Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Late Submission of MDS Discharge Assessment: The facility failed to timely complete and submit an MDS discharge assessment for two residents reviewed. For one resident, the discharge assessment was submitted 25 days after discharge. RN/MDS nurse, the Administrator, and the DON discussed the discrepancy, and the DON acknowledged the issue. The RAI Manual requires discharge assessments to be completed within 14 days of discharge and submitted within 14 days of completion.
A resident’s PEG tube medication administration did not follow the care plan or physician orders. An LPN crushed and gave multiple medications through the PEG tube without flushing between each medication, then flushed only after all meds were administered. The RN/ADON, DON, and MDS/care plan nurse confirmed the order and care plan were not followed.
An LPN administered multiple medications through a resident’s PEG tube without flushing between each medication as ordered. The resident had orders for 10 cc water flushes between meds, and the LPN later stated she forgot to flush between doses. The RN/ADON and DON confirmed the order was not followed.
Failure to provide daily oral care for a resident who was totally dependent on staff for personal hygiene and oral care. The resident, who had hemiplegia, aphasia, and moderate cognitive impairment, stated his teeth had not been brushed for over three weeks and wanted oral care at least once daily. Observations showed significant plaque buildup on the upper and lower teeth, and the RN supervisor and CNA confirmed the resident had not received the required daily oral care.
Food Held at Unsafe Temperatures Before Service: Food items were observed on the steam table below the facility’s holding expectation, including chicken, pureed noodles, pureed peas, pureed chicken, scrambled eggs, and pureed eggs. The DM acknowledged that steam table foods should maintain at least 135 F and stated the kitchen window AC unit blew directly over the steam table, contributing to premature cooling. Food was then plated, placed onto carts, and served to residents in the dining hall at these temperatures.
An LPN administered oral meds and eye drops to a resident with CKD and glaucoma, but when several pills rolled under the breakfast tray, she picked them up with her bare hands before applying gloves. The resident objected, and both the IP/ADON and DON confirmed this was an infection control issue.
A facility failed to ensure PEG tube placement was checked before administering medications to a resident. An LPN administered medications without confirming the tube placement, which could lead to serious complications. The resident had diagnoses including esophageal obstruction and dysphagia and was cognitively intact.
Late Submission of MDS Discharge Assessment
Penalty
Summary
The facility failed to complete and submit a Minimum Data Set (MDS) discharge assessment in a timely manner for two discharged residents reviewed. For Resident #98, who was admitted and later discharged home, the discharge assessment with an ARD of 06/14/2025 was submitted and accepted on 07/09/2025, which was 25 days after the discharge date. During record review and interviews, RN #2/MDS nurse, the Administrator, and the DON discussed the discrepancy; the Administrator stated understanding of the importance of timely MDS submission, and the DON stated she was aware of the discrepancy and saw where it could be a problem. The RAI Manual reviewed by the surveyor stated that a discharge assessment must be completed within 14 calendar days after discharge and submitted no later than 14 days after completion. The facility’s MDS Coding Policy stated that the facility uses the most up to date RAI manual for determining coding of each section of the resident assessment, timely and accurately.
Failure to Follow PEG Tube Medication Care Plan
Penalty
Summary
The facility failed to follow Resident #16’s comprehensive care plan related to PEG tube medication administration. The resident’s comprehensive person-centered care plan, created on 8/19/25, included the intervention to administer medications as ordered, and the physician orders specified that crushed medications placed in separate cups with 5 cc water were to be flushed with 10 cc of water between medications. Resident #16 was admitted on 1/30/25 with diagnoses including chronic respiratory failure with hypoxia, dyspnea unspecified, and encounter for attention to tracheostomy. During a morning medication pass, an LPN crushed and prepared multiple medications for PEG tube administration, including amiodarone, aspirin, clopidogrel, apixaban, furosemide, lansoprazole, potassium chloride, fish oil, and a multivitamin with minerals. The LPN administered the medications through the PEG tube without flushing between each medication and then flushed the tube with 30 cc of water after all medications were given. In interviews, the LPN stated she forgot to flush between medications and confirmed she did not follow the physician order. The RN/ADON, DON, and MDS/care plan nurse each stated the tube should have been flushed between medications and confirmed the care plan and physician orders were not followed.
PEG Tube Medications Not Flushed Between Doses
Penalty
Summary
The facility failed to administer medications through a PEG tube according to physician orders for one resident during a morning medication pass. The facility policy for administering medication through an enteral tube stated that each medication should be administered separately and flushed between medications. During observation, an LPN crushed multiple medications and placed each medication separately in a dispense cup with 5 cc of water, then administered Amiodarone HCl, Aspirin, Clopidogrel, Apixaban, Furosemide, lansoprazole, Potassium Chloride, Fish Oil, and Vision Formula/Lutein through the PEG tube without flushing between the medications. After all medications were given, the LPN flushed the tube with 30 cc of water. The resident involved had physician orders directing that 10 cc of water be used to flush between medications. The resident was admitted with diagnoses including chronic respiratory failure with hypoxia, dyspnea unspecified, and encounter for attention to tracheostomy, and had a BIMS score of 15 indicating cognitive intactness. During interviews, the LPN stated she forgot to flush between medications and acknowledged that flushing is needed to ensure residents receive all medication and to keep the PEG tube from becoming clogged. The RN/ADON and DON both stated the LPN should have followed the physician orders and flushed the PEG tube between medications.
Failure to Provide Daily Oral Care to a Dependent Resident
Penalty
Summary
The facility failed to provide daily oral care for a resident who was totally dependent on staff for personal hygiene and oral care. The facility policy stated that residents unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Resident #43, who was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side and aphasia, had an MDS BIMS score of 11, indicating moderate cognitive impairment, and Section GG documented total dependence on one staff member for all personal hygiene and oral care tasks. During observation and interview, the resident stated that it had been over three weeks since his teeth had been brushed and expressed a desire to have oral care at least once per day. Observations on two separate occasions showed significant plaque buildup on both the upper and lower teeth, and oral care had still not been provided at the follow-up observation. The RN Supervisor confirmed that the resident's teeth appeared as though they had not been brushed in some time and stated oral care should be provided daily as part of assigned ADL care. CNA #1 acknowledged being assigned to the resident on both the current and previous day and admitted she had not brushed his teeth on either day, despite knowing daily oral care was required as part of her responsibilities.
Food Held at Unsafe Temperatures Before Service
Penalty
Summary
The facility failed to ensure that food was palatable, attractive, and served at a safe and appetizing temperature for five of five sampled food items. A review of the facility policy titled Food: Quality and Palatability, dated 2/2023, stated that food would be prepared by methods that conserve nutritive value, flavor, and appearance and would be served at a safe and appetizing temperature. On 9/8/25 at 11:49 AM, food items on the steam table were observed at temperatures below the facility’s stated holding expectation, including chicken breast at 109 F, pureed noodles at 100 F, pureed peas at 101 F, and pureed chicken at 119 F; only chopped chicken reached 148 F. During an observation on 9/8/25 at 12:01 PM with the Dietary Manager, food was seen being placed from the oven onto the steam table, then plated, placed onto carts, and served to residents in the dining hall at the temperatures documented above. The Dietary Manager acknowledged that steam table foods should reach and maintain at least 135 F, and stated that the kitchen’s window air conditioning unit blew directly over the steam table and contributed to the food cooling prematurely. She further stated the facility had not implemented any corrective action or reliable protocol to maintain safe, warm, and appetizing food temperatures prior to meal service. On 9/9/25 at 7:47 AM, the window air conditioning unit was again observed running and blowing directly onto the steam table, and scrambled eggs were at 108 F while pureed eggs were at 100 F as food was plated, placed onto carts, and served to residents in the dining hall.
Medication Handling Infection Control Lapse
Penalty
Summary
The facility failed to administer medication in a manner to prevent infection for one of four medication administrations observed involving a resident with Peripheral Vascular Disease, unspecified anemia, Chronic Kidney Disease, and primary open-angle glaucoma, bilateral severe stage. During the morning medication pass, an LPN administered multiple oral medications and eye drops to the resident. The resident poured the medications onto the overbed table and took them one at a time, but three pills rolled under the breakfast tray. The LPN moved the tray back and picked up the pills with her bare hands, then placed them back on the resident’s overbed table. She sanitized her hands and applied gloves only afterward before administering the eye drops. The resident stated that the LPN put the gloves on too late and should have put them on before picking up the pills. The LPN later confirmed she was not supposed to pick up pills with her bare hands and stated it was an infection control issue. The IP/ADON also stated the LPN should not have touched the medication with her bare hands and should have let the resident pick them up by moving the tray, and the DON stated the LPN should have washed her hands before picking up the pills.
Failure to Check PEG Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to ensure the placement of a Percutaneous Endoscopic Gastrostomy (PEG) tube was checked prior to administering medications for a resident. During an observation, an LPN administered several medications to the resident without confirming the PEG tube placement. The LPN later acknowledged that she forgot to check the placement, which could lead to the medications entering the wrong area and causing the resident to become sick. The Director of Nursing confirmed that the LPN should have checked the placement to prevent serious complications related to tube displacement. The resident involved had been admitted to the facility with diagnoses including esophageal obstruction, a personal history of malignant neoplasm of the larynx, and dysphagia in the oropharyngeal phase. The resident was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15 on a recent assessment. The facility's policy required checking the enteral tube placement every four hours and prior to feeding or administering medication, which was not followed in this instance.
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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) |
|---|---|---|---|---|
| Myrtles Nursing Center, Llc | 1.7 mi | ★★★★★ | 1 | 0 |
| The Grove | 2.5 mi | ★★★★★ | 10 | 0 |
| Billdora Senior Care | 20.6 mi | ★★★★★ | 4 | 1 |
| Diversicare Of Tylertown | 20.9 mi | ★★★★★ | 4 | 0 |
| Jefferson Davis Community Hospital Ecf | 22.6 mi | ★★★★★ | 7 | 0 |
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