Inspection Reports for
Colony Pointe Senior Living

19 CSR 30-85.047(47)(A) Physicians Orders Followed: Based on interview and record review, facility staff failed to follow a physician's order to obtain a urinalysis for one resident (Resident #1) out of six sampled residents, and progress notes did not contain documentation of attempts or refusal for the urinalysis.

19 CSR 30-86.047(19) TB Screen Residents & Staff: Review and interview showed facility staff failed to ensure required two-step TB screening/testing was administered or documented for one of four sampled residents and for six sampled staff members.

19 CSR 30-86.047(20)(I) Personnel Record-physician statement, employ: Review showed six sampled employees did not have a physician's statement or designee documentation indicating the employee was mentally and physically capable of working in a long-term care facility.

19 CSR 30-86.047(51)(A)(1) Schedule II Meds-Reconcile Each Shift, Record: Record review and interview showed staff failed to reconcile Schedule II controlled medications each shift for multiple residents and reconciliation documentation was missing for several dates.

19 CSR 30-86.047(63)(A) Alz/Dementia Training-Direct Care Staff, 3 hr: Review and interviews showed new direct care staff did not receive the required Alzheimer’s/related dementia orientation training prior to or on the first day of work for six sampled staff.

19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: Observation and interview showed food storage and labeling deficiencies, including unsealed and unlabeled/unidentified food items in refrigerators and freezers and failure to reseal, label, and date prepackaged food.

19 CSR 30-86.022(2)(D) Inspection Rights, No Fire Hazard General Requirements: The facility failed to keep the facility free of fire hazards; multiple carbon monoxide detectors in hallways A, C and D and the kitchen detector were expired.

19 CSR 30-86.022(12)(C) Emergency Lighting -Battery Powered, 1.5 hrs Emergency Lighting: The facility failed to maintain main emergency lighting in good repair; emergency lights above exit doors in the B-hallway and the dining room did not activate when tested.

19 CSR 30-86.047(37) Appropriate Action & Notification: Based on interview and record review, facility staff failed to notify the physician for one resident of three sampled residents when the resident had an unwitnessed fall with a head injury and later experienced a change in level of consciousness. Record review and staff interviews showed delays in notification and failure to follow the facility's change-in-condition and fall follow-up procedures.

19 CSR 30-86.022(10)(A) Hazardous Area Requirements: The kitchen in the Arbors Unit was not properly separated from the remainder of the facility; a pass-through window approximately 36 inches by 24 inches had no fire shutter or connection to the fire alarm system, which could allow smoke and toxic gasses to pass from the kitchen to the dining room.

19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: Based on observation, record review and interview, facility staff failed to store food in a manner to protect it from potential contamination; multiple open, unlabeled and undated food items were observed in kitchens, pantries and refrigeration/freezer units.