Below 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 Neighborhoods Rehabilitation And Skilled Nursing B during CMS and state inspections, most recent first.
Failure to issue emergency discharge notice: A resident was sent to the hospital for uncontrolled pain and then told the facility would not accept the resident back because the acuity of care was higher than anticipated. The record contained no documentation of an emergency discharge notice, and the DON and Administrator stated the resident’s needs could not be met and no written discharge was issued.
Facility staff did not transcribe a physician's wound care order for a resident and failed to complete weekly skin assessments for three residents, despite standing orders and documented risk for skin breakdown. Staff interviews confirmed that required documentation and follow-through on physician orders and assessments were not consistently performed.
A resident who required two-person assistance for bed mobility and had enablers on both sides of the bed was not monitored for over four hours, contrary to facility policy requiring checks at least every two hours. The resident was found entrapped between the bedrail and mattress, unresponsive, and later pronounced dead. Both the CNA and LPN failed to perform the required monitoring and care as outlined in the resident's care plan.
A resident with recent hospitalization and significant medical changes was not reassessed for bed rail use as required by facility policy. Staff failed to document an updated bed rail assessment after the resident's return, and the resident was later found entrapped between the bed rail and mattress, unresponsive and subsequently pronounced deceased. Interviews confirmed the lack of reassessment and documentation following the significant change in condition.
Staff failed to transcribe and implement updated wound care orders for two residents with pressure ulcers, resulting in the continued use of outdated treatment protocols and improper wound care. Observations and interviews revealed that new orders from a wound clinic were not entered into the system, and wound care was not performed as prescribed, with staff citing oversight and unclear responsibilities for updating orders. The DON and administrator were unaware of these lapses, highlighting a breakdown in communication and adherence to policy.
Staff failed to follow infection control protocols during wound care for a resident with multiple wounds, including not performing hand hygiene, not changing gloves between tasks, not using gowns as required by Enhanced Barrier Precautions (EBP), and not ensuring PPE was available or signage was posted. The resident's care plan and physician orders lacked EBP instructions, and contaminated items were placed on uncleaned surfaces, increasing the risk of cross-contamination.
A resident with severe cognitive impairment and multiple diagnoses was found unresponsive and without a pulse. Staff failed to initiate CPR, despite a full code order, due to an RN's mistaken belief that the resident was a DNR because hospice was being considered. The RN did not verify code status in the medical record, and no hospice order was present. Interviews confirmed the resident was a full code and not on hospice, and the failure to perform CPR was contrary to facility policy and physician expectations.
Staff did not report to DHSS when a resident with severe cognitive impairment and a full code order was found unresponsive and did not receive CPR. The nurse on duty assumed the resident was DNR based on secondhand information and did not verify code status, resulting in no resuscitation. Facility leadership did not consider the incident neglect and did not report it as required by policy.
The facility failed to store medications safely, with expired medical supplies and medications found in multiple medication rooms and a cart. Staff interviews revealed a lack of a written process for checking expired medications, and uncertainty about audit documentation. The presence of expired items suggests ineffective implementation of storage processes.
The facility failed to ensure timely responses to residents' call lights, with reports showing repeated activations without prompt staff response. Residents expressed concerns about delays, especially at night, and staff interviews revealed challenges due to staffing shortages. The facility's leadership provided inconsistent information on expected response times, highlighting a systemic issue in addressing residents' needs.
A resident with schizophrenia and other mental health diagnoses did not receive their prescribed antipsychotic medication, Aristada, as required due to issues with medication delivery and documentation. The facility failed to document the administration of the medication, notify the physician, or monitor for adverse effects, despite policies requiring these actions. Interviews revealed that the medication was not received due to a lack of signature, leading to its return to the post office and outside hospital.
Failure to Issue Emergency Discharge Notice
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice for Resident #1 when the resident was discharged to the hospital and then not allowed to return to the facility. The resident’s face sheet showed admission to the facility and discharge to the local hospital on 5/20/26, and the progress notes documented that the resident was discharged back to the hospital at 11:48 A.M. for uncontrolled pain. Review of the resident’s medical record did not contain documentation of an emergency discharge notice issued to the resident. During interviews, the DON stated the facility was not informed of the full acuity of care and believed it could not meet the resident’s needs, and the Administrator stated the resident’s acuity was much higher than anticipated, the resident was sent to the hospital, and the hospital social worker was told the resident would not be permitted back because of the level of care needed; the Administrator also stated no written discharge was issued.
Failure to Transcribe Physician Orders and Complete Weekly Skin Assessments
Penalty
Summary
Facility staff failed to meet professional standards of practice by not transcribing physician's orders for one resident and not completing weekly skin assessments for three residents. For one resident with severe cognitive impairment and at risk for skin breakdown, a wound consultant ordered a hydrocolloid sheet to be applied weekly and as needed, but this order was not transcribed into the resident's Physician Order Sheet (POS) or Treatment Administration Record (TAR). The wound care nurse and charge nurse both acknowledged that the process for entering new wound care orders was not followed, and the wound care nurse did not verify that the orders were entered as required. Additionally, weekly skin assessments were not documented as completed for three residents who were all assessed as being at risk for skin breakdown and requiring assistance with activities of daily living. Review of the residents' records showed multiple missed weekly skin assessments over several months, despite standing physician orders for these assessments to be completed by licensed staff on specific days. Interviews with staff, including the DON, wound care nurse, and administrator, confirmed that the responsibility for entering new orders and completing weekly skin assessments was not consistently fulfilled. Staff interviews revealed a lack of clarity and follow-through regarding the process for transcribing and verifying physician orders, particularly those from the wound consultant. The facility's policy required all physician orders to be carried out as ordered and entered into the electronic medical record, but this was not done. The DON, wound care nurse, and administrator all stated that if something is not documented, it is considered not done, and acknowledged that the required documentation and follow-up were missing in these cases.
Failure to Perform Required Resident Rounds Resulting in Entrapment and Death
Penalty
Summary
Facility staff failed to monitor a resident at least every two hours as required by facility policy and based on the resident's needs. The resident, who was moderately cognitively intact and required two staff for bed mobility and transfers, was not checked between 11:00 P.M. and 3:10 A.M. Staff interviews and record reviews confirmed that the assigned CNA did not observe the resident during this period, and the LPN responsible for the resident's IV medication also did not return to the room to disconnect the IV as required. The resident had a physician's order for enablers (grab bars) on both sides of the bed and required significant assistance for mobility and transfers. The resident's baseline care plan indicated the need for a mechanical lift and two staff for bed mobility, transfers, and toileting. Despite these needs, staff did not assess or document the use of bed rails or grab bars, and the resident was left unattended for over four hours during the night shift. At approximately 3:10 A.M., the resident was found entrapped between the bedrail and mattress, face down and unresponsive. Staff had to forcefully remove the resident's head from between the rail and mattress. CPR was initiated, and emergency services were called, but the resident was pronounced dead. The investigation confirmed that the required two-hour checks were not performed, and both the CNA and LPN failed to monitor the resident as per policy and the resident's care plan.
Failure to Reassess Bed Rail Use After Significant Change in Condition Resulting in Resident Entrapment and Death
Penalty
Summary
Facility staff failed to reassess the use of bed rails for a resident following a significant change in condition, as required by facility policy. The resident, who had a history of weakness, recent hospitalization for a severe infection, and delirium, was readmitted to the facility with new medical interventions including a PICC line and a closed drain. Despite these changes, there was no documented updated assessment to determine the appropriateness and safety of continued bed rail use after the resident's return from the hospital. The facility's policy required reassessment of bed rail use after significant changes in a resident's status, as well as ongoing monitoring and proper documentation. However, interviews and record reviews revealed that neither nursing nor maintenance staff could provide documentation of a post-hospitalization bed rail assessment. The assistant administrator stated that routine checks were performed but could not confirm if the check occurred before or after the resident's return, nor if the resident was present in the bed at the time. Nursing staff were unclear about the resident's change in status and the requirements for reassessment. The deficiency resulted in a fatal incident where the resident was found entrapped between the bed rail and mattress, unresponsive and later pronounced deceased. Staff interviews confirmed that the resident's head was trapped between the rail and mattress, and that the required reassessment and documentation of bed rail appropriateness following the significant change in condition had not been completed.
Failure to Transcribe and Implement Wound Care Orders
Penalty
Summary
Facility staff failed to meet professional standards of quality by not transcribing and implementing wound care orders for two residents with pressure ulcers. For one resident, staff did not update the physician order sheet (POS) with new wound care instructions received from the wound clinic, resulting in the continued use of outdated treatment protocols. The wound nurse confirmed that the orders were not updated in the system because the nurse who received the new orders did not enter them, and the responsibility for updating orders was not clearly followed. Documentation on the Treatment Administration Record (TAR) showed treatments were administered according to the old orders, not the updated ones from the wound clinic. For another resident, the plan of care did not address the resident's wounds, and staff failed to document new wound care orders, including specific cleansing and dressing instructions. During observation, an LPN did not use the correct cleansing agents or dressings as prescribed in the new orders, instead using wound cleanser and foam dressings not specified in the orders. The LPN admitted to not updating the orders in the system and not following the prescribed wound care protocol, citing oversight as the reason for the errors. Interviews with staff, including the wound nurse, LPN, DON, and administrator, revealed a lack of clarity and consistency in the process for updating and implementing new physician orders. Staff acknowledged that it is the responsibility of the nurse receiving the orders to enter them promptly, but this was not consistently done. The DON and administrator were not aware that orders were not being updated or that wound care was not being performed as prescribed, indicating a breakdown in communication and adherence to facility policy.
Failure to Implement Infection Control and Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Facility staff failed to adhere to infection prevention and control protocols during wound care for a resident with multiple wounds. Observations revealed that an LPN did not perform hand hygiene or apply gloves before handling wound care supplies, did not clean scissors before use, and placed supplies directly on the treatment cart without a barrier. During wound care, the LPN did not use a gown, failed to change gloves and perform hand hygiene between tasks and wounds, and placed soiled items on the resident's bed and bedside table without cleaning these surfaces afterward. The LPN also used the same gloves for multiple tasks and wounds, increasing the risk of cross-contamination. The facility's policies on hand hygiene and Enhanced Barrier Precautions (EBP) require staff to perform hand hygiene before and after glove use, treat each wound individually, and use gowns and gloves for residents with chronic wounds. However, the resident's plan of care and physician orders did not include directions for EBP, and there was no signage or PPE available near the resident's room to alert staff or facilitate compliance with EBP. Interviews with the LPN, DON, and Administrator confirmed that staff were aware of the correct procedures but failed to implement them during the observed wound care. The resident involved was cognitively intact, at risk for pressure ulcers, and had multiple documented wounds requiring ongoing wound care. Despite these risk factors, the facility did not ensure that staff followed established infection control practices or that EBP protocols were implemented and communicated to staff. The lack of proper hand hygiene, glove changes, use of PPE, and environmental cleaning during wound care constituted a failure to prevent potential cross-contamination and infection.
Failure to Initiate CPR for Full Code Resident Due to Staff Miscommunication and Assumptions
Penalty
Summary
Facility staff failed to initiate Cardiopulmonary Resuscitation (CPR) for a resident who had a signed full code physician order. The resident, who had severe cognitive impairment and diagnoses including dementia, Alzheimer's disease, non-traumatic brain disorder, coronary artery disease, and heart failure, was found unresponsive during a medication pass. Staff documented that the resident did not have a pulse and confirmed the resident had expired, but did not attempt CPR. The investigation revealed that the registered nurse (RN) on duty did not verify the resident's code status and assumed the resident was a Do Not Resuscitate (DNR) because the resident was reportedly going on hospice, although there was no hospice order in the record. The RN admitted to being confused, not knowing what to do, and not checking the resident's code status in the medical record, despite knowing where to find this information. The certified medication technician who gave the report to the RN stated that the resident's family was considering hospice, but the resident was not on hospice at the time. Interviews with facility leadership and the resident's durable power of attorney confirmed that the resident was a full code and not on hospice. The physician also stated that staff are expected to follow the resident's code status and perform CPR as ordered, regardless of hospice consideration. The failure to verify code status and initiate CPR was a direct violation of facility policy and the resident's documented wishes.
Failure to Report Neglect After Staff Did Not Initiate CPR for Full Code Resident
Penalty
Summary
Facility staff failed to report to the Department of Health and Senior Services (DHSS) an incident of neglect involving a resident with a full code status. The resident, who had severe cognitive impairment and diagnoses including dementia, Alzheimer's, non-traumatic brain disorder, coronary artery disease, and heart failure, was found unresponsive without a pulse. Despite a physician order and care plan indicating full code status, the registered nurse on duty did not initiate CPR. The nurse assumed the resident was a DNR based on a report from a medication technician and did not verify the resident's code status in the medical record or facility documentation. The facility's policy required immediate reporting of suspected neglect to the state agency, but the incident was not reported. The Director of Nursing and the administrator both stated they did not believe the incident constituted neglect and therefore did not report it to DHSS. The nurse involved admitted to confusion and not checking the resident's code status, resulting in no resuscitation efforts being made for a resident who was documented as full code.
Medication Storage Deficiency Due to Expired Supplies
Penalty
Summary
The facility failed to store medications safely and effectively, as evidenced by expired medical supplies and medications found in multiple medication rooms and a medication cart. Observations revealed expired medical tubing, syringes, antiseptic bottles, and Nitroglycerin tablets in various locations within the facility. Interviews with staff, including a Certified Medication Technician (CMT) and Licensed Practical Nurses (LPNs), indicated a lack of a written process for checking medication carts for expired medications. Staff were expected to conduct weekly audits, but there was uncertainty about how these audits were documented. Further interviews revealed that there were no destruction logs for non-narcotic medications, and expired medications were either destroyed using a drug buster or placed in the main medication room for management to handle. The Director of Nursing and the Administrator confirmed that the pharmacy reviews medication storage for expired items, and medication technicians are supposed to check for expired medications weekly. However, the presence of expired medications suggests that these processes were not effectively implemented or followed.
Delayed Response to Call Lights in LTC Facility
Penalty
Summary
The facility staff failed to ensure that residents' call lights were answered in a timely manner, as evidenced by multiple instances where call lights were activated numerous times without a prompt response. The electronic call light report for several rooms showed that call lights were activated repeatedly, often nine times, before automatically shutting off after 45 minutes without a response. In some cases, responses were delayed by 30 to 40 minutes, indicating a significant delay in addressing residents' needs. Interviews with residents revealed dissatisfaction with the timeliness of call light responses, with some residents reporting that call lights were not answered for extended periods, especially at night. One resident expressed concern about the risk to resident well-being due to the lack of timely assistance, stating that they had to scream to get help when the call light did not work. The Resident Council members agreed with this sentiment, highlighting a broader issue of inadequate response times. Staff interviews provided further insight into the problem, with some CNAs acknowledging that call lights should be answered within a few minutes but admitting that it was challenging to meet this standard due to staffing shortages. The Assistant Director of Nursing and the Director of Nursing provided conflicting information about the expected response times, with some suggesting a 5-minute response time and others indicating it could take up to 30 minutes. The Administrator acknowledged that if a call light was announced nine times, it meant it was never answered, underscoring the facility's failure to meet its own standards for timely response to residents' needs.
Medication Management and Documentation Deficiency
Penalty
Summary
The report identifies a deficiency in the facility's medication management and documentation processes, specifically concerning a resident with a diagnosis of schizophrenia, bipolar depression, anxiety, and depression. The resident was prescribed Aristada, an antipsychotic medication, to be administered intramuscularly every four weeks. However, the facility failed to document the administration of this medication on multiple occasions, as evidenced by the Medication Administration Record (MAR) and progress notes. The MAR lacked documentation of the medication being administered, and progress notes indicated that the medication was unavailable and awaiting delivery, without evidence of physician notification or monitoring for adverse effects. The facility's policies on medication errors, reordering, and documentation require timely acquisition and administration of medications, as well as accurate documentation of any errors or omissions. Despite these policies, the facility did not follow up adequately when the medication was unavailable, nor did they document any adverse effects or notify the physician as required. Interviews with staff revealed that the medication was shipped but not received due to a lack of signature, resulting in the medication being returned to the post office and subsequently to the outside hospital. This lack of proper documentation and follow-up led to the resident not receiving the medication as prescribed. Interviews with the Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed the issues with medication delivery and documentation. The LPN acknowledged the absence of documentation regarding adverse effects and physician notification, while the DON explained the challenges in obtaining the medication from an outside hospital. The facility's failure to ensure timely administration and proper documentation of the resident's medication represents a breach of professional standards of care, as outlined in their policies.
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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) |
|---|---|---|---|---|
| Bluffs, The | 0.2 mi | ★★★★★ | 18 | 0 |
| Lenoir Health Care Center | 0.7 mi | ★★★★★ | 0 | 0 |
| Columbia Manor Health & Rehabilitation | 1 mi | ★★★★★ | 7 | 0 |
| South Hampton Place | 2.8 mi | ★★★★★ | 9 | 0 |
| Columbia Post Acute | 2.9 mi | ★★★★★ | 0 | 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.