Inspection Reports for
Columbia Post Acute
3535 BERRYWOOD DRIVE, COLUMBIA, MO, 65201-6584
Back to Facility Profile8 Reports
Inspection Report — Feb 10, 2025
Routine
Date: Feb 10, 2025
Visit Reason
CMS-2567 federal health survey and Missouri Department of Health and Senior Services State Form were included in this file; the survey type is not stated.
Findings
Two deficiencies were cited: one federal health deficiency for a medication administration error involving an incorrect morphine dose that required emergency care, and one Missouri state licensure deficiency regarding medication error reporting (Class II*).
Deficiencies (1)
19 CSR 30-85.042(51) Medication Errors/Adverse Reactions Reported: Refer to F760.
Report Facts
residents affected: 1
Inspection Report — Nov 15, 2024
Routine
Date: Nov 15, 2024
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Eight deficiencies were cited: five federal health deficiencies addressing care planning, medication transcription/administration errors, activity director qualifications, medication error rate, and resident bed/entrapment assessments; and three Missouri state deficiencies related to the medication system, protective oversight/voluntary leave, and the activity program.
Deficiencies (3)
19 CSR 30-85.042(46) Safe/Effective Medication System: Refer to F658 & F759.
19 CSR 30-85.042(65) Protective Oversight, Voluntary Leave: Refer to F909.
19 CSR 30-85.042(92) Activity Program: Refer to F680.
Report Facts
residents sampled: 25
medication administration opportunities observed: 38
medication errors observed: 2
sampled residents for medication error calculation: 21
Inspection Report — Aug 11, 2023
Routine
Date: Aug 11, 2023
Visit Reason
Federal health survey (CMS-2567) and Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
There are 5 federal health deficiencies covering medication/insulin administration and orders, tracheostomy/catheter/CPAP/wound care, assistance with ADLs/grooming, medication storage and safe lifts, food safety/handling, and bed rail entrapment assessments. There are 7 Missouri state licensure deficiencies that reference and mirror the federal findings and cite the corresponding 19 CSR rules.
Deficiencies (7)
19 CSR 30-85.042(45) Written Orders; Restraints: Refer to F658.
19 CSR 30-85.042(49) Injections, Insulin Administration: Refer to F658.
19 CSR 30-85.042(55) Medication Storage: Refer to F689.
19 CSR 30-85.042(65) Protective Oversight, Voluntary Leave: Refer to F909.
19 CSR 30-85.042(68) Res Groomed/Dressed Appropriately: Refer to F677.
19 CSR 30-87.030(2) Wash Hands/Arms & Clean Fingernails: Please refer to F812.
19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: Please refer to F812.
Report Facts
sampled dependent residents: 16
sampled residents for bed rail entrapment assessments: 8
residents affected (ADL assistance): 5
residents affected (bed rail entrapment): 5
Inspection Report — Aug 11, 2023
Life Safety
Date: Aug 11, 2023
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Federal CMS-2567 Life Safety survey (K-tags) and Missouri Department of Health and Senior Services State Form; a life safety survey (K-tag) with accompanying state licensure citations.
Findings
Four deficiencies were cited: two federal Life Safety deficiencies concerning fire drills and essential electrical system inspection/testing, and two Missouri state deficiencies that refer to those same issues.
Deficiencies (2)
19 CSR 30-85.022(33)(D) Fire Drill Requirements, Evacuation: Refer to K712.
19 CSR 30-85.032(31)(A) Electrical Wiring & Equipment Maintained: Refer to K918.
Inspection Report — Apr 28, 2022
Routine
Date: Apr 28, 2022
Visit Reason
Federal health survey (CMS-2567) and Missouri State Form licensure survey; the survey type is not stated.
Findings
Three deficiencies were cited: two federal health survey deficiencies involving failure to provide required written transfer/discharge notices and failure to conduct and document a comprehensive facility assessment, and one state licensure deficiency for transfer/discharge that references the federal finding.
Deficiencies (1)
19 CSR 30-88.010(15) 30 Day Notice-Transfer/Discharge: Please refer to F623.
Report Facts
residents sampled: 3
Inspection Report — Apr 28, 2022
Life Safety
Date: Apr 28, 2022
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CMS-2567 Life Safety Code survey (K-tag life safety deficiencies) with accompanying Missouri Department of Health and Senior Services State Form.
Findings
Ten deficiencies were cited: five federal Life Safety (K) deficiencies and five Missouri State Form deficiencies. The findings address range hood maintenance/cleaning, fire alarm inspection/testing documentation, sprinkler head cover/maintenance issues, unsealed smoke barrier penetrations, and missing simulated conditions in fire drill records.
Deficiencies (5)
19 CSR 30-85.022(9) Range Hood Certification: See deficiency cited at K324.
19 CSR 30-85.022(10)(F) Fire Alarm System Records: See deficiency cited at K345.
19 CSR 30-85.022(11)(C) Sprinkler System-Test/Maintain: See deficiency cited at K353.
19 CSR 30-85.022(29) Smoke Section Walls/Doors: See deficiency cited at K372.
19 CSR 30-85.022(33)(F) Fire Drill Records: See deficiency cited at K712.
Report Facts
smoke zones affected: 7
smoke barrier walls unmaintained: 6
Inspection Report — May 9, 2019
Routine
Date: May 9, 2019
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Twelve deficiencies were cited in this file: eight federal findings covering admission assessments and documentation, CPR initiation and staff CPR competency/response, quality of care and emergency supplies, tube feeding medication administration, nursing staff competency and training, medication administration errors, food sanitation/dishwashing, and infection prevention including water management; and four Missouri state licensure citations that reference the medication system, nursing care per resident condition, infection control, and utensil drying/storage.
Deficiencies (4)
19 CSR 30-85.042(47) Safe/Effective Medication System: See the deficiency cited at F759.
19 CSR 30-85.042(67) Nursing Care per Res Condition: See the deficiency cited at F678 and F684.
19 CSR 30-85.042(78) Infection Control/Communicable Disease: See the deficiency cited at F880.
19 CSR 30-87.030(84) Equip/Utensils Air Dried, Self-Drain Utensils: See the deficiency cited at F812.
Report Facts
medication opportunities observed: 25
medication errors observed: 7
medication error rate: 28
sampled residents affected by medication errors: 2
Inspection Report — May 9, 2019
Life Safety
Date: May 9, 2019
Visit Reason
CMS-2567 life safety survey (federal) with accompanying Missouri State Form licensure pages; the survey is a life safety survey.
Findings
Six deficiencies were cited: three federal life safety deficiencies involving emergency lighting, fire alarm system testing and maintenance, and fire drills; and three Missouri state licensure citations addressing the same areas.
Deficiencies (3)
19 CSR 30-85.022(10)(B) Fire Alarm System-Test/Maintain: Please refer to K345.
19 CSR 30-85.022(25) Emergency Lighting: Please refer to K291.
19 CSR 30-85.022(33)(D) Fire Drill Requirements, Evacuation: Please refer to K712.
Report Facts
required annual fire drills: 12
required full operational duration of emergency lighting: 1.5
13 CMS Surveys
Inspection Report — Feb 10, 2025
Routine
Date: Feb 10, 2025
Visit Reason
CMS-2567 federal health survey and Missouri Department of Health and Senior Services State Form were included in this file; the survey type is not stated.
Findings
Two deficiencies were cited: one federal health deficiency for a medication administration error involving an incorrect morphine dose that required emergency care, and one Missouri state licensure deficiency regarding medication error reporting (Class II*).
Deficiencies (1)
F760 Residents are Free of Significant Med Errors: Based on record review and interview, facility staff administered an incorrect dosage of morphine to one resident (Resident #1), resulting in the resident receiving 75 mg instead of the ordered 15 mg and requiring transfer to the emergency room.
Report Facts
residents affected: 1
Inspection Report — Nov 15, 2024
Routine
Date: Nov 15, 2024
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Eight deficiencies were cited: five federal health deficiencies addressing care planning, medication transcription/administration errors, activity director qualifications, medication error rate, and resident bed/entrapment assessments; and three Missouri state deficiencies related to the medication system, protective oversight/voluntary leave, and the activity program.
Deficiencies (5)
F657 Care Plan Timing and Revision: Facility staff failed to timely review and revise residents' care plans to reflect changes in needs for multiple residents, and several care plans lacked directions for bed rail or anticoagulant/medication issues.
F658 Services Provided Meet Professional Standards: Facility staff failed to accurately transcribe hospital discharge medication orders for a resident, resulting in the resident not receiving necessary eye drop medications.
F680 Qualifications of Activity Professional: The facility failed to ensure the activities program was directed by a qualified professional; the Activity Director position lacked documentation of required state-approved training/certification.
F759 Free of Medication Error Rts 5 Prcnt or More: Facility staff failed to maintain a medication administration error rate below 5%, with observed medication administration errors affecting residents.
F909 Resident Bed: Facility staff failed to conduct regular entrapment/bed system assessments for residents who used bed rails, and entrapment assessments had not been completed since June 2024.
Report Facts
residents sampled: 25
medication administration opportunities observed: 38
medication errors observed: 2
sampled residents for medication error calculation: 21
Inspection Report — Nov 15, 2024
Life Safety
Date: Nov 15, 2024
Visit Reason
CMS-2567 Life Safety Code survey (federal) and a Missouri Department of Health and Senior Services State Form licensure inspection are included in this file; the survey type is not stated.
Findings
Zero deficiencies were cited. The CMS Life Safety and Emergency Preparedness sections did not result in deficiencies and the Missouri licensure inspection cited no state licensure deficiencies.
Inspection Report — Aug 11, 2023
Routine
Date: Aug 11, 2023
Visit Reason
Federal health survey (CMS-2567) and Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
There are 5 federal health deficiencies covering medication/insulin administration and orders, tracheostomy/catheter/CPAP/wound care, assistance with ADLs/grooming, medication storage and safe lifts, food safety/handling, and bed rail entrapment assessments. There are 7 Missouri state licensure deficiencies that reference and mirror the federal findings and cite the corresponding 19 CSR rules.
Deficiencies (5)
F658 Services Provided Meet Professional Standards: Based on observation, interview and record review facility staff failed to maintain professional standards of care including incorrect insulin pen administration and failure to obtain or follow physician orders and care plans for tracheostomy, catheter use, CPAP and dialysis and to assess wound dressings on admission.
F677 ADL Care Provided for Dependent Residents: Based on observation, interview, and record review facility staff failed to assist five out of 16 sampled dependent residents with grooming and bathing.
F689 Free of Accident Hazards/Supervision/Devices: Based on observation, interview and record review, facility staff failed to secure and store medications to prevent access and failed to ensure safe mechanical lift transfers, leaving medication carts unlocked and creating risks for residents and staff.
F812 Food Procurement,Store/Prepare/Serve-Sanitary: Based on observation, interviews, and record review, facility staff failed to follow food safety practices including wearing hairnets/beard guards, maintaining ice machine drainage through an air gap, keeping kitchen equipment clean, and performing proper handwashing and glove use.
F909 Resident Bed: Based on observation, interview and record review, facility staff failed to conduct or complete entrapment assessments and measurements to identify areas of possible entrapment on admission and quarterly for five of eight sampled residents who used bed rails.
Report Facts
sampled dependent residents: 16
sampled residents for bed rail entrapment assessments: 8
residents affected (ADL assistance): 5
residents affected (bed rail entrapment): 5
Inspection Report — Aug 11, 2023
Life Safety
Date: Aug 11, 2023
Visit Reason
Federal CMS-2567 Life Safety survey (K-tags) and Missouri Department of Health and Senior Services State Form; a life safety survey (K-tag) with accompanying state licensure citations.
Findings
Four deficiencies were cited: two federal Life Safety deficiencies concerning fire drills and essential electrical system inspection/testing, and two Missouri state deficiencies that refer to those same issues.
Deficiencies (2)
K712 Fire Drills: Based on interview and record review, facility staff failed to conduct required quarterly fire drills at varying times on each shift between July 2022 and June 2023. Records showed drills were often conducted at the same times.
K918 Electrical Systems - Essential Electric System Maintenance and Testing: Facility staff failed to provide complete and verifiable documentation of inspections and testing of essential electrical systems, including annual feeder circuit breaker inspections and periodic exercising of main and feeder circuit breaker components. The records reviewed did not contain documentation of these inspections or tests.
Inspection Report — Apr 28, 2022
Routine
Date: Apr 28, 2022
Visit Reason
Federal health survey (CMS-2567) and Missouri State Form licensure survey; the survey type is not stated.
Findings
Three deficiencies were cited: two federal health survey deficiencies involving failure to provide required written transfer/discharge notices and failure to conduct and document a comprehensive facility assessment, and one state licensure deficiency for transfer/discharge that references the federal finding.
Deficiencies (2)
F623 Notice Requirements Before Transfer/Discharge: Based on interview and record review, facility staff failed to notify the resident and/or resident representative in writing of a facility-initiated transfer to a hospital, including the reasons for the transfer, the bed-hold policy, or required agency contact information for three sampled residents.
F838 Facility Assessment: Based on record review and interview, facility staff failed to conduct and document a thorough facility-wide assessment to determine what resources are necessary to care for residents, as the facility assessment did not include required elements such as acuity levels, staff competencies, and resident census data.
Report Facts
residents sampled: 3
Inspection Report — Apr 28, 2022
Life Safety
Date: Apr 28, 2022
Visit Reason
CMS-2567 Life Safety Code survey (K-tag life safety deficiencies) with accompanying Missouri Department of Health and Senior Services State Form.
Findings
Ten deficiencies were cited: five federal Life Safety (K) deficiencies and five Missouri State Form deficiencies. The findings address range hood maintenance/cleaning, fire alarm inspection/testing documentation, sprinkler head cover/maintenance issues, unsealed smoke barrier penetrations, and missing simulated conditions in fire drill records.
Deficiencies (5)
K324 Cooking Facilities: Based on observation, interview and record review, staff failed to maintain the range hood and provide routine cleaning of the range hood baffle filters, resulting in excessive accumulation of grease and dust.
K345 Fire Alarm System - Testing and Maintenance: The facility failed to provide and maintain documentation of 100% inspection and testing of the fire alarm system and the records did not include required detail such as location of detectors or functional test results.
K353 Sprinkler System - Maintenance and Testing: Facility staff failed to ensure recessed sprinkler head covers fit tightly and that there were no unsealed gaps around cover plates; multiple flat cover plates were not securely attached and unsealed gaps were observed in many locations.
K372 Subdivision of Building Spaces - Smoke Barrier Construction: Based on observations and interviews, facility staff failed to maintain six of seven smoke barrier walls with the required fire resistance rating and multiple unsealed holes/penetrations and inappropriate use of spray foam were observed.
K712 Fire Drills: Based on interview and record review, facility staff failed to conduct fire drills under varying/simulated conditions for several drills and records did not document a simulated condition for multiple dates.
Report Facts
smoke zones affected: 7
smoke barrier walls unmaintained: 6
Inspection Report — Sep 16, 2020
Routine
Date: Sep 16, 2020
Visit Reason
Federal CMS-2567 (statement of deficiencies) documenting a COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control survey conducted on 09/16/2020. No complaint or complaint number is stated in the file.
Findings
No federal health (F) or emergency preparedness (E) deficiencies were cited; the survey documents COVID-19 focused Emergency Preparedness and Infection Control initial comments indicating the facility was found in compliance.
Inspection Report — Jun 11, 2020
Routine
Date: Jun 11, 2020
Visit Reason
CMS-2567 federal health and emergency preparedness survey. A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted on 06/11/2020.
Findings
No health or emergency preparedness deficiencies were cited; the facility was found in compliance with applicable COVID-19 emergency preparedness and infection control requirements.
Inspection Report — May 9, 2019
Routine
Date: May 9, 2019
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Twelve deficiencies were cited in this file: eight federal findings covering admission assessments and documentation, CPR initiation and staff CPR competency/response, quality of care and emergency supplies, tube feeding medication administration, nursing staff competency and training, medication administration errors, food sanitation/dishwashing, and infection prevention including water management; and four Missouri state licensure citations that reference the medication system, nursing care per resident condition, infection control, and utensil drying/storage.
Deficiencies (8)
F658 Services Provided Meet Professional Standards: Facility staff failed to complete admission baseline nursing assessments for multiple residents and did not consistently follow physician orders for blood sugar notification and PICC line patency checks.
F678 Cardio-Pulmonary Resuscitation (CPR): Facility failed to ensure timely initiation of CPR and adequate staff preparedness, including lack of consistent CPR-certified staff on duty, unclear code status orders, and deficiencies in emergency response procedures and supplies.
F684 Quality of Care: Facility failed to ensure appropriate emergency preparedness and response, including orientation of agency staff to crash carts and emergency supplies, availability of glucagon/glucose for hypoglycemia, and timely staff response to acute changes in resident condition.
F693 Tube Feeding Mgmt/Restore Eating Skills: Facility staff failed to administer medications via a PEG/feeding tube according to physician orders and facility policy, including improper preparation/administration and incomplete documentation for a resident receiving enteral feedings.
F726 Competent Nursing Staff: Facility failed to ensure nursing staff competence and required education and documentation, including missing annual training hours, incomplete competency testing, and gaps in staff orientation and competency records.
F759 Free of Medication Error Rts 5 Prcnt or More: Facility medication error rate exceeded 5 percent; observed medication pass errors occurred resulting in a 28% error rate which affected sampled residents.
F812 Food Procurement,Store/Prepare/Serve-Sanitary: Facility staff failed to allow sanitized dishes to air dry and were observed stacking wet sanitized dishes, creating a risk for foodborne contamination.
F880 Infection Prevention & Control: Facility lacked a complete infection prevention program and water management elements, failed to perform required TB screening and proper glucometer disinfection, and had inconsistent use of gloves for PICC line medication administration.
Report Facts
medication opportunities observed: 25
medication errors observed: 7
medication error rate: 28
sampled residents affected by medication errors: 2
Inspection Report — May 9, 2019
Life Safety
Date: May 9, 2019
Visit Reason
CMS-2567 life safety survey (federal) with accompanying Missouri State Form licensure pages; the survey is a life safety survey.
Findings
Six deficiencies were cited: three federal life safety deficiencies involving emergency lighting, fire alarm system testing and maintenance, and fire drills; and three Missouri state licensure citations addressing the same areas.
Deficiencies (3)
K291 Emergency Lighting: Facility staff failed to conduct and/or document an annual 1½ hour functional test of the facility's emergency lighting system.
K345 Fire Alarm System - Testing & Maintenance: Facility staff failed to inspect, test and maintain the fire alarm system and failed to provide documentation of required detector sensitivity testing.
K712 Fire Drills: Facility staff failed to conduct fire drills under varied/expected and unexpected conditions quarterly on each shift and failed to document required simulated conditions for drills.
Report Facts
required annual fire drills: 12
required full operational duration of emergency lighting: 1.5
Inspection Report — May 7, 2018
Original Licensing
Date: May 7, 2018
Visit Reason
CMS-2567 federal health survey (initial survey) and Missouri Department of Health and Senior Services State Form licensure inspection; the survey type is stated as an initial/original survey.
Findings
No federal health deficiencies were cited and no state licensure deficiencies were cited.
Inspection Report — May 7, 2018
Life Safety
Date: May 7, 2018
Visit Reason
Federal CMS-2567 pages containing Emergency Preparedness and Life Safety initial comments, and a Missouri state licensure inspection form; the survey type is not stated.
Findings
No federal health or life safety deficiencies were cited on the CMS-2567 forms, and no state licensure deficiencies were cited on the Missouri state form.
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