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Complaint Investigation

Columbia Manor Health & Rehabilitation

Inspection Date: September 5, 2025
Total Violations 1
Facility ID 265778
Location COLUMBIA, MO
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Inspection Findings

F-Tag F0627

Resident Rights Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for

a safe transfer/discharge.

Based on interview and record review, facility staff failed to provide a discharge notice for one resident (Resident #1) and failed to allow Resident #1 to return to the facility when the hospital was unable to admit him/her and told the facility the resident was ready to return. The facility's census was 38.1. Review of the facility's Emergency Transfer or Discharge policy, revised 08/2018, showed emergency transfers or discharges may be necessary to protect the health and/or well-being of the resident(s), and should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures:-Notify the resident's attending physician;-Notify the receiving facility that the transfer is being made;-Prepare the resident for transfer-Prepare a transfer form to send with the resident;-Notify the representative or other family member;-Assist in obtaining transportation;-Others as appropriate or as necessary. 2. Review of Resident #1's Discharge-Return not anticipated Minimum Data Set (MDS), a federally mandated assessment, dated 08/27/25, showed an admission date of 08/21/25 and discharge date of 08/27/25.Review of the resident's nurse's note, dated 08/27/25 at 8:46 A.M., showed staff documented the resident transferred to the hospital. Review of the resident's nurse's note, dated 08/27/25 at 11:34 A.M., showed staff documented the resident was sent to

the hospital for fluid leakage from his/her skin, the hospital staff reported to facility staff they did not have a reason to admit the resident, requested facility staff to arrange the resident's return to the facility, but the hospital staff would be told no because the facility cannot care for the resident's needs. Review of the resident's progress note, dated 08/27/25 at 1:12 P.M., showed the administrator documented the facility will not allow the resident to return to the facility as facility staff are unable to care for the resident's current needs. Review of the resident's electronic medical record, dated 09/03/25, showed the medical record did not contain a 30-day discharge or an emergency discharge notice. During an interview on 09/04/25 at 1:10 P.M., the Social Service Director (SSD) said the administrator said the resident will not be allowed to return to the facility. During an interview on 09/05/25 at 12:44 P.M., the administrator said the nurse sends a discharge notice when a resident is discharged to the hospital. The administrator said staff did not issue a discharge notice when he/she was discharged to the hospital because staff were busy trying to safely transfer the resident out of the facility and did not plan for the resident to return to the facility. The administrator said the resident will not be allowed to return to the facility because the facility staff cannot adequately meet the resident's care needs at the facility. Complaint# 2605768

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

📋 Inspection Summary

COLUMBIA MANOR HEALTH & REHABILITATION in COLUMBIA, MO inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in COLUMBIA, MO, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from COLUMBIA MANOR HEALTH & REHABILITATION or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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