Columbia Manor Health & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Review of the facility's Past Call's log dated 08/02/25 showed:-At 7:19 A.M., room [ROOM NUMBER] call light response time of 30 minutes and 37 seconds;-At 9:33 A.M., room [ROOM NUMBER] call light response time of 56 minutes and 47 seconds;-At 1:31 P.M., room [ROOM NUMBER] call…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Review of the resident's Physician's Order Sheet (POS), dated April 2025, showed the physician orders directed staff to administer Metoprolol Tartrate (a medication used to decrease blood pressure) 50 milligrams (mg) one tablet twice daily, Baclofen (a muscle relaxant) 10…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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: central lines, urinary catheters, and feeding tubes, tracheostomy, urostomy, and wound care: any skin opening requiring a dressing. -Facilities should develop a method…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17; showed: -The bacterium Legionella can cause a serious type of pneumonia…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Observation on 05/28/24 at 10:30 A.M., showed the occupied room [ROOM NUMBER] with build up of a dark substance on the room floor tile grout…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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: include measurable, objectives and timeframe's, describe the services that are to be furnished to attain or maintain the residents highest practicable physical, mental, psychosocial well-being, describe services that would otherwise be provided for the above, but are not provided due to the resident exercising…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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: date and time the procedure was performed, name and title of person who performed the procedure, signature and title of person recording the data; -Notify the nurse supervisor if the resident refuses the procedure. 2. Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. During an interview on 05/30/24 at 11:42 A.M., CNA L said he/she should have put the residents feet in the footrests but did not because the resident has contractor in both legs. 3. Review of Resident #8's annual MDS, dated [DATE],…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Observation on 05/28/24 at 11:04 A.M., showed the resident in bed with a right quarter sized side rail in the upright position. Observation on 05/29/24 at 8:54 A.M., showed the resident in bed with a right…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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; -Nurse assistants failing to successfully complete the required training program within the first four months of their employment may be terminated from the employment or may be reassigned to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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; -The physician will identify, evaluate, and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. During an interview on 05/29/24 at 10:45 A.M., Nurse Aide (NA) J said when he/she applied to work at the facility he/she was told he/she would be required to pay for CNA training and certification. The payment is deducted from the NA's paycheck. During and interview on 05/29/24 at 11:30…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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; -If refused, appropriate entries will be documented in each resident's medical record indicating the date of the refusal of the pneumococcal vaccine; -For residents who receive the vaccine, the date of the vaccine, lot number, expiration data, person administering and the site of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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; -The resident's attending physician will clarify and present any relevant medical issues and decision to the resident or legal representative as the resident's condition changes in an effort to clarify and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Review of Resident #141's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/22/2024, showed staff assess the resident as follows: -admission date of 05/16/24; -Diagnosis of chronic kidney disease; -Did not receive dialysis as a resident. Review of the resident's Physician's Order Sheets (POS), dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Review showed the policy did not contain direction for 30-Day written notice of transfer with appeal rights, written notification of transfer, or written notice of the bed hold policy. 2. Review of Resident's #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 8/17/23,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Review of Resident #1's entry Minimum Data Set (MDS) a federally mandated assessment tool, dated 09/08/23, showed staff documented the resident entered the facility on 09/08/23 from an acute hospital. Review of the resident's baseline care plan, dated 09/08/23, showed staff assessed the resident as follows: -Cognitively Intact; -Received enteral tube…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Review of the facility's Handwashing/Hand Hygiene policy, dated 2001, showed: -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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); -Mobility (transfer and ambulation, including walking). Review of the facility's Bath, Shower/Tub policy, dated February 2018, showed staff are directed as follows:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.