Colonial Springs Healthcare Center

In the surveyor’s words

From the most serious findings on record at Colonial Springs Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Feb 18, 2022

  Based on observation, record review, and interview, the facility failed to protect all residents from abuse when one staff member (Certified Nurse Aide (CNA) A) used a walker to place and hold one resident (Resident #1) in the corner in response to his/her behaviors which resulted in the resident striking out while being held in the corner. The facility census was 106. The administrator was notified on 2/16/2022, at 12:30 P.M., of an Immediate Jeopardy (IJ) which began on 2/11/2022. The IJ was removed on 2/16/2022, as confirmed by surveyor onsite verification. […]

• No harm, potential for more than minimal, widespreadF812Dec 6, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF921Dec 6, 2024

  Based 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. […]

• No harm, potential for more than minimal, patternF625Dec 6, 2024

  Based 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. […]

• No harm, potential for more than minimal, patternF690Dec 6, 2024

  Based 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. […]