Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Pruitthealth- Columbia during CMS and state inspections, most recent first.
The facility failed to ensure a safe environment by using a mattress to transport a resident down the stairwell during an elevator outage. The resident, who was moderately cognitively impaired and used a wheelchair, was moved without a formal policy or training in place. Staff confirmed the elevator had been malfunctioning, and there was no documented emergency plan for such situations. The Administrator acknowledged the lack of formal training and documentation for handling elevator outages.
The facility failed to include the elevator in its Facility Assessment, despite its critical role in daily operations. Staff reported ongoing issues with the elevator, which was inoperable for several days. The Administrator stated that upper management advised against including the elevator in the assessment, and there was no specific policy for elevator outages.
The facility's main kitchen was found to have significant sanitation and food storage deficiencies. Kitchen equipment, including ovens and fryers, were dirty with grease and food debris. Food items in the cooler were improperly labeled and stored, with some past their use-by dates. Communication issues were noted between the Dietary Manager and Maintenance regarding equipment repairs, contributing to the deficiencies.
The facility did not have a qualified full-time social worker on site, as required for facilities with over 120 beds. Interviews revealed that the position had been vacant for several weeks, and a temporary social worker from a sister facility was assisting during the survey. The Administrator acknowledged the lack of a specific policy for social services, relying on federal regulations instead.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents requiring them, as observed in five out of seven residents reviewed. Rooms of residents with conditions like feeding tubes, HIV, or indwelling medical devices lacked appropriate signage, and staff did not use PPE during high-contact care activities. Interviews revealed that staff, including the Administrator and Infection Preventionist, were unaware of the CDC guidance and facility policy regarding EBP, leading to deficiencies in infection prevention and control.
A resident's advanced directives were not updated in a timely manner as requested by their Resident Representative (RR). Despite the RR's request to change the resident's code status to Do Not Resuscitate (DNR), the facility maintained a Full Code status. The facility's policy requires changes to be communicated and recorded, but this was not done. The facility lacked a full-time Social Worker, and the Temporary Social Worker confirmed the oversight. The Administrator acknowledged the failure to update the directives promptly.
A resident dependent on staff for ADL care did not receive adequate personal hygiene assistance, as required by facility policy. The resident's ADL documentation lacked records of showers or bed baths on multiple days, and observations showed poor hygiene. Interviews revealed that the resident's hair had not been washed for about a month, and the assigned CNA was unsure of the last hair wash. The facility's expectation is for residents to receive regular showers and bed baths, with proper documentation, which was not met in this instance.
A resident with multiple respiratory conditions was not provided the correct oxygen rate as per physician orders. Despite being ordered to receive oxygen at 3 LPM, observations showed the rate set at 4 LPM. Staff interviews revealed a lack of awareness and verification of the correct rate, leading to the deficiency.
The facility failed to remove expired medications and biologicals from one of its medication storage rooms. An Aerobika device was found unlabeled and without an expiration date or patient name, and an expired RCI Adult Non Rebreathing Mask was also discovered. An LPN confirmed these issues and discarded the items, acknowledging that expired medications should be removed.
The facility failed to properly dispose of garbage, as one dumpster was found with its doors open and trash on the ground. The facility's policy requires dumpsters to be closed and areas kept clean. The Dietary Manager confirmed the issue, stating that staff responsible for trash disposal should ensure all trash is placed in the dumpster. The Administrator noted that kitchen and housekeeping staff are responsible for checking dumpsters daily.
Facility Lacks Policy for Safe Resident Transport During Elevator Outages
Penalty
Summary
The facility failed to provide an environment free from potential accident hazards by using a mattress to transport a resident down the stairwell when the facility elevators were not operational. This incident involved a resident who was moderately cognitively impaired and used a wheelchair for mobility. The facility lacked a policy or emergency plan for elevator outages, and there was no documentation of maintenance records indicating the elevator was inoperable. Interviews with staff revealed that the elevator had been malfunctioning for over a week, and in the absence of a working elevator, staff resorted to using a mattress to transport residents down the stairwell. The Maintenance Director confirmed assisting with the mattress technique, which he learned from the previous Administrator, but there was no formal training provided to staff on this method. Staff members, including LPNs and RNs, indicated they had not received training or directives on handling such situations, and the Director of Nursing was unsure if there was a standard policy in place. The Administrator acknowledged the absence of an emergency plan specific to elevator outages and stated that the previous Administrator had communicated best practices verbally, but without documentation. The facility's approach to transporting residents during elevator outages involved using a stretcher or a mattress with handles, which the Administrator believed to be the least hazardous method. However, there was no formal education or training provided to staff on these techniques, leading to a deficiency in ensuring a safe environment for residents.
Elevator Exclusion in Facility Assessment
Penalty
Summary
The facility failed to include the use of an elevator in its Facility Assessment, which is essential for transporting residents during daily operations. The Administrator acknowledged the absence of a policy related to the elevator's operation or its inclusion in the Facility Assessment. The Maintenance Director reported ongoing issues with the elevator, which had been inoperable for several days, affecting the facility's operations. Despite these issues, the Administrator stated that upper management advised that the elevator did not need to be included in the Facility Assessment. Interviews with staff, including LPNs and RNs, confirmed the elevator's unreliability, with reports of it being down over the weekend and intermittently inoperable. The Director of Nursing noted that while emergency preparedness training exists, there is no specific policy for elevator outages. The Maintenance Director explained that when the elevator is inoperable, he must manually manage the elevator doors and alarms. The Administrator emphasized his responsibility for resident safety but reiterated that the elevator was excluded from the Facility Assessment based on guidance from senior management.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain proper sanitation and cleanliness in its main kitchen, as observed during a survey. The inspection revealed that the kitchen equipment, including the industrial double-door oven, deep fryer, and stove, were dirty and had significant accumulations of grease and food debris. The oven doors were covered with a brown substance, and the glass was greasy and cloudy. The deep fryer and stove also had heavy build-ups of grease and food debris, with the stove's backsplash covered in a black substance. Additionally, the kitchen's exit door had a heavy accumulation of a black substance and food debris running down it. The facility also failed to properly label and store food items in the main cooler. Observations showed that plastic bags containing Turkey Bologna and Turkey Salami were not in their original packaging and lacked open dates. A container of pepperoni was also not in its original packaging and had an expired use-by date. In the main preparation area, bins containing bread crumbs and flour had scoops left inside, with the flour scoop having a layer of caked-up flour. These findings indicate a lack of adherence to the facility's policies on labeling, dating, and storage of food items. Interviews with the Dietary Manager (DM) and the Director of Maintenance (DOM) revealed communication issues regarding equipment maintenance. The DM was unaware of the non-operational hood exhaust system, which the DOM had reported as needing repair. The DOM stated that dietary staff did not notify him about equipment needing repairs, and he had informed the DM and Dietary Supervisor about the hood fan issue a month prior. The DM acknowledged the kitchen's condition and stated that staff are expected to clean equipment after each use and check coolers daily. However, these expectations were not met, leading to the observed deficiencies.
Absence of Full-Time Social Worker in Facility
Penalty
Summary
The facility failed to employ a qualified full-time social worker, as required for facilities with more than 120 beds. This deficiency was identified during interviews with various staff members. The Administrator admitted that the facility did not have a full-time social worker on site and lacked a policy regarding social services. A temporary social worker, who was not assigned to this facility, was brought in to assist during the survey. The temporary social worker confirmed their primary assignment was at a sister facility and was uncertain about the duration of the absence of the regular social worker. The Administrator further revealed that the position had been vacant for several weeks, although the exact date was unknown, and acknowledged the absence of a specific policy related to social services, relying instead on federal regulations for guidance.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure appropriate signage and the use of Personal Protective Equipment (PPE) for residents on Enhanced Barrier Precautions (EBP), as observed in five out of seven residents reviewed. The facility's policy, last revised on 04/30/24, mandates the use of EBP to prevent the transmission of Multi-Drug-Resistant Organisms (MDRO) through targeted gown and glove use during high-contact resident care activities. However, observations revealed that rooms of residents requiring EBP, such as those with feeding tubes, HIV, or indwelling medical devices, lacked appropriate signage, and staff were not donning PPE as required. Several residents, including those with severe cognitive impairments and dependencies on staff for Activities of Daily Living (ADLs), were not provided with the necessary precautions. For instance, a resident with a feeding tube did not have the required signage outside their room. Another resident with HIV and dependent on staff for ADLs also lacked appropriate signage. Staff, including CNAs and LPNs, were observed providing care without wearing the necessary PPE, such as gowns and gloves, during high-contact activities like catheter and wound care. Interviews with facility staff, including the Administrator and Infection Preventionist (IP), revealed a lack of awareness and understanding of the CDC guidance and facility policy regarding EBP. Staff members, including CNAs and LPNs, expressed the belief that PPE was only necessary when residents had active infections, contrary to the policy that requires PPE use for residents with certain conditions regardless of infection status. This lack of compliance and understanding contributed to the deficiency in infection prevention and control measures.
Failure to Update Advanced Directives in a Timely Manner
Penalty
Summary
The facility failed to update the advanced directives of a resident, identified as R521, in a timely manner as requested by their Resident Representative (RR). R521 was admitted with diagnoses including vascular dementia, type 2 diabetes, muscle weakness, and hypertension, and was cognitively intact at the time of admission. The RR had requested a change in R521's code status from Full Code to Do Not Resuscitate (DNR) on 07/10/24, but the facility did not update the advanced directives accordingly. The facility's policy requires that any changes in advanced directives be communicated to the attending physician and recorded in the resident's medical record, which was not done in this case. Interviews revealed that the RR communicated the request to the facility staff, including a Nurse Practitioner and a Social Worker, but the change was not implemented. The Social Worker who was informed of the request no longer works at the facility, and the facility currently lacks a full-time Social Worker. The Temporary Social Worker confirmed that the advanced directives should have been updated and suggested that documents could be mailed to the RR if they are unable to visit the facility. The Administrator acknowledged that the advanced directives should have been updated in a timely manner, indicating a lapse in the facility's process for handling such requests when the RR cannot physically sign the paperwork.
Failure to Provide Adequate ADL Care
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care to a resident, identified as R46, who is dependent on staff assistance. The facility's policy requires Certified Nursing Assistants (CNAs) and nurses to document ADL care in the Electronic Healthcare Record (EHR) or on a CNA ADL Flow Sheet Form if EHR is unavailable. However, a review of R46's ADL documentation for July 2024 showed no records of showers or bed baths being provided or offered on multiple days. Observations and interviews revealed that R46 had long fingernails with a buildup of an unknown substance, greasy hair, and noticeable dandruff, indicating a lack of personal hygiene care. Interviews with R46 and her Resident Representative confirmed that ADL care was not consistently provided in a timely manner. R46 stated that her hair had not been washed for about a month, except once by therapy staff using a shower cap technique while she was in bed. The assigned CNA was unsure of the last time R46's hair was washed or offered to be washed. The Unit Manager and LPN2 stated that the expectation is for residents to receive a shower three times a week and a daily bed bath, with hair washing as needed. They also emphasized the importance of documenting ADL care in the EHR, which was not adhered to in this case.
Failure to Administer Correct Oxygen Rate
Penalty
Summary
The facility failed to provide Resident 30 with the correct oxygen rate as per physician orders. The resident, who was admitted with multiple respiratory-related diagnoses including secondary malignant neoplasm of the right lung, pulmonary nocardiosis, acute respiratory failure with hypoxia, and chronic obstructive pulmonary disease (COPD) with acute exacerbation, was ordered to receive oxygen at 3 liters per minute (LPM) via nasal cannula continuously. However, observations on multiple occasions revealed that the oxygen flow rate was set at 4 LPM, contrary to the physician's order. Interviews with staff, including a Licensed Practical Nurse (LPN) and a Nurse Consultant, indicated a lack of awareness and verification of the correct oxygen rate. The LPN stated that the resident was on 3 LPM, despite observations showing otherwise. The Nurse Consultant acknowledged the discrepancy and indicated a need to review the cause of the incorrect oxygen rate. The deficiency was identified through a combination of policy review, observation, and staff interviews, highlighting a failure in adhering to the physician's orders for oxygen administration.
Expired and Unlabeled Medications Found in Storage
Penalty
Summary
The facility failed to ensure that expired medications and biologicals were removed from storage in one of the two medication storage rooms. During an observation, it was found that an Aerobika device was not labeled, lacked an expiration date, and did not have a patient name. Additionally, an RCI Adult Non Rebreathing Mask was found to have expired. The facility's policy requires that medications and biologicals be stored safely and securely, with nurses responsible for checking medications for expiration and deterioration before administration. However, these procedures were not followed, leading to the presence of expired and improperly labeled items in the medication storage room. During an interview, an LPN confirmed the issues identified in the medication storage room and acknowledged that expired medications should be discarded. The LPN expressed uncertainty about how the Aerobika device was distributed without proper labeling and subsequently discarded the expired and unlabeled items.
Improper Garbage Disposal
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed in one of the two dumpsters reviewed. The facility's policy on waste disposal, specifically for the Dietary Services, mandates that dumpster lids, doors, and plugs should always be closed, and the surrounding areas should be kept clean and free of debris. However, during an initial walk-through of the outside dumpster area, one dumpster was found with its doors open, and trash and debris were observed on the ground surrounding the dumpsters. A follow-up observation confirmed the same issues, which were verified by the Dietary Manager. The Dietary Manager acknowledged that trash is taken out daily and that the staff responsible for taking out the trash should ensure all trash and debris are placed in the dumpster, not left on the ground. The Administrator also stated that kitchen staff and possibly housekeeping are responsible for checking the dumpsters daily during morning walk-throughs, and if trash drops on the floor, facility staff are responsible for picking it up and disposing of it properly.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 47 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Columbia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Forest Acres Post Acute | 0.2 mi | ★★★★★ | 0 | 0 |
| Midlands Health & Rehabilitation Center | 0.8 mi | ★★★★★ | 7 | 0 |
| C M Tucker Jr Nursing Care Center Fewell And Stone | 1.2 mi | ★★★★★ | 1 | 1 |
| C M Tucker Jr Nursing Care Center Roddey Pavilio | 1.2 mi | ★★★★★ | 0 | 0 |
| White Oak Manor - Columbia | 1.4 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Pruitthealth- Columbia.
100% money-back within 48 hours.
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.