Inspection Reports for
Columbia Post Acute
3535 BERRYWOOD DRIVE, COLUMBIA, MO, 65201-6584
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
6.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
18% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
67 residents
Based on a February 2025 inspection.
Occupancy 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
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
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 |
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