Columbia Manor Health & Rehabilitation
COLUMBIA MANOR HEALTH & REHABILITATION in COLUMBIA, MO — inspection on February 27, 2026.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
he/she expected staff to notify him/her of any skin changes or if the resident did not take his/her
on 03/02/26 at 9:56 A.M., the attending physician said he/she had not seen the resident during
the lump to the resident's forehead, and that the resident had refused his/her medications.
The physician said he/she would also expect staff to notify the Hospice Physician/staff as well.
During an interview on 03/02/26 at 3:36 P.M., the Hospice Physician said he/she would expect facility staff to notify him/her of the lump/swelling to the resident's forehead, as well as the medication refusals prior to discharge so the hospice staff could better monitor and follow up at their next home assessment of the resident.
Intake #2789733 & complaint #2786826
265778 02/27/2026
Columbia Manor Health & Rehabilitation 2012 Nifong Boulevard Columbia, MO 65201
Review of the facility's Abuse Investigation and Reporting policy, revised 07/2017, showed an alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than 24 hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury. 2.
Review of Resident #1's Electronic Medical Record (EMR), dated 02/18/26 through 02/23/26, showed the resident admitted to the facility from home on [DATE], had a documented resident representative, and discharged back to home on [DATE] after a planned five-day stay.
Review of the facility's investigation, dated 2/25/26, showed staff documented: -On 02/24/26, the resident representative reported to the Director of Nursing (DON), allegations of bruises and injuries of unknown origin to the resident;-On 02/25/26 at 9:40 A.M., the resident representative made a second report to the administrator, that when the resident returned home from the facility, the resident had a lump to his/her left forehead, laceration above his/her left ear, bruising to his/her left side/underarm, and excoriation to his/her genitals.
Staff began an investigation;.-On 02/26/26, residents were interviewed, staff were in-serviced on the abuse and neglect policy, and the administrator reported the allegations to DHSS.
The report did not contain documentation facility staff contacted DHSS within the 24-hour required timeframe after the resident representative reported the allegations.
Review of the DHSS complaint/facility self-report database did not contain a report facility reported allegations of bruises and injury of unknown origin for over 48 hours after the resident representative reported the allegations to facility staff.
During an interview on 02/27/26 at 10:31 A.M., the administrator said staff should have probably made an initial report to DHSS within two hours after the resident representative initially reported the allegations on 02/24/26, but since there was no suspicion of abuse, and rather bruises and injury of unknown origin, staff should have notified DHSS within 24 hours (on 02/25/26).
The administrator said he/she first became aware of the allegations on 02/25/26, and should have notified DHSS within 24 hours, but he/she got busy with the investigation and did not realize the 24 hours timeframe had passed before he/she submitted the report to DHSS.
During an interview on 02/27/26 at 11:19 A.M., the DON said the resident representative reported to him/her on the morning 02/24/26 the resident had an abrasion to his/her left side, a laceration approximately 0.5 inches above his/her left ear, bruising under his/her left armpit, and a [NAME] to his/her back, but did not specify abuse/neglect or accuse anyone.
The DON said the resident was no longer at the facility, and he/she immediately started to interview staff regarding any known incidents or falls, and none were reported.
The DON said based on the information received from the resident representative, and interviews from staff, he/she should have notified DHSS within 24 hours of the allegations of bruises and injury of unknown origin.
Intake #2789733 & complaint #2786826
265778 02/27/2026
Columbia Manor Health & Rehabilitation 2012 Nifong Boulevard Columbia, MO 65201
Review of the facility's admission Assessment and Follow up: Role of the Nurse policy, revised 09/2012, showed staff are directed to conduct a physical assessment on admission, including the eyes, ears, nose, throat, head, neck, and skin.
Conduct supplemental assessments (following facility forms and protocol) including skin assessment.
The policy did not specify the frequency for which staff should complete a skin assessment. 2.
Review of Resident #1's Electronic Medical Record (EMR), dated 02/18/26 through 02/23/26, showed the resident with diagnoses to include Parkinsonism unspecified, essential tremors, and Atrial Fibrillation, admitted to facility from home on [DATE] with coordinated hospice services for a planned five-day stay, and discharged back to home on [DATE].
Review of the resident's incident report, dated 02/21/26 at 6:30 P.M., showed Licensed Practical Nurse (LPN) A documented the resident had a lump on his/her left forehead, no discoloration, denied pain or discomfort, and no identified injuries.
Review of the resident's EMR, dated 02/21/26 through 02/23/26, did not contain documentation staff completed a skin assessment after staff reported the lump to the resident's forehead, or a skin assessment prior to the resident's planned discharge on [DATE].
Review of the facility's investigation, dated 2/25/26, showed staff documented the resident representative reported to the administrator, that when the resident returned home from the facility on 02/23/25, the resident had a lump to his/her left forehead, laceration above his/her left ear, bruising to his/her left side/underarm, and excoriation to his/her genitals.
During an interview on 02/27/26 at 11:19 A.M., the DON said it was standard protocol for the nurse to complete a skin assessment with any identified skin changes, and the day of a resident's planned discharge.
The DON said he/she was not sure why LPN A or the nurse at discharge did not complete a skin assessment.
During an interview on 02/27/26 at 12:07 P.M., LPN C said the nurse is expected to complete a head-to-toe assessment and document a skin assessment prior to a resident's planned discharge. LPN C said he/she was responsible to complete the resident's skin assessment prior to discharge but he/she did not.
During an interview on 02/27/26 at 1:03 P.M., the administrator said although it is not specified in the facility policy, he/she expects the nurses to complete a skin assessment on admission, with any identified skin changes, and prior to a planned discharge as standard nursing protocol.
During an interview on 02/27/26 at 1:17 P.M., LPN A said he/she should have completed a skin assessment to follow up on the incident report on 02/21/26, but he/she got busy and forgot.
During an interview on 03/02/26 at 3:36 P.M., the Hospice Physician said he/she would expect facility staff to complete a skin assessment on the resident prior to discharge as standard procedure, particularly since he/she was only there for a short stay, to ensure there were no new skin concerns during his/her stay.
Intake #2789733 & complaint #2786826