assessments of the resident's condition, monitoring for complications before and after dialysis treatments, and provide ongoing communication and collaboration with the dialysis clinic. The facility census was 37. 1. Review of the facility's policy End-Stage Renal Disease, Care of a Resident with, dated 09/2010, showed the policy did not contain direction on pre and post dialysis assessments or collaboration with the dialysis clinic. 2. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to provide one resident (Resident #5) a 30-day discharge notice and refused to readmit the resident after a hospital stay. The facility census was 40. 1. Review of the facility's policy, Emergency Transfer or Discharge, revised August, 2018, showed if a resident exercises his or her right to appeal a transfer or discharge notice he or she will not be transferred or discharged while the appeal is pending, unless the failure to discharge or transfer endanger the health or safety of the resident or other individuals in the facility. A resident is transferred or discharged despite his or her pending appeal, the danger that failure to transfer of discharge will be documented. [...]

Inspectors wroteBased on observation, interview, and record review, staff failed to maintain professional standards of care when staff did not accurately transcribe one resident's (Resident #1) nutrition orders by gastrostomy tube (G-tube), a tube inserted in the abdomen which brings nutrition directly to the stomach. The facility census was 73. 1. Review of the facility's Medication Utilization and Prescribing Policy, revised 04/2018, showed staff are directed as follows: -Medications and/or treatments should be administered only upon the signed order of a person lawfully authorized to prescribe; -Staff should follow all valid medical provider orders timely unless there is an emergency which would temporarily delay the implementation of the order. 2. [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility staff failed to perform hand hygiene as often as necessary. Facility staff failed to use the sanitizing solution according to facility policy and manufacturer's instructions. This failure had the potential to affect all facility occupants. The census was 38 1. Review of the 2017 Food and Drug Administration's (FDA) Food Code showed: -Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils and after handling soiled equipment or utensils; -To avoid re-contaminating their hands or surrogate prosthetic devices, food employees may use disposable paper towels or similar clean barriers when touching surfaces such as manually operated faucet handles on a hand washing sink. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide care to meet basic hygiene needs when staff failed to assist eight residents (Resident #4, #7, #9, #10, #20, #22, #29 and #36) out of 12 sampled residents who required assistance with showers. Additionally, staff failed to adapt the wheelchair for one dependent resident (Resident #20), resulting in sores on the resident's arm. The facility census was 38. 1. Review of the facility's Activities of Daily Living (ADLs) policy, dated March 2018, showed staff are directed as follows: -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: -Hygiene (bathing, dressing, grooming, and oral care); [...]