Neighborhoods Rehabilitation And Skilled Nursing B
NEIGHBORHOODS REHABILITATION AND SKILLED NURSING B in COLUMBIA, MO — inspection on September 5, 2025.
Found 2 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
During an interview on [DATE] at 12:24 P.M., LPN C said he/she last laid eyes on the resident
cephalosporin antibiotic) two gram Intravenous ((IV fluids, medications, or nutrients directly into the body's bloodstream through a vein using a small tube called a catheter). He/She said CNA B was responsible for rounds and should perform rounds every two hours. LPN C said he/she forgot to return to the resident and disconnect his/her IV from his/her Peripherally Inserted Central Catheter (PICC) line. He/She said CNA B and LPN A told him/her the resident was found with his/her head between the bed rails. LPN C said he/she should have removed the resident's antibiotic at 11:00 P.M., but that he/she forgot.
During an interview on [DATE] at 1:51 P.M., CNA B said he/she is responsible for rounds every two hours, but he/she last laid eyes on the resident around 10:00 P.M. or 11:00 P.M.
He/She thought the nurse would go back in the room to unhook the resident's IV medication, but he/she never did. CNA B said he/she walked into the resident's room around 3:10 A.M. and saw the IV pole hanging across the bed, the resident sitting with his/her knees on the ground, his/her left check on the mattress, and his/her right cheek on the bed rail, the resident was not moving. He/She said the resident's nurse LPN C was gone so he/she ran to the next unit and got LPN A who called 911, and initiated CPR
During an interview at 2:44 P.M., the Director of Nursing (DON) said CNA B is responsible for rounds every two hours, but CNA B thought LPN C would lay eyes on the resident when he/she removed the resident's IV, and the nurse never removed the IV. He/She said both CNA B and LPN C should have checked on the resident sooner. He/She said the standard is to check residents every two hours or as needed.
Complaint #2599782
265840 09/05/2025
Neighborhoods Rehabilitation and Skilled Nursing B 3003 Falling Leaf Court Columbia, MO 65201
During an interview on 8/26/25 at 10:04 A.M., LPN A said CNA B came to get
jeopardy to resident health or resident was on the left side of the bed, on his/her knees, with his/her head resting between the safety siderail and the mattress.
The LPN said he/she had to take the palm of his/her hand and forcefully removed the residents head from between the rail and the mattress. He/She said the residents head
he/she called 911 and started chest compressions because the resident was unresponsive.
During an interview on 08/26/2025 at 1:51 P.M., CNA B said he/she walked into the resident's room and saw him/her not moving.
The CNA said the resident was sitting with his/her face leaned on the mattress and bed rail. He/she was on his/her knees.
During an interview on 8/29/25 at 11:25 A.M. the Assistant Administrator said he/she was responsible for completing measurements for bed rails.
He/She said he/she did a routine check of the resident's bed rails on 8/15/25 as part of their Quality Improvement Plan, but that he/she does not have documentation to show that anywhere.
The Assistant Administrator said the 15th of the month is when he/she completes all routine checks it just happened to be the same day the resident came back from the hospital.
During an interview on 09/02/25 at 4:17 P.M., the Physician said he/she would say the resident experienced a significant change in status after his/her recent hospitalization. He/She said the resident had a severe infection in his/her hip that caused the hospitalization that turned septic. He/She had received a report from the local hospital and had spoken with the facility and both reported to him/her the resident had delirium.
The physician said they were all uncertain if it was acute from the infection or if it was going to be the resident's new baseline.
During an interview on 9/3/25 at 12:30 P.M., the assistant administrator said that he/she does not remember what time of day on 8/15/25 that he/she assessed the residents bed rail. He/She said he/she also does not remember if it was before or after the resident returned from the hospital.
The assistant administrator said he/she could not recall if the resident was in the bed or not when he/she assessed the bed rails.
The Assistant Administrator said since he/she was not one hundred percent confident with any of the answers then he/she does not want to say either way as these are routine for him/her so he/she does not remember. He/She said a residents' ability to use bed rails are done by a therapy evaluation and he/she was just the one who puts them on or takes them off.
The assistant administrator said that would be a nursing question as to who assessed the residents need or appropriateness for the bed rails after the resident returned from the hospital.
During an interview on 9/3/25 at 1:03 P.M., Registered Nurse (RN) A said nursing staff get the bed rail measurements from maintenance, and nursing staff are responsible to complete the nursing assessment portion of the bed rail assessments. He/She said the bed rail policy states they are to reassess residents after a significant change for to ensure the resident can still safely use the bed rails. RN A said he/she is not sure if the resident had a significant change or not because he/she does not know the resident well enough to know that. RN A said he/she has just been filling in here for a few months from a sister facility. He/She said the nursing assessment sheet they fill out says pass or fail after the questions are answered and if there are no fails that would suggest the resident is appropriate for the use of side rails. NOTE: At the time of the survey, the violation was determined to be at the immediate jeopardy level J.
Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level.
This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s).
Complaint #2599782
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.