Deficiencies (last 3 years)
Deficiencies (over 3 years)
1.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
69% better than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
4
3
2
1
0
Occupancy
Latest occupancy rate
41% occupied
Based on a January 2023 inspection.
Occupancy rate over time
Inspection Report
Life Safety
Census: 24
Deficiencies: 2
Date: Jan 11, 2023
Visit Reason
The inspection was a fire safety inspection conducted to assess compliance with fire hazard and emergency lighting regulations.
Findings
The facility failed to maintain fire safety standards due to expired carbon monoxide detectors and emergency lights that did not activate during testing. These deficiencies affected all 24 residents present during the inspection.
Deficiencies (2)
19 CSR 30-86.022(2)(D) Inspection Rights, No Fire Hazard. The facility presented a fire hazard as three carbon monoxide detectors in hallways and one in the kitchen were expired. This deficiency affected all 24 residents.
19 CSR 30-86.022(12)(C) Emergency Lighting - Battery Powered, 1.5 hrs. The facility failed to maintain emergency lighting in good repair as two emergency lights above exit doors failed to activate during testing. This deficiency affected all 24 residents.
Report Facts
Facility census: 24
Deficiency affected residents: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Manager | Stated he was not aware of expired detectors and would get replacements; also stated he would get emergency lights fixed |
Inspection Report
Plan of Correction
Census: 40
Deficiencies: 1
Date: Aug 27, 2020
Visit Reason
The inspection was conducted to evaluate compliance with regulations regarding appropriate action and notification following an unwitnessed fall with head injury and change in condition of a resident.
Findings
Facility staff failed to notify the physician promptly for one resident after an unwitnessed fall with head injury and subsequent change in consciousness. The facility's policies on change of condition and fall follow-up protocols were not fully followed.
Deficiencies (1)
19 CSR 30-86.047(37) Appropriate Action & Notification: Facility staff failed to notify the physician for one resident after an unwitnessed fall with head injury and change in level of consciousness the following day.
Report Facts
Facility census: 40
Inspection Report
Plan of Correction
Census: 19
Deficiencies: 1
Date: Mar 3, 2020
Visit Reason
The inspection was conducted as part of a licensure inspection focusing on fire safety compliance in an assisted living facility.
Findings
The facility failed to ensure the kitchen in the Arbors Unit was properly separated from the remainder of the facility by smoke stop partitions. A window between the kitchen and dining room lacked a fire shutter connected to the fire alarm system, allowing smoke and toxic gases to pass through in case of fire.
Deficiencies (1)
19 CSR 30-86.022(10)(A) Hazardous Area Requirements: The facility failed to separate the kitchen in the Arbors Unit from the rest of the facility by a minimum of smoke stop partitions. A window between the kitchen and dining room lacked a fire shutter connected to the fire alarm system, allowing smoke and toxic gases to pass through in case of fire.
Report Facts
Facility census: 19
Deficiency tag: 1
Inspection Report
Plan of Correction
Census: 42
Deficiencies: 1
Date: Feb 6, 2019
Visit Reason
The inspection was conducted to assess compliance with food protection regulations, specifically regarding the proper storage, labeling, and handling of food items at Colony Pointe-Assisted Living by Americare.
Findings
The facility failed to store food in a manner that protected it from potential contamination, with numerous observations of unsealed, unlabeled, and undated food items in various kitchen storage areas. The Dietary Manager acknowledged noncompliance and outlined corrective actions including staff training and daily compliance rounds.
Deficiencies (1)
19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: Facility staff failed to store food properly to protect it from contamination, with multiple instances of unsealed, unlabeled, and undated food items observed in kitchen storage areas.
Report Facts
Facility census: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed regarding food storage and labeling practices; responsible for corrective actions and staff training | |
| Administrator | Signed the plan of correction and involved in compliance oversight |
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