Colonial Springs Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to ensure all allegations of possible abuse were reported immediately to management and within two hours to the State Survey Agency (Department of Health and Senior Services - DHSS) when staff failed to report an allegation of possible abuse made by one resident (Resident #1). The facility census was 118. Review of the facility's policy Patient Abuse/Neglect, Elder Abuse, and Persons with Disability Abuse, reviewed August 2024, showed the following:-The facility designee will report or assist the person with direct knowledge of the concern to report immediately, within two hours of the allegation of mental, physical, verbal, or sexual abuse or if there has been bodily injury related to abuse. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents were treated with dignity and respect when one staff (Certified Nurse Aide (CNA F)) spoke in disrespectful tone and cursed when interacting with one resident (Resident #3). The facility census was 106. Review of the facility's policy titled Resident Rights, Rules and Regulations, revised 10/01/21, showed residents have the right to be treated with dignity and respect.1. Review of Resident #3's face sheet (admission data) showed the following:-admission date of0 5/01/19;-Diagnoses included dislocation of right ankle joint. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received written notice before resident room changes when staff failed to provide and document room change notifications for one resident (Resident #1). The facility census was 106. Review of the facility's policy titled Changes in Patient/Resident Condition: Notification Guidelines, revised January 2025, showed the facility will promptly notify the resident and new roommate assignment in writing and the resident's legal representative or interested family member by phone if applicable when there is a change in room or roommate assignment. Review of the facility's policy titled Room and Roommate Transfers, revised 08/15/18, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure timely notification of each resident's family/responsible party of changes in condition when staff failed to notify one resident's (Resident #1)'s x-ray results following a fall. A sample of four residents was reviewed in a facility with a census of 106. Review of the facility policy titled Changes in Patient/Resident Condition: Notification Guidelines, revised January 2025, showed the following:-Physicians, patients, residents, hospice when applicable, and families will be notified in a timely manner of changes in clinical conditions and environmental changes affecting the patient or resident;-Purpose to provide timely communication of condition and environmental changes to care providers, patients, residents, and families;-When patient/resident changes are noted nursing staff will notify the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to have a complete grievance process in place when staff failed to consistently document in a timely manner grievances, steps taken to follow-up on the grievance, and resolution for one resident one resident (Resident #1). The facility census was 106. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan for all residents when staff failed to complete a baseline care plan within 48 hours of admission for one resident (Resident #2). The facility census was 106. Review of the facility's policy titled Assessments in Long Term Care, revised February 2026, showed the following:-Licensed nursing staff will begin to initiate an admission assessment of the patient when the patient presents to the nursing unit. The nursing assessments and screening assessments will be completed within 24 hours of admission. Additional assessments may be completed when there is a significant change in the patient's condition or diagnosis;-Purpose to provide an initial assessment to use as a baseline. [...]

Inspectors wroteBased on interviews and record review, the facility failed to keep residents free from accident hazards when one staff (Certified Nurse Aide (CNA) F) assisted one resident (Resident #3) in a unsafe manner while using a sit to stand lift (mechanical lift) and when staff (CNA I) did not utilize a gait belt (a 2-to-4-inch wide, sturdy belt, typically made of canvas or nylon, placed around a patient's waist to help caregivers safely assist with walking, standing, or transferring) during a transfer out of bed with one resident (Resident #5). The facility census was 106. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services that meet the needs of all residents when staff failed to provide medications as ordered by the prescriber to meet the needs of each resident when the facility failed to administer medications within the time frame specified by the provider for two residents (Resident #2 and Resident #6) out of four residents sampled . The census was 106. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served in a manner that prevent possible contamination when the ice machine has a black substance on the deflector shield, a dented can was on the shelf for use, and scoops were left in the sugar and cornstarch. This has the potential to affect all residents who consumed food from the facility kitchen. The facility census was 109. 1. Review of the 2013 Missouri Food Code showed equipment food-contact surfaces and utensils shall be clean to sight and touch. Review of the facility's policy Ice Machines, dated 2024, showed the following: -Ice machine bins shall be cleaned on a quarterly schedule by departments utilizing cubers with bins; -Ice machines shall be cleaned using the wash, rinse, and sanitize process by removing all ice and water from the bin; [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain a sanitary environment for all residents and staff when staff failed to ensure the fans located in the walk-in refrigerator and walk in freezer were kept clean. The facility census was 109. Review showed the facility did not provide a policy that addressed maintenance of the refrigerator or freezer fans. 1. Review of the facility's weekly cleaning schedule showed the staff responsible for cleaning the fans in the freezer or refrigerator was not listed. Observation on 12/02/24, beginning at 9:27 A.M., showed the following: -Black and brown substances on the plastic casing on the refrigerator fans; -Black and brown substance on the plastic casing covering the fans in the freezer. Observation on 12/04/24, beginning at 9:37 A.M., showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to give ensure all residents received bed hold information upon transfer when staff failed to provide the facility's bed hold policy to the resident and/or resident's representative for five residents (Residents #32, #35, #261, #31, and #68) who were transferred out to the hospital. The facility census was 109. Review of the facility's policy entitled Bed Hold and Re-Admission, dated 2024, showed the following information: -Residents and their family members or legal representatives will be informed of the bed hold policy in writing upon admission as part of the admission contract; -In the case of an emergency, a written notification will be made within 24 hours of the transfer. Review of the facility's bed hold policy card showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure catheter (sterile tube inserted into the bladder to drain urine) usage and care per standards of practice when staff failed to obtain physician's orders regarding placement of a catheter and catheter care for two residents (Resident #29 and Resident #33) in a sample of size of 3. The facility census was 109. Review of a facility's policy entitled Urinary Catheterization, dated 2024, showed urinary catheters should be placed only under the direction of a physician's order. 1. Review of Resident #29's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 08/24/23; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have pharmacy services in place to ensure a consistent counting, reconciliation, and destruction of controlled substances when staff failed to consistently document the number of medication packages and doses of controlled medications at the change of shift on the controlled substance shift change log and failed document administration on individual resident controlled drug record logs for three residents (Resident #13, #34, and #35) located in one of four medication carts in the facility. The facility census was 109. Review of the facility's policy titled Controlled Substances, PHA04-02, revised 09/24, showed the following: -Pharmacy services is responsible for the proper safeguarding of controlled substances throughout all the hospital and facilities connected to the facility; [...]

Inspectors wroteBased on record review and interview, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN - form CMS-10055) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for one resident (Resident #49) of three sampled residents who remained in the facility upon discharge from Medicare Part A services. The facility census was 109. Review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C -09-20), dated 01/09/09, showed the following: -The Notice of Medicare Provider Non-Coverage (NOMNC - form CMS-10123) is issued when all covered Medicare services end for coverage reasons; [...]

Inspectors wroteBased on record review and interview, facility staff failed to complete a quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) assessment for two residents (Residents #18 and #77) within 92 days of the prior assessment. The facility had a census of 109. Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, Chapter 2, Assessments for the RAI, showed the following information: -The quarterly assessment is an Omnibus Budget Reconciliation Act of 1987 (OBRA) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type; [...]

Inspectors wroteBased on observations, record review, and interview, the facility failed to provide enteral nutrition per standards of practice when staff failed to administer tube feeding consistently as ordered and failed to ensure the orders were clear and accurate for one resident (Resident #102), out of a sample of one resident. The facility census was 109. Review of the facility policy, titled Tube Feedings, dated 11/2023, showed the following: -Tube feeding shall be administered by licensed nursing personnel upon recommendation of registered dietician and/or order by physician; -For continuous method of administration, staff should assure tubing is connected, fill the chamber one-half full and prime tubing, hang the container from the infusion pump pole, thread the tubing through the infusion pump, head of bed elevated 30 to 45 degrees at all times; -Connect the tubing to the feeding tube. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% when the facility staff made two errors out of 28 opportunities resulting in an error rate of 7.14% when facility staff failed to administer medication at the specified scheduled dosing time, before a meal and separate from other medications, for two residents (Resident # 98 and Resident # 101). The facility census was 109. Review of the facility's policy titled Medication Administration and Documentation, NUR09-09, revised 12/24, showed the following: -Medications are administered in accordance with prescriber orders; -Standard administration times may be adjusted by pharmacy staff due to drug/food incompatibilities with the following agents: Thyroid preparations 6:00 A.M.; [...]

Inspectors wroteBased on interview and record review, the facility failed implement an abuse/neglect policy that ensured all reported allegations of possible abuse were reported to the State Survey Agency (Department of Health and Senior Services - DHSS) within two hours when staff failed to reported a documented allegation of touching of genitalia between two residents (Resident #1 and #2). The facility census was 105. Review of the facility policy titled, Patient Abuse/Neglect, Elder Abuse, and Persons with Disability Abuse, ADM03-03, last revised August 2021, showed the following: -Staff, employees, and physicians will follow regulations and standards in identification of and procedures for handling alleged victims of abuse; [...]

Inspectors wroteBased on interview and record review, the facility failed implement an abuse/neglect policy that ensured staff completed and documented a timely investigation of all reported allegations of possible abuse when staff failed to complete a documented investigation of a documented allegation of touching of genitalia between two residents (Resident #1 and #2). The facility census was 105. Review of the facility policy titled, Patient Abuse/Neglect, Elder Abuse, and Persons with Disability Abuse, ADM03-03, last revised August 2021, showed the following: -All complaints will be reviewed by the department director or facility administrator to determine the need for investigation; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of one resident's (Resident #71) needs when the resident was unable to safely toilet due to a large commode kept in the resident's bathroom. The facility census was 108. Record review of the facility's admission agreement, revised 8/15/18, showed the following: -Room and roommate transfers - The facility reserves the right of room and roommate transfer at its discretion. The facility agrees to allow resident to designate a roommate of his or her choice at any time, so long as accommodation of the resident's designation is practicable, both residents live at the facility, both residents consent to the arrangement, and the request does not infringe upon the rights of another resident; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary services to identify pressure ulcers (refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) timely when staff failed to accurately monitor skin during showers and failed to complete a weekly assessment for one resident (Resident #28) who was at risk for pressure ulcers. The facility census was 108. Record review of the facility policy titled, Pressure Ulcer/Wound Assessment and Treatment, revised January, 2023, showed the following: -Residents will be assessed per Braden scale (a measured assessment to determine pressure ulcer risk based on predetermined criteria) by licensed nursing professional for the potential to develop and the presence of a pressure ulcer/wound upon admission to the facility/program; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services were provided to allow residents to maintain or improve range of motion when the facility failed provide a restorative nursing program for two residents (Resident #28 and Resident #53). The facility census was 108. Record review of the facility policy titled, Range of Motion Exercises, revised August 2020, showed the following: -Rehabilitation services will provide range of motion (ROM) exercises to residents as appropriate; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents had assistance devices accessible to help prevent possible falls when staff failed to ensure the the call light and wheel chair were readily accessible for one resident (Resident #85) with a history of falls. The facility census was 108. Record review of the facility's policy titled Fall Program, revised 07/2022, showed the following: -The facility will identify resident intrinsic and extrinsic fall risk factors, identify and implement fall prevention/management interventions, and provide resident and family fall prevention/management education; -The purpose is to provide staff, resident education and resident specific interventions which promote a safe environment with the goal of preventing/ managing falls; -Universal/low risk fall prevention interventions will be implemented for residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to consistently provide nutritional interventions and nutritional supplements for two residents (Resident #40 and Resident #74 ) with identified weight loss. The facility census was 108. Record review of the facility policy, titled Supplemental Feedings, revised 10/2021, showed the following: -It is the policy of Nutritional Services and nursing to provide supplemental feedings to residents that need additional nutrition; -The purpose is to provide additional nutritional support for residents that cannot receive it just by eating three meals a day; -The doctor may request that a resident receive supplemental feedings in addition to their regular diet; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow policies and procedures for immunization of residents against influenza in accordance with national standards of practice when staff administered two annual influenza shots less than a month apart for two residents (Resident #45 and #78). The facility had a census of 108. Record review of the facility's policy titled Nursing Protocol: Adult Outpatient Vaccine Schedule, revised 10/2022, showed the following: -The purpose of the policy is to outline an adult vaccine schedule for long-term care (LTC) facilities to follow. Utilizing a standardized process for vaccinating adults promotes clinical staff competency and patient safety. This practice also facilitates an easy to follow schedule in Health Maintenance in the patient Electronic Medical Record (EMR); [...]