Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Columbia Post Acute during CMS and state inspections, most recent first.
A resident with a recent fracture and intact cognition was given 75 mg of Morphine instead of the prescribed 15 mg after an RN and LPN misread the concentration of liquid Morphine and miscalculated the dose. The error was discovered only after administration, leading to the resident experiencing adverse symptoms and requiring emergency room monitoring.
Facility staff failed to update and utilize care plans for several residents, resulting in deficiencies in addressing their changing needs. Care plans lacked critical information such as the use of bed rails, anticoagulant medication, and management of chronic diarrhea. Staff interviews revealed a reliance on whiteboards and hospital paperwork instead of care plans, leading to gaps in care planning.
The facility failed to conduct regular entrapment assessments for residents using bed rails, as required by their policy. Observations showed residents with cognitive impairments and mobility assistance needs using bed rails without documented assessments. The administrator admitted that assessments had not been completed since the responsible staff member was terminated, leading to a lapse in ensuring resident safety.
A medication administration error occurred when a nurse failed to prime insulin pens before administering doses to a resident with diabetes, resulting in a 5.26% error rate. The facility's policy and manufacturer's recommendations require priming to ensure accurate dosing by removing air bubbles. The error was acknowledged by the RN, Unit Manager, and DON.
A resident with glaucoma did not receive necessary eye drop medications due to the facility's failure to accurately transcribe hospital discharge orders. The facility's policy on medication reconciliation was not followed, resulting in discrepancies between the hospital orders and the facility's records. Despite multiple checks by staff, the medications were incorrectly listed as 'as needed' instead of scheduled, leading to the resident not receiving the prescribed treatment.
The facility failed to ensure the activities program was directed by a qualified professional. There was no policy regarding qualifications for the Activity Director (AD) position, and the job description did not require certification. The AD's file lacked documentation of a state-approved training course, and both the AD and the administrator were unaware of the certification requirement.
Significant Medication Error Due to Incorrect Morphine Dosage Administration
Penalty
Summary
Facility staff failed to ensure a resident remained free from significant medication errors when an incorrect dosage of Morphine was administered. The resident, who was cognitively intact and had a recent fracture of the left fibula, had a physician order for Morphine Sulfate 15 mg every four hours as needed for pain. When the resident requested pain medication, the only available Morphine was a concentrated liquid form. The RN and LPN involved misread the concentration on the vial, calculating and administering 3.7 ml of the liquid, which equated to 75 mg of Morphine instead of the prescribed 15 mg. The error occurred because both the RN and LPN misinterpreted the medication label, believing the concentration was 20 mg per five ml rather than the correct 20 mg per one ml. The RN drew up and administered the incorrect dose, and only after administration did the LPN realize the mistake. The resident was then monitored, and the Nurse Practitioner was notified, who ordered Narcan to reverse the opioid effect. The resident subsequently experienced symptoms including pain, diarrhea, nausea, decreased oxygen saturation, and increased respirations, and was sent to the emergency room for monitoring. Interviews with staff confirmed that the error resulted from a miscalculation during a busy shift change, with the LPN distracted while receiving report and the RN assuming the liquid was equivalent to the pill form. The facility's medication administration policy required staff to verify the right medication, dose, and method, but these steps were not properly followed, leading to the significant medication error.
Failure to Update and Utilize Care Plans for Residents
Penalty
Summary
The facility staff failed to review and revise the care plans for seven residents, leading to deficiencies in addressing the residents' changing needs. The care plans were not updated to reflect significant changes in the residents' conditions, such as the discontinuation of a urinary catheter for one resident and the use of anticoagulant medication and bed rails for another. Additionally, the care plans did not include necessary interventions for residents with cognitive impairments, mobility assistance needs, and frequent bowel incontinence. The facility's policy requires care plans to be developed within seven days of the completion of the Minimum Data Set (MDS) and revised as residents' conditions change. However, the care plans for several residents did not include critical information, such as the use of bed rails, anticoagulant medication, and management of chronic diarrhea. Interviews with staff revealed a lack of awareness and use of care plans, with some staff relying on whiteboards and hospital paperwork for resident care instructions instead. The Director of Nursing (DON) and the MDS Coordinator acknowledged the omissions in the care plans and the importance of including all relevant information to ensure proper care. Despite the facility's policy and the availability of care plans, staff did not consistently use them, leading to gaps in care planning and potential risks for the residents involved.
Failure to Conduct Regular Entrapment Assessments for Residents Using Bed Rails
Penalty
Summary
The facility staff failed to conduct regular entrapment assessments for seven residents who used bed rails, as required by the facility's Bed Safety and Bed Rails policy. This policy, dated August 2022, mandates that bed rails are prohibited unless specific criteria are met, and that any gaps in the bed system must comply with safety dimensions established by the FDA. Despite these requirements, the maintenance department records showed no completed entrapment assessments since June 2024, indicating a lapse in routine inspections of beds and related equipment for entrapment risks. Observations and record reviews revealed that residents with varying levels of cognitive impairment and mobility assistance needs were using bed rails without documented entrapment assessments. For instance, Resident #5, who was moderately cognitively impaired and required supervision for bed mobility, was observed with bed rails raised on both sides, yet their medical record lacked an entrapment assessment. Similar deficiencies were noted for other residents, including those with mild to severe cognitive impairments and those requiring partial to maximal assistance for bed mobility. The administrator acknowledged during an interview that the staff member responsible for completing entrapment assessments had been terminated in June 2024, and the new maintenance director had not completed the assessments. This oversight resulted in a failure to ensure the safety of residents using bed rails, as no entrapment assessments had been conducted since the previous staff member's departure.
Medication Administration Error Due to Improper Insulin Pen Priming
Penalty
Summary
The facility staff failed to maintain a medication administration error rate of less than 5%, resulting in a 5.26% error rate during the observation of 38 medication administration opportunities. This error rate affected one resident out of 21 sampled residents. The errors involved the administration of insulin to a resident with diabetes, where the registered nurse (RN) did not prime the insulin pens before administering Humalog and Glargine insulin, as required by the manufacturer's recommendations and the facility's medication administration policy. The resident involved had a diagnosis of diabetes and was receiving insulin injections as per the physician's orders. The RN acknowledged the failure to prime the insulin pens, which is necessary to ensure accurate dosing by removing air bubbles. The Unit Manager and the Director of Nursing (DON) confirmed that not priming the insulin pen is considered a medication error. The facility's administrator expects staff to adhere to the standards of practice and facility policies regarding medication administration.
Failure to Transcribe Eye Drop Medication Orders Correctly
Penalty
Summary
Facility staff failed to accurately transcribe a resident's eye drop medication orders from the hospital, resulting in the resident not receiving necessary medications during their stay. The facility's policy on medication reconciliation, revised in July 2017, outlines the process of comparing pre-discharge medications to post-discharge medications to prevent unintended changes or omissions. However, the staff did not adhere to this policy, leading to discrepancies between the hospital discharge orders and the facility's Physician Order Sheet (POS) and Medication Administration Record (MAR). The resident, who was moderately cognitively impaired and had a diagnosis of primary open-angle glaucoma, did not receive the prescribed eye medications as ordered. The hospital discharge orders specified scheduled administration of Atropine, Brimonidine, Difluprednate, and Latanoprost eye drops, but the facility's POS listed them as 'as needed' for eye irritation. Interviews with the pharmacist, physician, LPN, and DON revealed that the facility orders should have matched the hospital discharge orders, and the failure to do so could harm the resident's glaucoma condition. Despite multiple staff members checking the medication list, the error persisted, and the medications were not administered correctly.
Unqualified Activity Director
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional. The facility did not have a policy regarding the qualifications required for the Activity Director (AD) position. The job description for the AD was undated and did not specify the necessity for certification, although it outlined the responsibilities of planning, organizing, developing, and directing the activity department in accordance with various standards and regulations. Upon review of the AD's employee file, it was found that there was no documentation of the AD having completed a state-approved training course. During interviews, both the AD and the administrator admitted to being unaware of the certification requirement for the position.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Columbia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Neighborhoods Rehabilitation And Skilled Nursing B | 2.9 mi | ★★★★★ | 4 | 2 |
| Villa At Blue Ridge, The | 3 mi | ★★★★★ | 11 | 0 |
| Bluffs, The | 3 mi | ★★★★★ | 18 | 0 |
| Lenoir Health Care Center | 3.5 mi | ★★★★★ | 0 | 0 |
| Columbia Manor Health & Rehabilitation | 3.7 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.