Waters of Columbia City Skilled Nursing Facility

In the surveyor’s words

From the most serious findings on record at Waters of Columbia City Skilled Nursing Facility, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Feb 22, 2024

  Based on interview and record review, the facility failed to ensure respiratory status was effectively assessed after a medication error for 1 of 3 residents reviewed for change of condition. See F760 for additional information regarding Resident Q. This deficient practice resulted in a change in the resident's condition and subsequent death (Resident Q). The Immediate Jeopardy began on [DATE] when Resident Q was administered MS Contin 30 mg (extended-release morphine tablet) (an opioid pain medication) that was not prescribed for her. The facility failed to adequately assess and monitor the resident for respiratory depression after identifying the medication error. This resulted in a change of condition and death of the resident. […]

• Immediate jeopardy, isolatedF760Feb 22, 2024

  Based on interview and record review, the facility failed to ensure Resident Q did not receive an opioid medication that was ordered for another resident and failed to ensure Resident Q was effectively monitored for signs and symptoms of adverse reaction for 1 of 3 residents reviewed for significant medication errors. This deficient practice resulted in Resident Q becoming unresponsive and the resident expired (Resident Q). The Immediate Jeopardy began on [DATE] when Resident Q was administered a MS Contin 30 mg (extended release morphine) (an opioid medication for pain) tablet not prescribed for her. The facility failed to adequately assess and monitor the resident's condition after identifying the medication error. This resulted in a change of condition and death of the resident. […]

• No harm, potential for more than minimal, widespreadF812Dec 12, 2025

  Based on observation, interview, and record review the facility failed to maintain safe food distribution, the storage, monitoring, and sanitation of tableware for 45 of 45 residents residing in the facility who eat meals prepared in the kitchen. Findings include:During an observation, on 12/7/2025 at 9:45 AM, the dishwasher rinse cycle, the thermometer indicated the temperature was 173 degrees Fahrenheit (F). The Dietary Manager was notified, and the dishes were run through the dishwashing cycle a second time with a rinse temperature of 172 degrees F, and 175 degrees F for a third cycle. […]

• No harm, potential for more than minimal, widespreadF812Oct 21, 2024

  Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage practices for facility prepared leftovers. Food prepared in the facility kitchen was consumed by 27 of 27 residents who lived in the facility. Findings include: On [DATE] at 9:05 AM, a tour of the kitchen was guided by the [NAME] 7. Five plastic containers were observed on the counter next to the sink. The dates on the containers ranged from [DATE] through [DATE]. During an interview, on[DATE] at 9:07 AM, [NAME] 7 indicated the containers held leftovers that were going to be thrown away. […]

• No harm, potential for more than minimal, patternF550Dec 12, 2025

  Based on observation, interview, and record review the facility failed to ensure dignity was provided during meal service for 6 of 14 residents seated together in the main dining room (Resident 49, Resident 3, Resident 31, Resident 1, and Resident 36).Findings include:During a continuous observation of dining service in the main dining room, between 12/07/2025 11:37 AM and 12:43 PM, 3 staff members passed drinks to residents seated in the dining room and then left the room. 14 residents were present in the dining room. On 12/07/2025 11:52 AM Resident 1 began yelling asking for her lunch and requesting more to drink.On 12/07/2025 12:03 PM Resident 3 began yelling, calling for staff to wipe Resident 36's face. […]