Inspection Reports for
Columbia Post Acute
3535 BERRYWOOD DRIVE, COLUMBIA, MO, 65201-6584
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
8.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
53% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
96% occupied
Based on a February 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Census: 67
Deficiencies: 1
Date: Feb 10, 2025
Visit Reason
The inspection was conducted due to a medication error incident where a resident was administered an incorrect dosage of Morphine.
Findings
The facility failed to ensure one resident remained free from significant medication errors when an incorrect dosage of Morphine was administered, resulting in actual harm and emergency room transfer. Interviews and record reviews confirmed the error and subsequent actions taken.
Deficiencies (1)
Failure to ensure residents are free from significant medication errors, specifically incorrect Morphine dosage administration.
Report Facts
Census: 67
Morphine dosage administered: 75
Prescribed Morphine dosage: 15
Narcan dosage: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Administered incorrect Morphine dosage and monitored resident after error |
| LPN D | Licensed Practical Nurse | Assisted in medication administration and identified dosage error |
| Nurse Practitioner | Ordered Narcan administration and emergency room transfer | |
| Director of Nursing | Director of Nursing | Discussed standing order and counseled RN A on medication errors |
| Administrator | Administrator | Acknowledged medication error and outlined notification procedures |
Inspection Report
Routine
Census: 66
Deficiencies: 5
Date: Nov 15, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with federal and state regulations related to care planning, medication administration, activities program qualifications, bed safety, and medication error rates.
Findings
The facility failed to properly review and revise care plans for residents with changing needs, accurately transcribe medication orders resulting in missed medications, ensure the activities program was directed by a qualified professional, maintain medication administration error rates below 5%, and conduct regular entrapment assessments for bed rails. Several residents' care plans lacked necessary directions related to medications, bed rail use, and conditions such as dementia and diarrhea. Medication errors were observed related to insulin pen priming. The facility had not completed entrapment assessments since June 2024.
Deficiencies (5)
Failed to review and revise care plans with changes in residents' needs for seven residents.
Failed to accurately transcribe one resident's eye drop medication orders resulting in missed medications.
Activities program was not directed by a qualified professional; Activity Director lacked required certification.
Medication administration error rate exceeded 5% due to failure to prime insulin pens before administration.
Failed to conduct regular entrapment assessments for bed rails for seven residents; no assessments completed since June 2024.
Report Facts
Residents affected: 7
Medication administration opportunities observed: 38
Medication administration errors: 2
Medication administration error rate: 5.26
Facility census: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in medication error finding related to insulin pen priming |
| LPN J | Licensed Practical Nurse | Interviewed regarding medication transcription and administration errors |
| DON | Director of Nursing | Interviewed regarding care plan deficiencies, medication errors, and entrapment assessments |
| AD | Activity Director | Interviewed regarding lack of certification and qualifications |
| Pharmacist M | Pharmacist | Interviewed regarding medication administration and transcription errors |
| Physician L | Physician | Interviewed regarding medication transcription errors |
| Unit Manager N | Unit Manager | Interviewed regarding insulin administration procedures |
| Administrator | Facility Administrator | Interviewed regarding activities program qualifications and entrapment assessments |
Inspection Report
Routine
Census: 66
Deficiencies: 1
Date: Nov 15, 2024
Visit Reason
The inspection was conducted to ensure the nursing facility meets professional standards of quality, specifically reviewing medication administration and reconciliation processes.
Findings
Facility staff failed to accurately transcribe one resident's eye drop medication orders from the hospital, resulting in the resident not receiving necessary medications during their stay. Multiple staff members reviewed the medication list, but the orders were entered incorrectly, posing potential harm to the resident with glaucoma.
Deficiencies (1)
Failure to accurately transcribe and administer resident #18's eye drop medication orders as per hospital discharge instructions.
Report Facts
Facility census: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pharmacist M | Pharmacist | Interviewed regarding medication orders and administration for resident #18 |
| Physician L | Physician | Interviewed about hospital orders and medication transcription for resident #18 |
| Licensed Practical Nurse J | Licensed Practical Nurse | Interviewed about medication entry and administration process for resident #18 |
| Director of Nursing | Director of Nursing | Interviewed about medication reconciliation and review process during resident admission |
Inspection Report
Annual Inspection
Census: 66
Deficiencies: 8
Date: Nov 15, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations and evaluate the quality of care provided at Columbia Post Acute.
Findings
The facility was found deficient in multiple areas including care plan timing and revision, medication administration errors, qualifications of the activity professional, and entrapment assessments related to bed rails. Several residents' care plans lacked required documentation and directions, and medication orders were not properly transcribed or administered.
Deficiencies (8)
F657 Care Plan Timing and Revision: Facility failed to review and revise care plans with changes in residents' needs for seven residents. Care plans lacked directions for anticoagulant medication and bed rail use.
F658 Services Provided Meet Professional Standards: Facility failed to accurately transcribe medication orders for one resident, resulting in missed necessary medications during stay.
F680 Qualifications of Activity Professional: Facility failed to ensure the activities program was directed by a qualified professional. The Activity Director was not certified and had not taken required training.
F759 Free of Medication Error Rates 5% or More: Facility failed to maintain medication administration error rate below 5%, with a 5.26% error rate observed in 38 opportunities.
F909 Resident Bed: Facility failed to conduct regular entrapment assessments for bed rails for seven residents and did not complete entrapment assessments since June 2024.
A4055 Safe/Effective Medication System: Facility failed to maintain a safe medication system as evidenced by medication errors and transcription failures. Refer to F658 and F759.
A4074 Protective Oversight, Voluntary Leave: Facility failed to provide 24-hour protective oversight and supervision for residents on voluntary leave. Refer to F909.
A4101 Activity Program: Facility failed to designate a qualified employee responsible for the activity program. Refer to F680.
Report Facts
Resident census: 66
Medication administration opportunities observed: 38
Medication administration error rate: 5.26
Residents sampled for care plan deficiencies: 7
Residents with entrapment assessment deficiencies: 7
Inspection Report
Life Safety
Deficiencies: 0
Date: Nov 15, 2024
Visit Reason
The inspection was conducted as a life safety code survey and licensure inspection of the Columbia Post Acute facility.
Findings
No deficiencies were cited in the Emergency Preparedness portion, Life Safety Code portion, or state licensure inspection. The facility met applicable provisions of the 2012 Life Safety Code and related reference documents.
Inspection Report
Routine
Census: 64
Deficiencies: 17
Date: Aug 11, 2023
Visit Reason
Routine inspection of Columbia Post Acute nursing facility to assess compliance with professional standards of care, medication administration, resident care plans, safety, and facility sanitation.
Findings
The facility failed to follow manufacturer's guidelines for insulin pen administration, obtain specific physician orders for various resident treatments including tracheostomy care, catheter use, CPAP, and dialysis, and failed to assess wounds on admission. Additionally, deficiencies were found in resident grooming assistance, medication cart security, mechanical lift safety, kitchen sanitation, food storage, hand hygiene, and bed rail entrapment assessments.
Deficiencies (17)
Failure to follow manufacturer's guidelines for insulin pen administration for Resident #22.
Failure to obtain specific physician orders for tracheostomy care and lack of suction machine at bedside for Resident #1.
Failure to obtain orders and plan of care for catheter use for Residents #308 and #323, and failure to discontinue catheter order for Resident #26 who no longer used a catheter.
Failure to obtain order and plan of care for CPAP machine use for Resident #15.
Failure to obtain dialysis order and provide written communication between facility and dialysis center for Resident #18.
Failure to assess under wound dressings on admission for Resident #308.
Failure to assist five dependent residents (#5, #12, #21, #33, #313) with grooming and bathing as per care plans.
Failure to secure medication carts, leaving them unlocked and unattended, allowing potential access to medications by unauthorized persons.
Improper storage of heparin and saline flush syringes in resident rooms without physician orders.
Failure to ensure resident #319 self-administered medications safely; medications left unattended on bedside table.
Failure to use mechanical lifts safely for residents #5 and #7, including improper positioning of lift legs and lack of support during transfers.
Dietary staff failed to wear hairnets and beard guards properly, exposing hair and facial hair during food preparation.
Ice machine did not drain through an air gap and drain pipe contained black and brown substance.
Kitchen was not maintained in a clean and sanitary manner with visible dirt, crumbs, grease buildup, and dust on multiple surfaces and equipment.
Food storage deficiencies including unlabeled, undated, and improperly stored food items in walk-in freezer, refrigerator, and food prep areas.
Dietary staff failed to perform handwashing appropriately and improperly used gloves, including handling clean items with contaminated gloves.
Failure to conduct or complete entrapment assessments and measurements for bed rails on admission and quarterly for five residents (#1, #26, #36, #37, #308).
Report Facts
Facility census: 64
Insulin dose: 9
Blood sugar: 160
Blood pressure: 199
Shower dates documented: 9
Length of beard: 2
Length of beard: 0.75
Length of goatee: 1
Number of seasoning containers undated: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT F | Certified Medication Technician | Observed failing to follow insulin pen administration guidelines and leaving medication cart unlocked |
| LPN C | Licensed Practical Nurse | Provided interviews on insulin pen administration, catheter orders, dialysis communication, medication cart security, and medication administration |
| DON | Director of Nursing | Provided multiple interviews regarding facility expectations for care standards, orders, medication cart security, dialysis communication, wound care, shaving, mechanical lifts, and bed rail assessments |
| LPN E | Licensed Practical Nurse | Interviewed regarding tracheostomy care and heparin flush storage |
| RN U | Registered Nurse | Interviewed regarding dialysis assessments and mechanical lift transfers |
| CNA G | Certified Nurse Aid | Interviewed regarding shower frequency and mechanical lift transfers |
| CNA K | Certified Nurse Aid | Observed and interviewed regarding mechanical lift transfers and shaving assistance |
| Cook Q | Cook | Observed not wearing beard guard and improper hand hygiene |
| DA R | Dietary Aide | Observed not wearing beard guard and improper hand hygiene |
| Dietary Manager | Interviewed regarding dietary staff hygiene, kitchen sanitation, food storage, and handwashing policies | |
| Administrator | Interviewed regarding facility policies and staff responsibilities for hygiene, sanitation, and safety |
Inspection Report
Plan of Correction
Census: 64
Deficiencies: 5
Date: Aug 11, 2023
Visit Reason
The document is a Plan of Correction submitted by Columbia Post Acute following a state survey conducted on 08/11/2023. It addresses deficiencies found during the inspection related to professional standards of care, resident assistance, accident hazards, food safety, and resident bed safety.
Findings
The facility was found deficient in maintaining professional standards of care including insulin administration, tracheostomy care, catheter care, and resident assistance with activities of daily living. Additional deficiencies included failure to secure medications, provide adequate supervision and assistance devices, maintain food safety and sanitation, and conduct regular bed safety inspections.
Deficiencies (5)
F658 Services Provided Meet Professional Standards: Facility staff failed to maintain professional standards of care in insulin administration, tracheostomy care, catheter use, and dialysis communication for multiple residents.
F677 ADL Care Provided for Dependent Residents: Staff failed to assist five out of 16 sampled residents with grooming and bathing, and residents had unkempt hair and long fingernails.
F689 Free of Accident Hazards/Supervision/Devices: Facility staff failed to secure medications and provide safe mechanical lift transfers, risking resident safety.
F812 Food Procurement, Store, Prepare, Serve, Sanitary: Facility staff failed to maintain food safety standards including wearing hairnets and beard guards, and maintaining clean kitchen equipment and food storage.
F909 Resident Bed: Facility staff failed to conduct regular inspections and assessments of bed frames, mattresses, and bed rails to identify entrapment risks for residents.
Report Facts
Facility census: 64
Deficiency counts: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in interviews related to insulin administration, tracheostomy care, catheter care, and bed rail assessments |
| Certified Medication Technician F | Certified Medication Technician (CMT) | Observed and interviewed regarding insulin pen use and medication cart security |
| Licensed Practical Nurse C | Licensed Practical Nurse (LPN) | Interviewed regarding insulin pen use, catheter orders, and bed rail assessments |
| Registered Nurse U | Registered Nurse (RN) | Interviewed regarding dialysis assessments and resident care |
| Certified Nurse Aid K | Certified Nurse Aid (CNA) | Observed assisting residents with grooming and bed mobility |
| Certified Nurse Aid W | Certified Nurse Aid (CNA) | Observed assisting with mechanical lift transfers |
| Certified Nurse Aid X | Certified Nurse Aid (CNA) | Observed assisting with mechanical lift transfers |
| Certified Nurse Aid L | Certified Nurse Aid (CNA) | Interviewed regarding mechanical lift transfers and resident care |
| Dietary Manager | Dietary Manager | Interviewed regarding food safety and kitchen sanitation policies |
Inspection Report
Life Safety
Census: 64
Capacity: 70
Deficiencies: 2
Date: Aug 11, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with the Life Safety Code and fire safety regulations, including fire drills and electrical system maintenance.
Findings
The facility failed to conduct fire drills at various times on each shift quarterly as required, and failed to provide complete documentation for electrical system inspections and testing. These deficiencies have the potential to affect all facility occupants.
Deficiencies (2)
K712 Fire Drills: Facility staff failed to conduct fire drills at various times on each shift quarterly from July 2022 through June 2023, contrary to NFPA 101 requirements.
K918 Electrical Systems: Facility staff failed to inspect and test essential electrical systems and provide complete documentation of annual feeder circuit breaker inspections and periodic exercising of main and feeder circuit breaker components.
Report Facts
Facility census: 64
Facility capacity: 70
Fire drills required: 12
Fire drills unannounced: 4
Inspection Report
Plan of Correction
Census: 63
Deficiencies: 2
Date: Apr 28, 2022
Visit Reason
The inspection was conducted to evaluate compliance with transfer/discharge notice requirements and facility assessment regulations, as part of a federal survey of Columbia Post Acute.
Findings
The facility failed to notify residents or their representatives in writing about transfers or discharges as required by regulation. Additionally, the facility did not conduct a thorough facility-wide assessment to determine necessary resources for resident care.
Deficiencies (2)
F623: The facility failed to notify residents or their representatives in writing of transfers or discharges, including reasons, bed hold policy, and appeal rights, for three sampled residents. The facility census was 63 at the time of the survey.
F838: The facility failed to conduct and document a thorough facility-wide assessment to determine resources necessary to care for residents during day-to-day operations and emergencies. The assessment lacked documentation of acuity levels and staff competencies.
Report Facts
Facility census: 63
Number of identified deficient patients: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chris McClain | Administrator | Signed plan of correction and referenced in interviews regarding transfer/discharge notifications |
| Director of Nursing | Interviewed regarding notification of resident transfers | |
| Social Services Director | Interviewed regarding notification of resident transfers |
Inspection Report
Annual Inspection
Census: 63
Deficiencies: 2
Date: Apr 28, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident transfer notifications and facility-wide resource assessment.
Findings
The facility failed to provide timely written notification to residents or their representatives regarding transfers to hospitals, including required information such as bed hold policy and appeal rights. Additionally, the facility did not conduct or document a thorough facility-wide assessment to determine necessary resources for resident care during daily operations and emergencies.
Deficiencies (2)
Failure to notify residents and/or representatives in writing of facility-initiated transfers to hospital, including reasons for transfer, bed hold policy, and agency contact information for three sampled residents.
Failure to conduct and document a thorough facility-wide assessment to determine necessary resources for resident care during day-to-day operations and emergencies.
Report Facts
Facility census: 63
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Stated nursing contacted families by phone regarding resident transfers |
| Social Services Director | Social Services Director | Responsible for paperwork and stated notifications were verbal, no written notices issued |
| Administrator | Administrator | Interviewed regarding staffing based on acuity and lack of documented facility assessment |
| DON | Director of Nursing | Interviewed regarding staffing based on acuity and lack of documented facility assessment |
Inspection Report
Life Safety
Census: 63
Capacity: 70
Deficiencies: 5
Date: Apr 28, 2022
Visit Reason
The inspection was a Life Safety Code survey conducted to assess compliance with fire safety and emergency preparedness regulations.
Findings
The facility failed to maintain the range hood and fire alarm system properly, did not ensure adequate fire drill documentation, and had multiple deficiencies related to sprinkler system maintenance, smoke barriers, and fire drills. These failures had the potential to affect all facility occupants.
Deficiencies (5)
K324 Cooking Facilities: The facility staff failed to maintain the range hood by not providing routine cleaning of the range hood baffle filters, leading to excessive grease and dust accumulation and increased fire risk.
K345 Fire Alarm System - Testing and Maintenance: The facility staff failed to provide and maintain documentation of 100% inspection and testing of the fire alarm system, including missing information on smoke detector tests.
K353 Sprinkler System - Maintenance and Testing: The facility staff failed to ensure recessed sprinkler head covers fit tightly without unsealed gaps, and failed to address sprinkler head and flat cover plate issues in multiple locations.
K372 Subdivision of Building Spaces - Smoke Barrier Construction: The facility staff failed to maintain six out of seven smoke barrier walls with the required fire resistance rating, including unsealed holes and combustible spray foam.
K712 Fire Drills: The facility staff failed to conduct fire drills under varying conditions for seven out of twelve months and did not maintain documentation of simulated conditions for fire drills.
Report Facts
Facility census: 63
Facility capacity: 70
Number of fire drills missed: 7
Number of smoke barrier walls non-compliant: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chris McClain | Administrator | Signed the plan of correction and mentioned in interviews regarding maintenance policies |
| Certified Dietary Manager | CDM | Interviewed regarding range hood filter maintenance |
| Maintenance Director | Interviewed regarding maintenance and inspection of range hood, fire alarm, sprinkler system, smoke barriers, and fire drills |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 16, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant CMS and CDC guidelines.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Report Facts
Regulatory citation: 42
Inspection Report
Routine
Deficiencies: 0
Date: Jun 11, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Enforcement
Census: 41
Capacity: 41
Deficiencies: 8
Date: May 9, 2019
Visit Reason
The inspection was conducted as an enforcement action following an Immediate Jeopardy (IJ) situation related to deficiencies in professional standards of care, CPR response, medication administration, infection control, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to complete admission baseline nursing assessments, failure to provide CPR and emergency response properly, medication errors exceeding 5%, inadequate infection control practices, and failure to maintain a safe and effective medication system. Immediate jeopardy was identified but later removed after corrective actions were implemented.
Deficiencies (8)
F658: Facility staff failed to complete admission baseline nursing assessments for six residents and failed to follow physician orders for blood sugar and PICC line monitoring. The facility census was 41.
F678: Facility staff failed to provide CPR to a resident in full cardiac arrest and failed to ensure staff with CPR certification were always on duty. The facility census was 41.
F684: Facility failed to orient agency nurses to emergency supplies including crash carts, glucagon, and glucose gel, and failed to maintain policies for cardiopulmonary resuscitation and emergency medical response.
F693: Facility failed to administer medications through percutaneous endoscopic gastrostomy (PEG) tube properly and failed to prevent complications related to enteral feeding. The facility census was 41.
F726: Facility failed to ensure nursing staff competency through education, testing, and annual training requirements. The facility census was 41.
F759: Medication error rates exceeded 5%, with 7 errors out of 25 opportunities affecting two residents. The facility census was 41.
F812: Facility staff failed to allow sanitized dishes to air dry properly, failed to prevent foodborne pathogens, and failed to maintain proper food service safety standards. The facility census was 41.
F880: Facility failed to establish an effective infection prevention and control program, failed to maintain water management to prevent Legionnaires' disease, and failed to properly disinfect glucometers. No patients were identified as affected.
Report Facts
Facility census: 41
Medication error rate: 28
Immediate Jeopardy removal date: May 8, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Involved in CPR response and emergency care for resident in cardiac arrest |
| RN J | Registered Nurse | Interviewed regarding emergency response and resident care |
| LPN D | Licensed Practical Nurse | Reported on staff assistance during emergency and medication administration |
| DON | Director of Nursing | Oversaw nursing staff training, policy implementation, and corrective actions |
| ADM | Administrator | Provided statements on staff expectations and corrective actions |
Inspection Report
Life Safety
Census: 41
Capacity: 70
Deficiencies: 3
Date: May 9, 2019
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and related fire safety regulations, including emergency lighting, fire alarm system testing and maintenance, and fire drills.
Findings
The facility failed to conduct required annual functional testing of emergency lighting and detector sensitivity testing for the fire alarm system. Additionally, fire drills were not conducted under varied conditions as required, and documentation of these tests and drills was incomplete.
Deficiencies (3)
K291 Emergency Lighting: Facility staff failed to conduct the required annual 1.5-hour functional test of all emergency lighting equipment. This failure could result in equipment failure and delay evacuation during an emergency.
K345 Fire Alarm System - Testing and Maintenance: Facility staff failed to inspect, test, and maintain the fire alarm system detector sensitivity annually as required. This failure could affect all facility occupants in an emergency.
K712 Fire Drills: Facility staff failed to conduct fire drills under varied conditions on each shift quarterly for the months of May 2018 through April 2019. This failure could delay response procedures in the event of a fire.
Report Facts
Facility census: 41
Total capacity: 70
Fire drills required annually: 12
Fire drills unannounced: 4
Inspection Report
Original Licensing
Deficiencies: 0
Date: May 7, 2018
Visit Reason
The inspection was conducted as an initial licensure survey for Columbia Post Acute facility.
Findings
No healthcare deficiencies or state licensure deficiencies were cited as a result of this initial survey and licensure inspection.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 7, 2018
Visit Reason
This document is a plan of correction related to a Life Safety Code inspection and licensure inspection of Columbia Post Acute facility.
Findings
The facility met the applicable provisions of the LTC Emergency Preparedness requirements and the 2012 edition of the Life Safety Code. No state licensure deficiencies were cited as a result of this inspection.
Document
Deficiencies: 0
Visit Reason
The document does not contain any readable text or content to determine the visit reason.
Findings
No findings or content are available due to lack of readable text.
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