CEDARHURST OF BLUE SPRINGS.

PRINTED: 05/15/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A, BUILDING: B, WING 31581 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 20551 E TRINITY PLACE BLUE SPRINGS, MO 64015 CEDARHURST OF BLUE SPRINGS PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (5) COMPLETE DATE (x4) 10 PREFIX TAG A4704| 19 CSR 30-86.047(6) Operator/Administrator Responsibilities The operator shall be responsible to assure compliance with all applicable laws and regulations. The administrator shall be fully authorized and empowered to make decisions regarding the operation of the facility and shall be held responsibie for the actions of all employees. The administrator ' s responsibilities shall include oversight of residents to assure that they receive care as defined in the individualized service plan. III This regulation is not met as evidenced by: Class II* Based on observation, interview, and record review, the operator failed to assure the facility remained in compliance with all applicable laws and regulations when the Administrator placed Resident #6 and #7 in room 228 together which was licensed by the Department of Health and Senior Services (DHSS) for one resident. The facility census was 66. The facility did not provide a policy regarding placement of residents in rooms per approved beds. Review of a bed listing dated 01/08/25 showed room 228 was licensed by DHSS for one bed. 1. Observation of room 228 on 04/30/25 at 10:35 A.M. showed: -Resident #6 and Resident #7's names on the name placard outside the room; -There was one twin sized bed in the bedroom area and one couch in the living room area; -Resident #6 was laying on the couch; -Resident #7 was sleeping on the twin size bed in Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S Si TURE STATE FORM TITLE (X6) DATE gece) yucz11 PRINTED: 01/09/2026 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 31581 B. WING 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 20551 E TRINITY PLACE BLUE SPRINGS, MO 64015 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) CEDARHURST OF BLUE SPRINGS A4704) 19 CSR 30-86.047(6) Operator/Administrator Responsibilities The operator shall be responsible to assure compliance with all applicable laws and regulations. The administrator shall be fully authorized and empowered to make decisions regarding the operation of the facility and shall be held responsible for the actions of all employees. The administrator ' s responsibilities shall include oversight of residents to assure that they receive care as defined in the individualized service plan. WII This regulation is not met as evidenced by: Class II* Based on observation, interview, and record review, the operator failed to assure the facility remained in compliance with all applicable laws and regulations when the Administrator placed Resident #6 and #7 in room 228 together which was licensed by the Department of Health and Senior Services (DHSS) for one resident. The facility census was 66. The facility did not provide a policy regarding placement of residents in rooms per approved beds. Review of a bed listing dated 01/08/25 showed room 228 was licensed by DHSS for one bed. 1. Observation of room 228 on 04/30/25 at 10:35 A.M. showed: -Resident #6 and Resident #7's names on the name placard outside the room; -There was one twin sized bed in the bedroom area and one couch in the living room area; -Resident #6 was laying on the couch; -Resident #7 was sleeping on the twin size bed in Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 05/23/25 STATE FORM 6899 YUCZ11 If continuation sheet 1 of 9 PRINTED: 01/09/2026 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 31581 B. WING 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 20551 E TRINITY PLACE BLUE SPRINGS, MO 64015 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) CEDARHURST OF BLUE SPRINGS Continued From page 1 the bedroom area; -There was not enough space to place a second bed for Resident #2. During an interview on 04/30/25 at 2:35 P.M., Resident #6 said: -He/She and Resident #7 had lived at the facility for approximately six months, and had lived in this room the entirety of their stay; -The room felt a little small; -There was not enough room in the bedroom area for Resident #7's hospital bed and a bed for himself/herself, -He/She stored his/her personal belongings in an entry way closet because there was not enough space in the bedroom closet for his/her personal belongings. During an interview on 04/30/25 at 3:05 P.M. the Administrator said: -He/She did not realize room 228 was licensed for one resident. * Higher classification merited due to the extent of the violation. 19 CSR 30-86.047(19) TB Screen Residents & Staff The facility shall screen residents and staff for tuberculosis as required for long-term care facilities by 19 CSR 20-20.100. Il This regulation is not met as evidenced by: Class II Based on interview and record review, the facility failed to ensure the required two step tuberculosis (TB) screening test or an annual evaluation was Missouri Department of Health and Senior Services STATE FORM 6899 YUCZ11 If continuation sheet 2 of 9 PRINTED: 01/09/2026 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 31581 B. WING 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 20551 E TRINITY PLACE BLUE SPRINGS, MO 64015 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) CEDARHURST OF BLUE SPRINGS Continued From page 2 completed for two of six sampled residents (Residents #2 and #3). The facility census was 66 residents. General requirements for TB testing for residents in Long Term Care Facilities, 19 CSR 20-20.100, reads as follows: -Long-term care facilities shall screen their residents for tuberculosis. Each facility shall be responsible for ensuring that all test results are completed and that documentation is maintained; -Within one month prior to or one week after admission, all residents new to long-term care are required to have the initial test of a two-step TB test; -If the resident's initial test is negative, the second test should be given one to three weeks later. The CDC (Centers for Disease Control) states TB tests should be read 48 to 72 hours after administration; -All long-term care facility residents shall have a documented annual evaluation to rule out signs and symptoms of TB disease; -All positive findings shall require a chest X-ray to rule out active pulmonary disease; -Individuals with a positive finding need not have repeat annual chest X-rays. They shall have a documented annual evaluation to rule out signs and symptoms of tuberculosis disease. The facility did not provide a policy regarding TB screening. 1. Review of Resident #2's record showed: -He/She was admitted to the facility on 02/05/24: -The last TB screening was the two step screening completed at admission; -The first step was administered on 02/06/24 and read on 02/08/24: -The second step was administered on 03/03/24 Missouri Department of Health and Senior Services STATE FORM 6899 YUCZ11 If continuation sheet 3 of 9 PRINTED: 01/09/2026 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 31581 B. WING 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 20551 E TRINITY PLACE BLUE SPRINGS, MO 64015 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) CEDARHURST OF BLUE SPRINGS Continued From page 3 and read on 03/06/24; -Resident #2 was due for his/her annual screening on 03/07/25. 2. Review of Resident #3's record showed: -He/She was admitted to the facility on 04/19/19: -The most current TB screening was dated on 05/01/23; -No TB screen was found or 2024 or 2025. During an interview on 04/30/25 at 3:05 P.M. the Administrator said: -He/She did not realize Resident #2 and #3 were not up to date on their annual TB screening; -He/She expected these to be completed at admission and annually thereafter. 19 CSR 30-87.030(11) Food-Safe, Obtain From Appropriate Sources Food shall be in sound condition, free from spoilage, filth or other contamination and shall be safe for human consumption. Food shall be obtained from sources that comply with all laws relating to food and food labeling. The use of food in hermetically sealed containers that was not prepared in a food-processing establishment is prohibited. Nothing in this section shall prohibit facilities from using fresh vegetables or fruits purchased from farmers ' markets or obtained from the facility garden or residents ' family gardens. I/II This regulation is not met as evidenced by: Class II Based on observation, interview, and record review the facility failed to ensure food was obtained from sources that were in compliance Missouri Department of Health and Senior Services STATE FORM 6899 YUCZ11 If continuation sheet 4 of 9 PRINTED: 01/09/2026 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 31581 B. WING 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 20551 E TRINITY PLACE BLUE SPRINGS, MO 64015 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) CEDARHURST OF BLUE SPRINGS Continued From page 4 with all laws relating to food and food labeling. This had the potential to affect all residents. The facility census was 66. The facility did not provide a policy regarding labeling and dating food items. 1. Observations of the walk-in cooler in the kitchen on 4/30/25 at 10:20 A.M. showed: -A gallon sized Ziploc bag of raw chicken with no label or date; -Half of a 10 Ib. roll of ground beef wrapped in plastic with no label or date; -Half of a tub of sour cream with no label or date of when it was opened. During an interview on 4/30/25 at 3:05 P.M. the Administrator said: -He/She expected all food to be labeled and dated; -Dietary staff were responsible for ensure food was labeled and dated. 19 CSR 30-87.030(14) Food-Clean Containers, Storage, Covers Food, whether raw or prepared, if removed from the container or package in which it was obtained, shall be stored in a clean covered container except during necessary periods of preparation or service. Container covers shall be impervious and nonabsorbent except that linens or napkins may be used for lining or covering bread or roll containers. III This regulation is not met as evidenced by: Class III Based on observation and interview the facility Missouri Department of Health and Senior Services STATE FORM 6899 YUCZ11 If continuation sheet 5 of 9 PRINTED: 01/09/2026 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 31581 B. WING 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 20551 E TRINITY PLACE BLUE SPRINGS, MO 64015 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) CEDARHURST OF BLUE SPRINGS Continued From page 5 failed to ensure all food if removed from its original container was stored in a clean covered container, when prepared food was found left uncovered. This had the potential to affect all residents. The facility census was 66. The facility did not provide a policy regarding food storage. 1. Observation of the kitchen's walk in refrigerator on 04/30/25 at 10:19 A.M. showed: -A tray of 31 prepared ramikens of condiments left uncovered on the bread rack; -A tray holding 11 prepared bowls of pudding left uncovered on the bread rack below the tray of condiments. During an interview on 04/30/25 at 3:05 P.M. the Administrator said: -He/She expected food to be covered and stored appropriately. 19 CSR 30-87.030(55) Ventilation Hoods, Clean, Filters Removable Ventilation hoods and devices shall be designed to prevent grease or condensation from collecting on walls and ceilings and from dripping into food or onto food-contact surfaces. Filters or other grease-extracting equipment shall be readily removable for cleaning and replacement if not designed to be cleaned in place. Ill This regulation is not met as evidenced by: Class III Based on observation and interview the facility failed to ensure all ventilation hoods were kept clean to prevent grease from dripping into food or Missouri Department of Health and Senior Services STATE FORM 6899 YUCZ11 If continuation sheet 6 of 9 PRINTED: 01/09/2026 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 31581 B. WING 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 20551 E TRINITY PLACE BLUE SPRINGS, MO 64015 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) CEDARHURST OF BLUE SPRINGS Continued From page 6 onto food-contact surfaces. This had the potential to affect all residents. The facility census was 66 residents. The facility did not provide a policy regarding cleaning of vent hood filters. 1. Observation in the kitchen on 04/30/25 at 10:19 A.M. showed: -The vent hood filters above the grill, griddle, and fryer were caked with grease hanging over the edge of the hood above the surface below. During an interview on 04/30/25 at 10:25 A.M. the Dietary Manager said: -He/She was still new to the facility, but he/she was aware of the concern for cleanliness and was working on improvements. During an interview on 04/30/25 at 3:05 P.M. the Administrator said: -The Dietary Manager was very new, and was still working things out in the kitchen regarding cleaning; -He/She expected the hood vents to be a part of the culinary services' weekly cleaning. 19 CSR 30-88.010(4) Resident Rights-Admission/Annual Review Each resident admitted to the facility, or his or her next of kin, legally authorized representative or designee, shall be fully informed of the individual's rights and responsibilities as a resident. These rights shall be reviewed annually with each resident, and/or his or her next of kin, legally authorized representative or designee, either in a group session or individually. II/III Missouri Department of Health and Senior Services STATE FORM 6899 YUCZ11 If continuation sheet 7 of 9 PRINTED: 01/09/2026 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 31581 B. WING 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 20551 E TRINITY PLACE BLUE SPRINGS, MO 64015 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) CEDARHURST OF BLUE SPRINGS Continued From page 7 This regulation is not met as evidenced by: Class III Based on observation, interview, and record review the facility failed to ensure resident rights were reviewed annually with each resident, and/or his/her next of kin, legally authorized representative or designee for five of six sampled residents (Resident #1, #2, #3, #4, and #5). The facility census was 66 residents. The facility did not provide a policy regarding annual review of resident rights. Observation on 04/30/25 showed the resident rights poster was posted on the wall right outside the dining hall. 1. Review of Resident #1's record showed: -He/She was admitted to the facility on 10/19/22: -No review of resident rights was found. 2. Review of Resident #2's record showed: -He/She was admitted to the facility on 02/05/24; -The last review of resident rights was signed and dated on 01/30/24. 3. Review of Resident #3's record showed: -He/She was admitted to the facility on 04/19/19; -The last review of resident rights was signed and dated on 04/17/19. 4. Review of Resident #4's record showed: -He/She was admitted to the facility on 07/01/22: -The last review of resident rights was signed and dated 06/27/22. 5. Review of Resident #5's record showed: -He/She was admitted to the facility on 07/29/24: -No resident rights review was found. Missouri Department of Health and Senior Services STATE FORM 6899 YUCZ11 If continuation sheet 8 of 9 PRINTED: 01/09/2026 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 31581 B. WING 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 20551 E TRINITY PLACE BLUE SPRINGS, MO 64015 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) CEDARHURST OF BLUE SPRINGS Continued From page 8 During an interview on 04/30/25 at 3:05 P.M. the Administrator said: -He/She did not realize resident rights were to be reviewed annually. Missouri Department of Health and Senior Services STATE FORM 6899 YUCZ11 If continuation sheet 9 of 9 PLAN OF CORRECTION Provider/Supplier Waid, Cedarhurst Blue Springs Street Address, a ' City, Zip: 20551 E Trinity Place Blue Springs, MO 64015 [———— Date of Survey: 4/30/2025 EEE a... PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) The bed listing form has been be updated and submitted to DHSS. It is attached to the POC. COMPLETION DATE A window insert has been added to the patio door which allows the living room to function as a bedroom per DHSS regulatory code. As such, an exception is not required. Staff discussed moving to a bigger apartment with the residents, but they were not interested in doing so. Should the residents decide to stay in the same room in the future, either the bed will be upsized so that two people can comfortably sleep together, or two twin-sized beds will be placed in the room and have the required 3-foot clearance between the beds. Attached to this POC are the following documents: e Email from Shay Patterson documenting approval of type B units (unit 228) for double occupancy so long as an operable window insert is added to the patio door. A4704 Once the insert is added, the living room meets the requirements of a bedroom per regulations and can function as such. o Note that the email states that a policy is not required: that it is recommended that staff document the discussion of the living arrangement with the residents. In the future, the community will do so. o Note that the community initially received an exception for (6) of the type B units for double occupancy, but after finding an acceptable permanent solution, a rescind request was made for the exception. Email from David East (ECU) approving the inserts Specification sheet for the window insert Original exception dated 10/16/2019 Exception rescind request dated 5/26/2023 A picture can be provided if needed next Thursday May 29, 2025, when the company D&K Commercial Mh. J ED 2/22) 05 Will Be complete on 5/29/2025 Exteriors, LLC, will be here to install the window for the patio door. A4724 TB Screen Residents & Staff: Investigating the TB tag, the ED, found Resident 2: TB Screen Two Step: 3/6/24 TB Screen Yearly: 5/13/2025 (2 months late on TB) Resident 3: TB Screening 05/05/2022 TB Screening 5/1/2023 TB Screening 5/16/2024 Yearly 5/14/2025 These were found in ECP under individual resident, under add. 5/21/2025 Reports, and then under Cedarhurst TB Screen and Cedarhurst TB Screen/Two Step. Going forward, to make sure that all residents are not behind and have a current TB. The DON will ensure that a TB 2 step is done at admission and then following everyone will have a yearly TB annual screening in May. Even residents who would have admitted during the months of January to April, will still receive an annual screening in the month of May. The ED, Hannah Brown, will audit these quarterly to make sure that no one was missed and that all residents have a current TB screening. A7016 Food-Safe, Obtain from Appropriate Sources: Hannah Brown, Executive Director, will complete random audits for the next six months but at least 1 per month that is a part of a quality assurance program, but we will do monthly for the 6 months instead of quarterly, to look at cleanliness of kitchen, labeled food in all food storage areas of kitchen. Alongside that, the Dining Services Director, the cooks, and the dining services aides, have been in-serviced on 5/19/2025, on food labeling and the importance of that. When and if new employees start, this will be included in their training. 5/21/2025 Food- Clean Containers, Storage, Covers: Hannah Brown, Executive Director, will complete random audits for the next six months but at least 1 per month that is a part of a quality assurance program, but we will do monthly for the 6 months instead of quarterly, to look at cleanliness of kitchen, labeled food in all food storage areas of kitchen, and covered food even when used shortly for a meal will be adequality covered. Alongside that, the Dining Services Director, the cooks, and the dining services aides, have been in-serviced on 5/19/2025, on 5/21/2025 food labeling and the importance of that. When and if new employees start, this will be included in their training. Ventilation Hoods, Clean, Filters Removable: The vent hood filters above the grill, griddle, and fryer, were cakes with grease hanging over the edge of the hood above the surface below. The entire team including the new DSD, Chris Beckham, was in- serviced on the policies and procedures on the cleanliness of the kitchen, the hood filters, and then grill/fryer/oven area on A7057 May 19, 2025. There is a cleaning scheduling for weekly 6/21/2025 cleaning and monthly cleaning, and it will be monitored by the DSD, Chris Beckham, and audited by Hannah Brown, the Executive Director. While our policy only states hood filters to be cleaned monthly, our cleaning schedule is a weekly cleaning schedule and will be followed to ensure build up on grease is minimal. Resident Rights- Admission/Annual Review: Our annual residents rights will be done each May for all residents. When new residents do admission resident rights acknowledgement, between the months of January and April, they will still be required to do an annual resident rights review in May to ensure A8004 everyone has a current and active residents right review each 5/21/2025 year. Hannah, the Executive Director, and Rae Buxton, the Assistant Executive Director, will oversee collecting and monitoring those. The monitoring is in ECP (electronic medical records system) and the current signed documents are all in | ECP under files. The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approval of the plan of correction being submitted on this form.

PRINTED: 03/17/2025 FORM APPROVED Missouri Department of Health and Senior Services {X3) DATE SURVEY COMPLETED STATEMENT OF DEFICIENCIES AND FLAN OF CORRECTION (41) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A, BUILDING: 03/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 20551 E TRINITY PLACE BLUE SPRINGS, MC 64015 (%4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (E4CH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) CEDARHURST OF BLUE SPRINGS Aé2i? 19 CSR 30-86.022(5)(D) Fire Drill Requirements, Evacuation Fire Grills and Emergency Preparedness. (D) A minimum of twelve (12) fire drills shall be conducted annually with at least one {1} every three (3) months on each shift. Ai least four (4) of the required fire drills must be unannounced to residents and staff, excluding staff whe are assigned to evaluate staff and resident response to the fire drill. The fire drills shail include a resident evacuation at least once a year. II/IIl This regulation is nct met as evidenced by: Class II Based on record review and interview en March 10, 2025, Facility failed to conduct one (1) fire drill every three (3) months on each shift and a full resident ¢vacualion once a year. Facility census was Sixty-six (66). This affected sixty-six (66) of sixty-six (66) residents. Record review March 10, 2025 at 3:00 P.M., showed six (6) fire drills for tst shift, four (4} fire drills for 2nd shift, one (1) fire drills for 3rd shift and none for September and no full evacuation. Fire Drills from March 2024 through February 2025 were performed as follows: March 16, 2024 - 1st shift April 30. 2024 - 2nd shift May 16, 2024 - ist shift June 27, 2024 - 1st shifl July 18, 2024 - 1st August 31, 2024 - 2nd shift September 2024 - none October 25, 2024 - 2nd shift ' Novernber 5, 2024 - (st shift December 21, 2024 - 3rd shitt January 16, 2025 - 1st shift LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPREGENTATI TITLE 4X6) DATE la fo Y " biuk [ew Mt a ae 5y90 O6P2141 — IF continuation sfeet 1 of 14 Missouri Department of Health and Senior Services is aaa STATE FORM PRINTED: 01/09/2026 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA (X2} MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 03/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 20551 E TRINITY PLACE BLUE SPRINGS, MO 64015 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) CEDARHURST OF BLUE SPRINGS 19 CSR 30-86.022(5){D) Fire Drill Requirements, Evacuation Fire Drills and Emergency Preparedness. (DB) A minimum of twelve (12) fire drills shall be conducted annually with at least one (1) every three (3) months on each shift. At least four (4) of the required fire drills must be unannounced to residents and staff, excluding staff who are assigned to evaluate staff and resident response to the fire drill. The fire drills shall include a resident evacuation at least once a year. IVill This regulation is not met as evidenced by: Class Ill Based on record review and interview on March 10, 2025, Facility failed to conduct one (1) fire drill every three (3) months on each shift and a full resident evacuation once a year. Facility census was sixty-six (66). This affected sixty-six (66) of sixty-six (66) residents. Recerd review March 10, 2025 at 3:00 P_M., showed six (6) fire drills for 1st shift, four (4) fire drills for 2nd shift, one (1) fire drills for 3rd shift and none for September and no full evacuation. Fire Drills from March 2024 through February 2025 were performed as follows: March 18, 2024 - 1st shift April 30. 2024 - 2nd shift May 16, 2024 - 1st shift June 27, 2024 - Ist shift July 18, 2024 - ist August 31, 2024 - 2nd shift September 2024 - none October 25, 2024 - 2nd shift November 5, 2024 - ist shift December 21, 2024 - 3rd shift January 16, 2025 - ist shift Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X68) DATE 04/07/25 STATE FORM 6898 OGP211 If continuation sheet 1 of 14 PRINTED: 01/09/2026 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA (X2} MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 03/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 20551 E TRINITY PLACE BLUE SPRINGS, MO 64015 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) CEDARHURST OF BLUE SPRINGS Continued Fram page 1 February 24, 2025 - 2nd shift During an interview on March 10, 2025 at 4:35 P.M., the Environmental Service Director said, “I just started in October of 2024 and | arn trying to get them straighten out. 19 CSR 30-86.022(9}(C) Fire Alarm System-Test/Maintain Complete Fire Alarm Systems. (C) All facilities shall test and maintain the complete fire alarm system in accordance with NFPA 72, 1999 edition. i/1] This regulation is not met as evidenced by: Class ll Based on record review and interview on March 10, 2025, the facility failed to test and maintain the complete fire alarm system in accordance with the National Fire Protection Association (NFPA) 72, 1999 edition. Facility census was sixty-six (66). This affected sixty-six (66) of sixty-six (66) residents. Review of the facility fire alarm paperwork on March 10, 2025 at 3:00 P.M., showed no documentation for the semi-annual fire alarm inspection. The only fire alarm paperwork was an annual fire alarm report on May 17, 2024. During an interview on March 10, 2025 at 4:35 P.M., the Environmental Service Director said, "! just started in October of 2024 and haven't had the chance to look at all the paperwork, but will look at getting it scheduled.” Record review of NFPA 72 1999, 7-1.1.1: Missouri Department of Health and Senior Services STATE FORM 6838 O6P211 {f continuation sheet 2 of 14 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER CEDARHURST OF BLUE SPRINGS (X2) MULTIPLE CONSTRUCTION A. BUILDING: BLUE SPRINGS, MO 64015 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer 's recommendations, and shall verify correct operation of the fire alarm system. NFPA Standard: System defects and malfunctions shall be corrected. If a defect or malfunction is not corrected at the conclusion of systern inspection, testing, or maintenance, the systern owner, or the owner’ s designated representative shall be informed of the impairment in writing within 24 hours. 1999 NFPA 72, 7-1.1.2 NFPA Standard: The owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and alterations or additions to this system. The delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request. 1999 NFPA 72, 7-1.2 Record review of NFPA 72, Chapter 14.3 showed: Unless otherwise permitted by 14.3.2 visual inspections shall be performed in accordance with the schedules in Table 14.3.1 or more often if required by the authority having jurisdiction. -Batteries -Transient suppressors - Fire alarm control unit trouble signals - In-building fire emergency voice/alarm communications equipment - Remote annunciators - Initiating devices - Guard’ s tour equipment - Combination systems - Interface equipment - Alarm notification appliances - supervised Missouri Department of Health and Senior Services STATE FORM 899 O6P211 PRINTED: 01/09/2026 FORM APPROVED {X3} BATE SURVEY COMPLETED 03/10/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 20551 E TRINITY PLACE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) {f continuation sheet 3 of 14 PRINTED: 01/09/2026 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA (X2} MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 03/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 20551 E TRINITY PLACE BLUE SPRINGS, MO 64015 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) CEDARHURST OF BLUE SPRINGS Continued From page 3 - Exit marking audible notification appliances - Supervising station alarm systems - transmitters - Special procedures - Supervising station alarm systems - receivers* 19 CSR 30-86.022(11)(A) Complete Sprinkler System-NFPA 13 Sprinkler Systems. (A) Facilities licensed on or after August 28, 2007, or any section of a facility in which a major renovation has been completed on or after August 28, 2007, shail install and maintain a complete sprinkler system in accordance with NFPA 13, 1999 edition. IAI This regulation is not met as evidenced by: Class Il Based on observation and interview on March 10, 2025, the facility failed to install and maintain a complete sprinkler system in accordance with NFPA 13, 1999 edition. Facility census was sixty-six (66). This affected sixty-six (66) of sixty-six (66) residents. Observation at 12:12 P_M., showed a porch and deck combo, that expands more than four (4) feet from the building that is not protected with sprinkler heads, at the north side court yard with exposed floor joists. Observation at 12:12 P.M., showed a porch and deck combo, that expands more than four (4) feet from the building that is not protected with sprinkler heads, at the south side court yard with exposed floor joists. Observation at 12:41 P.M_, showed sprinkler Missouri Department of Health and Senior Services STATE FORM 6838 O6P211 {f continuation sheet 4 of 14 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER CEDARHURST OF BLUE SPRINGS (X2) MULTIPLE CONSTRUCTION A. BUILDING: BLUE SPRINGS, MO 64015 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 head was missing the cover plate assembly in the Dining Hail. (The missing cover plate assembly can and will allow smoke fo travel to other parts of the facility) Observation at 4:50 P.M., showed two (2) porch and deck combos, that extends more than four (4) feet from the building that are not protected with sprinkler heads, at the front side of the building with exposed floor joisis. Observation at 4:52 P.M., showed two (2) porch and deck combos, that extends more than four (4) feet from the building that are not protected with sprinkler heads, at the north side of the building with exposed floor joists. During an interview on March 10, 2025 at 4:35 P.M., the Environmental Service Director said, "I will contact the sprinkler company to get it replaced and | will address the porches.” Review of the following chapters of the 1999 National Fire Protection Association (NFPA) 13: 5-5.5.3.1 Sprinklers shall be installed under fixed obstruction over four (4) feet (1.2m) wide such as ducts, decks, open grates flooring, cutting tables, and overhead doors. 5-13.8* Exterior Roofs or Canopies. 5-13.8.1 Sprinkler shall be installed under exterior roos or canopies exceeding four (4) feet (1.2m) in width. Exception: Sprinklers are permitted to be omitted where the canopy or roof is of noncombustible or limited combustible construction. 5-13.8.2* Sprinklers shall be installed under roofs Missouri Department of Health and Senior Services STATE FORM 899 O6P211 PRINTED: 01/09/2026 FORM APPROVED {X3} BATE SURVEY COMPLETED 03/10/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 20551 E TRINITY PLACE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) {f continuation sheet § of 14 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER CEDARHURST OF BLUE SPRINGS (X2) MULTIPLE CONSTRUCTION A. BUILDING: BLUE SPRINGS, MO 64015 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 5 or canopies over areas where combustibles are stored and handled. 19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements Trash and Rubbish Disposal. (A) Only metal or UL- or FiV-fire-resistant rated wastebaskets shall be used for trash. II This regulation is not met as evidenced by: Class IL Based on observation and interview on March 10, 2025, facility fails to ensure only metal or UL- or F(-fire-resistant rated wastebaskets shail be used for trash. Facility census was sixty-six (66). This affected sixty-six (66) of sixty-six (66) residents. Observations from 11:24 A.M. through 3:00 P.M., Showed unapproved trash cans were found in the following rooms: one (1) in room 103 one (1) in the Beauty shop two (2) in room 104 one (1) in room 105 one (1) in room 107 one (1) in room 113 two (2) in room 201 one (1) in room 207 one (1) in room 213 one (1) in room 215 two (2) in room 216 two (2) in room 217 one (1) in room 218 one (1) in room 219 one (1) in room 223 one (1) in room 225 Missouri Department of Health and Senior Services STATE FORM 899 O6P211 PRINTED: 01/09/2026 FORM APPROVED {X3} BATE SURVEY COMPLETED 03/10/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 20551 E TRINITY PLACE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) {f continuation sheet 6 of 14 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER CEDARHURST OF BLUE SPRINGS (X2) MULTIPLE CONSTRUCTION A. BUILDING: BLUE SPRINGS, MO 64015 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 6 During an interview on March 10, 2025 at 4:35 P.M., the Environmental Service Director said, “I am going to give nursing a list to pull tonight.” 19 CSR 30-86.022(17) Oxygen Storage Requirements Oxygen storage shall be in accordance with NFPA 99, 1999 Edition. II/HI This regulation is not met as evidenced by: Class Ill Based on observation and interview on March 10, 2025, the facility failed to store portable oxygen cylinders in accordance with NFPA 99, 1999 Edition. Facility census was sixty-six (66). This affected sixty-six (66) of sixty-six (66) residents. Observation at 1:21 P.M., showed two (2) oxygen cylinders, standing upright and not stored in an approved rack, or secured by a chain or band in the living room next to a dresser in resident room 221. This resident had three (3) oxygen cylinders in the room. During an interview on March 10, 2025 at 4:35 P.M., the Environmental Service Director said, "Nursing removed them and | will talk fo them about insuring they are right. Review of the following chapters of the 1999 National Fire Protection Association (NFPA) 99, showed: 8-3.1.11 Storage Requirements Missouri Department of Health and Senior Services STATE FORM 899 O6P211 PRINTED: 01/09/2026 FORM APPROVED {X3} BATE SURVEY COMPLETED 03/10/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 20551 E TRINITY PLACE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) {f continuation sheet 7 of 14 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER CEDARHURST OF BLUE SPRINGS (X2) MULTIPLE CONSTRUCTION A. BUILDING: BLUE SPRINGS, MO 64015 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 7 8-3.1.11.2 Storage for non-flammable gases less than 3000 ft3 (85 m3) (a) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. (b) Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor. (c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either: 1. Aminimum distance of 20 ft (6.1 m), or 2. Aminimum distance of 5 ft (1.5m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or 3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage. 19 CSR 30-86.032(2) Substantially Constructed & Maintained The building shall be substantially constructed and shall be maintained in good repair and in accordance with the construction and fire safety rules in effect at the time of initial licensing. I/II This regulation is not met as evidenced by: Class Hl Based on observation and interview on March 10, 2025, the facility failed to ensure the building was being maintained in good repair and in Missouri Department of Health and Senior Services STATE FORM 899 O6P211 PRINTED: 01/09/2026 FORM APPROVED {X3} BATE SURVEY COMPLETED 03/10/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 20551 E TRINITY PLACE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) {f continuation sheet 8 of 14 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER CEDARHURST OF BLUE SPRINGS (X2) MULTIPLE CONSTRUCTION A. BUILDING: BLUE SPRINGS, MO 64015 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 8 accordance with the construction and fire safety rules in effect at the time of initial licensing. Facility census was sixty-six (66). This affected sixty-six (66) of sixty-six (66) residents. Observation at 12:24 P.M., showed a large hole in the ceiling above the sprinkler riser in the Riser Room. The size of the hole was approximately ft by 2ft. that could be observed. Observation at 12:24 P.M., showed an area in the ceiling where the ceiling and wall join, had crack in it, in resident room 220. Observation at 12:24 P_M., showed drywall tape where fhe ceiling and wail join in the Furnace roam on the second floor near front entrance, needing repair. Observation at 2:58 P.M., showed drywall tape where the ceiling and wall join in resident room 13, needing repair. Observation at 2:59 P.M., showed drywall tape where the ceiling and wail join in resident room 15, needing repair. During an interview on March 10, 2025 at 4:35 P_M_, the Environmental Service Director said, "! will start work on the items right away." 19 CSR 30-86.032(10) Heaters-Approved Label, Venting, No Portable In newly licensed facilities or if a new heating system is installed in an existing licensed facility, the heating of the building shail be restricted to steam, hot water, permanently installed electric heating devices or a warm air system employing Missouri Department of Health and Senior Services STATE FORM 899 O6P211 PRINTED: 01/09/2026 FORM APPROVED {X3} BATE SURVEY COMPLETED 03/10/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 20551 E TRINITY PLACE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) {f continuation sheet 9 of 14 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER CEDARHURST OF BLUE SPRINGS (X2) MULTIPLE CONSTRUCTION A. BUILDING: BLUE SPRINGS, MO 64015 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 9 central heating plants with installation such as to safeguard the inherent fire hazard, or approved installation of outside wall heaters which bear the approved label of the American Gas Association or National Board of Fire Underwriters. The foregoing requirements are applicable to residential care facilities. In assisted living facilities, the heating of the building shall be restricted to steam, hot water, permanently installed electric heating devices or a warm air systern employing central heating plants with installation such as to safeguard the inherent fire hazard, or approved installation of outside wall heaters which bear the approved label of the American Gas Association or National Board of Fire Underwriters. For all facilities, oil or gas heating appliances shall be properly vented to the outside and the use of portable heaters of any kind is prohibited. If approved wall heaters are used, adequate guards shall be provided to safeguard residents. I/Il This regulation is not met as evidenced by: Class fl Based on observation and interview on March 10, 2025, the facility failed to ensure only approved heating sources were used within the facility. Facility census was sixty-six (66). This affected sixty-six (66) of sixty-six (66) residents. Observation at 11:45 A.M., showed a portable space heater in the living room area of resident room 102. The fireplace heater was part of the TV stand and was not in use aft the tirne of discovery. Observation at 11:45 A.M., showed a portable space heater in the bathroom of resident room 116. The heater was not plugged into an outlet. Missouri Department of Health and Senior Services STATE FORM 899 O6P211 PRINTED: 01/09/2026 FORM APPROVED {X3} BATE SURVEY COMPLETED 03/10/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 20551 E TRINITY PLACE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) If continuation sheet 10 of 14 PRINTED: 01/09/2026 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA (X2} MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 03/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 20551 E TRINITY PLACE BLUE SPRINGS, MO 64015 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) CEDARHURST OF BLUE SPRINGS Continued From page 10 Upon discovery the Environmental Service Director removed the space heater. During an interview on March 10, 2025 at 4:35 P.M., the Environmental Service Director said, “I will work with the resident in room 102 to disconnect the heating element and keep a better eye on the other space heaters. 19 CSR 30-86.032(13) Electrical Wiring, Maintained, inspected In facilities that are constructed or have plans approved after July 1, 2005, electrical wiring shall be installed and maintained in accordance with the requirements of the National Electrical Code, 1999 edition, National Fire Protection Association, Inc., incorporated by reference, in this rule and available by mail at One Batterymarch Park, Quincy, MA 02269, and local codes. This rule does not incorporate any subsequent amendments or additions to the materials incorporated by reference. Facilities built between September 28, 1979 and July 1, 2005 shail be maintained in accordance with the requirements of the National Electrical Code, which was in effect at the time of the original plan approval and local codes. This rule does not incorporate any subsequent amendments or additions. In facilities built prior to September 28, 1979, electrical wiring shall be maintained in good repair and shall not present a safety hazard. All facilities shall have wiring Inspected every two (2) years by a qualified electrician. HAH This regulation is not met as evidenced by: Class Hi Based on observation and interview on March 10, Missouri Department of Health and Senior Services STATE FORM 6838 O6P211 if continuation sheet 11 of 14 PRINTED: 01/09/2026 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA (X2} MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 03/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 20551 E TRINITY PLACE BLUE SPRINGS, MO 64015 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) CEDARHURST OF BLUE SPRINGS Continued From page 11 2025, the facility failed to maintain the building electrical wiring in good repair in accordance with the requirements of the National Electrical Code, 1999 edition. Facility census was sixty-six (66). This affected sixty-six (66) of sixty-six (66) residents. Observation at 12:53 P.M., showed a ceiling light hanging from its wires in the closet of the Activity Center. During an interview on March 10, 2025 at 4:35 P.M., the Environmental Service Director said, "I will address it right away.” 19 CSR 30-86.032(18) Extension Cords/Duplex Receptacles If extension cords are used, they must be Underwriters ' Laboratory (UL)-approved or shall comply with other recognized electrical appliance approval standards and sized to carry the current required for the appliance used. Only one (1) appliance shail be connected to one (1) extension cord and only two (2) appliances may be served by one (1) duplex receptacle. If extension cords are used, they shall not be placed under rugs, through doorways or located where they are subject to physical damage. II/Ill This regulation is not met as evidenced by: Class Hl Based on observation on March 10, 2025, the facility failed to insure that ail extension cords and adapters being used, comply with the Underwrites' Laboratory (UL). Facility census was sixty-six (66). This affected sixty-six (66) of sixty-six (66) residents. Missouri Department of Health and Senior Services STATE FORM 6838 O6P211 If continuation sheet 12 of 14 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER CEDARHURST OF BLUE SPRINGS (X2) MULTIPLE CONSTRUCTION A. BUILDING: BLUE SPRINGS, MO 64015 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 12 Observations from 11:24 A.M. through 3:00 P.M., Showed unapproved extension cords and adapters in the following rooms: one (1) three-way adapter in room 101 one (1) six-way adapter in room 105 one (1) three-way adapter and one (1) extension cord in room 115 one (1) extension cord in room 116 one (1) three-way adapier in room 117 one (1) six-way adapter and one (1) extension cord in room 118 one (1) extension cord in room 119 one (1) two-way adapter and one (1) extension cord in room 205 one (1) extension cord in room 219 During an interview on March 10, 2025 at 4:35 P.M., the Environmental Service Director said, "I will try to keep a better eye on it.“ 19 CSR 30-86.032(23) Rooms Neat, Orderly, Cleaned Daily Rooms shall be neat, orderly and cleaned daily. H/HI This regulation is not met as evidenced by: Class fll. Based on observation and interview on March 10, Facility census was sixty-six (66). This affected sixty-six (66) of sixty-six (66) residents. Observation at 1:29 P.M., Show excessive clutter in resident room 222. This includes clothes, blankets, bed sheets and trash around the resident's recliner. Staff said the resident hardly Missouri Department of Health and Senior Services STATE FORM 2025, facility fails to keep rooms neat and orderly. 899 O6P211 PRINTED: 01/09/2026 FORM APPROVED {X3} BATE SURVEY COMPLETED 03/10/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 20551 E TRINITY PLACE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) If continuation sheet 13 of 14 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER 20551 E TRINITY PLACE BLUE SPRINGS, MO 64015 CEDARHURST OF BLUE SPRINGS SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 13 moves out the recliner. The amount of clutter in this room would impede the resident's ability to exit in a timely manner during an emergency. During an interview on March 10, 2025 at 4:35 P.M., the Environmental Service Director said, "! will have the administrator talk to the resident, regarding room.” Missouri Department of Health and Senior Services STATE FORM 899 O6P211 (X2) MULTIPLE CONSTRUCTION PRINTED: 01/09/2026 FORM APPROVED {X3} BATE SURVEY COMPLETED 03/10/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) lf continuation sheet 44 of 14 PLAN OF CORRECTION Cedarhurst of Blue Springs Provider/Supplier Name: tdi 20551 E Trinity Place, Blue Springs, MO 64015 March 10, 2025 Date of Survey: PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN GF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} DATE The Environmenta! Services Director has in TELS fire drills that will alternate for each shift for each month so that a monthly fire drill takes place. The previous ESD did not do this. Example- (Jan, 1st shift fire drill, Feb, 2" shift fire drill, March 3° shift fire A2217 drill and continues). The full evacuation drill is planned for April 3/25/2025 10, 2025. Since October, 2024, current ESD has done fire drills monthly and will continue to do so, Hannah, the Executive Director, will monitor monthly, to ensure that Fire Drills are being done by ESD. Semi-annual fire alarm inspections have been scheduled. The last one that was completed was 5/22/2024. Fire alarm A2249 inspection to be completed for the annual on May 7, 2025 by Prodigy Fire and then semi-annual will be completed in November 2025. This has been put inte TELS so that ESD and ED can monitor to ensure they are being completed. We are actively working with the original engineering firm to verify how we can add branch lines to extend out to the balconies. We will not be able to fully complete the project within 30 days, but we can continually update the FM with progress reports at an interval of your preference until the project is complete. 3/28/2025 Crporate has reached out to St. Louis Design Alliance architect Jeffrey Mugg (architect of note on the building plans) to understand how we can resolve the balcony sprinkler issue. Initial contact was 3/17; followed up again on 3/24 and 4/7. What we are trying figure out is the best route - extend sprinklers to exterior or modify balcony to qualify as 'non- combustible’. Either route is sure to be costly so we are trying to do our homework to ensure we get things right. TBD ESD contacted Predigy Fire Solutions concerning sprinkler head that was missing the cover plate assembly can in the dining 14/25 room. They have sent an invoice on 3/25/2025 and are scheduled to come fix the sprinkler head on 4/4/25. Christie, A3201 A3211 ESD, working with Prodigy Fire Solutions and this has been completed as of 4/4/2025. Only metal wastebaskets shall be used for trash. All nonmetal fire resistant wastebaskets have been removed from apartments and beauty shop and have been replaced with metal fire resistant wastebaskets from Direct Supply. Christie removed and replaced ali waste baskets in the community. Along with the removal, 10 ensure in the future this is nat an issue, ED will 3/25/2025 attach Welcome Letter that states that fire resistant wastebaskets are the only wastebaskets that can be used in apartments. Christie, ESD, and Tammy, DON, will do weekly checks to ensure that ne new non fire resistant wastebaskets are in use. Oxygen tanks were lefts in apartment 221 by family and nursing staff did not place them in correct and approved location for oxygen storage. All nursing staff were in-serviced on 3/13/2025 about correct oxygen storage according to 19 CSR 30- 86.022(17). The oxygen tanks from apartment 221 were 3/13/2025 removed 3/10/2025. Tamara Moore, DON, will continue to in- service staff and monitor rooms to ensure that this doesn’t happen again. As this was an isolated incident that is very rare. This is not common practice here at Cedarhurst Blue Springs. 1. Large hole in ceiling above the sprinkler riser room had a hole that was approximately 1ft by 2ft. Christie repaired this and will continue to monitor for concerns. 2. Apt 220 had crack where ceiling and wall join. Christie repaired this and will continue to monitor for concerns. 3. Furnace room on the 2" floor near front entrance showed drywall tape where the ceiling and wall join. Christie repaired this and will continue to monitor for concerns. 4. Apt 13 showed drywall tape where ceiling and wall join. Christie repaired this and will continue to monitor for concerns. 5. Apt 15 showed drywall tape where ceiling and wall join. Christie repaired this and wil! continue to monitor for concerns. All concerns were repaired by Christie, ESD, by 3/14/2025 and have been checked by Hannah, ED, to ensure they are completely repaired. 28/25 * There was a portable space heater in Apt 102 that is also a TV Stand. When apt 102 moved in they were made aware that the heating function would have to be disabled if they wanted to nave that in the apt. They did not do so. Due to the cost of the piece of furniture, the family has given permission to put an electrical plug lock on the electrical plug that would prevent the ability to plug it in which means that the heating function and any function requiring electricity would not work. Christie install the plug lock on 3/14/2025 and Hannah, ED, confirmed it was completed. e Apt 116 had a space heater in the bathroom that was removed on 3/11/2025 by Christie, ESD. The family came on 3/12/2025 and picked up the space heater. 3/14/2025 To ensure this doesn't happen in the future, families and residents are going to sign a Welcome Letter that states space heaters are not allowed. Christie, ESD, and Tamara Moore, DON, will continualiy monitor rooms to make sure no one brings a space heater in. In the activity room closet was a ceiling light hanging from the wires. ESD, compteted this repair on the ceiling light and the ceiling light has no exposed wires at this time. Christie, ESD, completed this, and Hannah, EO confirmed repair was made. Unapproved extension cords were in apartments listed: 101, 105, 115, 116, 117, 118, 118, 205, and 219. All extension cords have been removed and all residents and families have been instructed tnat the only type of extension cords that can be in apartments or the community are UL approved. A3214 3/12/2025 A3219 3/11/2025 To ensure this doesn’t happen in the future, families and residents are going to sign a Welcome Letter that states space to only use UL fire power strips. Christie, ESD, and Tamara Moore, DON, will continually monitor rooms to make sure no one has unapproved extension cords in their apartments. Resident apartment 222 showed excessive clutter including clothing, blankets, bed sheets, and trash around the resident's recliner, The resident and the resident's family were talked to and the room was cleaned up. The resident understands that she cannot have excessive clutter or laundry surrounding her and has agreed to let staff put clean clothing away instead of letting it sit around her living room. AI224 3/12/2025 Staff and family worked together to remove trash, cluttered items, they put clothing away, talking with family and resident about the need for laundry to be put away. Staff cleaned chair and entire apartment. Staff now will be putting laundry away. Christie, ESD, and Tammy Moore, DON, will monitor weekly to ensure resident will not be allowed any clutter to build up in the apartment. The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approval of the plan of correction being submitted on this form. An administrator signature on the 2567 & approved POC could not be found in file. PRINTED: 07/17/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA (X2} MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED R 07/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 20551 E TRINITY PLACE BLUE SPRINGS, MO 64015 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) CEDARHURST OF BLUE SPRINGS {A2268} 19 CSR 30-86.022(11)(A) Complete Sprinkler {A2268} System-NFPA 13 Sprinkler Systems. (A) Facilities licensed on or after August 28, 2007, or any section of a facility in which a major renovation has been completed on or after August 28, 2007, shall install and maintain a complete sprinkler system in accordance with NFPA 13, 1999 edition. {Al This regulation is not met as evidenced by: This deficiency is uncorrected. For prior examples, refer to Staternent of Deficiencies dated March 10, 2025. Class Il Based on observation and interview, the facility failed to install and maintain a complete sprinkler systern in accordance with NFPA 13, 1999 edition. Facility census was sixty-seven (67). This affected sixty-seven (67) of sixty-seven (67) residents. Observation on July 8, 2025, showed six (6) porch and deck combos, that had deck widths wider than four (4) feet from the building with exposed floor joists that were not protected with sprinkler heads nor covered with a noncombustible or limited combustible construction material, on all sides of the building. During an interview on July 8, 2025 at 3:22 P.M_, the Environmental Service Director said, he/she would let the administrator know. Review of the following chapters of the 1999 National Fire Protection Association (NFPA) 13: 5-5.5.3.1 Sprinklers shall be installed under fixed obstruction over four (4) feet (1.2m) wide such as Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X68) DATE STATE FORM 6898 O68P212 lf continuation sheet 1 of 2 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER 20551 E TRINITY PLACE BLUE SPRINGS, MO 64015 CEDARHURST OF BLUE SPRINGS SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {A2268} {A2268} Continued From page 1 ducts, decks, open grates flooring, cutting tables, and overhead doors. 5-13.8" Exterior Roofs or Canopies. 5-13.8.1 Sprinkler shall be installed under exterior roofs or canopies exceeding four (4) feet (1.2m) in width. Exception: Sprinklers are permitted fo be omitted where the canopy or roof is of noncornbustible or limited combustible construction. 5-13.8.2* Sprinklers shall be installed under roofs or canopies over areas where combustibles are stored and handied. Missouri Department of Health and Senior Services STATE FORM 899 O6P212 (X2) MULTIPLE CONSTRUCTION PRINTED: 07/17/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED R 07/08/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) lf continuation sheet 2 of 2 An administrator signature on the 2567 & approved POC could not be found in file. PRINTED: 11/13/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA (X2} MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED R 11/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 20551 E TRINITY PLACE BLUE SPRINGS, MO 64015 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) CEDARHURST OF BLUE SPRINGS {A2268} 19 CSR 30-86.022(11)(A) Complete Sprinkler {A2268} System-NFPA 13 Sprinkler Systems. (A) Facilities licensed on or after August 28, 2007, or any section of a facility in which a major renovation has been completed on or after August 28, 2007, shall install and maintain a complete sprinkler system in accordance with NFPA 13, 1999 edition. {Al This regulation is not met as evidenced by: This deficiency is uncorrected. For prior examples, refer to Staternent of Deficiencies dated March 10, 2025 and July 8, 2025. Class Il Based on observation and interview, the facility failed to install and maintain a complete sprinkler systern in accordance with NFPA 13, 1999 edition. Facility census was fifty-eight (58). This affected fifty-eight (58) of fifty-eight (58) residents. Observation on November 4, 2025, at 11:57 A.M., showed a porch and deck combo, that had a deck width wider than four feet (4") from the building with combustible exposed floor joists that were not protected with sprinkler heads, nor covered with a noncombustible or limited combustible construction material, located on the North side of the interior courtyard. Observation on November 4, 2025, at 11:57 A.M., showed a porch and deck combo, that had a deck width wider than four feet (4°) from the building with combustible exposed floor joists that were not protected with sprinkler heads, nor covered with a noncombustible or limited combustible construction material, located on the South side of the interior courtyard. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X68) DATE STATE FORM 6898 O6P213 lf continuation sheet 1 of 3 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER CEDARHURST OF BLUE SPRINGS (X2) MULTIPLE CONSTRUCTION A. BUILDING: BLUE SPRINGS, MO 64015 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {A2268} | Continued From page 1 Observation on November 4, 2025, at 12:08 P.M., showed a porch and deck combo, that had a deck width wider than four feet (4") from the building with combustible exposed floor joists that were not protected with sprinkler heads, nor covered with a noncombustible or limited combustible construction material, located on the Southeasi side of main entrance to the facility. Observation on November 4, 2025, at 12:09 P.M, showed a porch and deck combo, that had a deck width wider than four feet (4") from the building with combustible exposed floor joists that were not protected with sprinkler heads, nor covered with a noncombustible or limited combustible construction material, located on the Northeast side of main entrance to the facility. Observation on November 4, 2025, at 12:11 P.M., showed three (3) porch and deck combo, that had decks with widths wider than four feet (4”) from the building with combustible exposed floor joists that were not protected with sprinkler heads, nor covered with a noncombustible or limited combustible construction material, located on the North exterior side of facility. During an interview on November 4, 2025, at 12:12 P.M., the Environmental Service Director said, we are still working on the coverage under the decks and will get with the Division of Fire Safety and Department of Health and Senior Services fo come up with a solution. Docurnent review of the following Sections of Chapter 5 of the 1999 Edition of National Fire Protection Association (NFPA) 13: 5-5.5.3.1 Sprinklers shall be installed under fixed Missouri Department of Health and Senior Services STATE FORM {A2268} 899 O6P213 PRINTED: 11/13/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED R 11/04/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 20551 E TRINITY PLACE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) If continuation sheet 2 of 3 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER 20551 E TRINITY PLACE BLUE SPRINGS, MO 64015 CEDARHURST OF BLUE SPRINGS SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {A2263}| Continued From page 2 {A2268} obstruction over four (4) feet (1.2m) wide such as ducts, decks, open grates flooring, cutting tables, and overhead doors. 5-13.8* Exterior Roofs or Canopies. 5-13.8.1 Sprinkler shail be installed under exterior roofs or canopies exceeding four (4) feet (1.2m) in width. Exception: Sprinklers are permitted to be ornitted where the canopy or roof is of noncornbustible or limited combustible construction. 5-13.8.2* Sprinklers shall be installed uncler roofs or canopies over areas where combustibles are stored and handled. Missouri Department of Health and Senior Services STATE FORM 899 O6P213 (X2) MULTIPLE CONSTRUCTION PRINTED: 11/13/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED R 11/04/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) lf continuation sheet 3 of 3

PRINTED: 10/17/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 31581 $$$ i$ 10/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 20551 E TRINITY PLACE BLUE SPRINGS, MO 64015 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE DATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY CEDARHURST OF BLUE SPRINGS 19 CSR 30-86.022(3)(D) Fire Extinguishers UL/FM, Maintain/Check Fire Extinguishers. (D) All fire extinguishers shall bear the label of the Underwriters ' Laboratories (UL) or the Factory Mutual (FM) Laboratories and shall be installed and maintained in accordance with NFPA 10, 1998 edition. This includes the documentation and dating of a monthly pressure check. II/III This regulation is not met as evidenced by: Class III Based on observations and an interview on 10/3/23 this facility failed to document and date all of the fire extinguishers being checked monthly. The facility census was seventy (70). This potentially affected seventy (70) of seventy (70) residents. Observations during the fire safety inspection walkthrough on 10/3/23 showed the extinguishers hadn 't had their monthly checks done for a couple of months. During an Interview on 10/3/23 at 11:42 A.M. the Environmental Services Director stated he/she was behind on checking them, but would get them all caught up. 19 CSR 30-86.022(4)(A)(1)(2) Range Hood-On or before 7/11/80 Range Hood Extinguishing Systems. (A) In facilities licensed on or before July 11, 1980, or in any facility with fewer than twenty-one (21) beds, the kitchen shall provide either: 1. An approved automatic range hood extinguishing system properly installed and Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM ea98 01X311 If continuation sheet 1 of 13 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 31581 NAME OF PROVIDER OR SUPPLIER 20551 E TRINITY PLACE CEDARHURST OF BLUE SPRINGS BLUE SPRINGS, MO 64015 SUMMARY STATEMENT OF DEFICIENCIES ID (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) TAG (X4) ID PREFIX TAG Continued From page 1 maintained in accordance with NFPA 96, 1998 edition; or 2. Aportable fire extinguisher of at least ten pounds (10 Ibs.) ABC-rated, or the equivalent, in the kitchen area in accordance with NFPA 10, 1998 edition. II/Ill This regulation is not met as evidenced by: Class Ill Based on observation, record review and interview on 10/3/23 this facility had failed to have the range hood extinguishing system maintained in accordance with NFPA 96, 1998 edition which in part requires the hood extinguishing system to be certified at least twice annually by a qualified person. The facility census was seventy (70). This potentially affected seventy (70) of seventy (70) residents. Observation on 10/3/23 at 12:50 P.M. showed an inspection tag on the hood extinguishing system dated March 2023. During an interview on 10/3/23 at 12:50 P.M. the Environmental Services Director stated the hood company was scheduled to come out this Friday. 19 CSR 30-86.022(5)(B)(1 - 10) Fire Drill/Evacuation Plan Requirements Fire Drills and Emergency Preparedness. (B) The plan shall include, but is not limited to, the following: 1. Aphased response ranging from relocation of residents to an immediate area within the facility; relocation to an area of refuge, if applicable; or to Missouri Department of Health and Senior Services STATE FORM 6899 01X311 (X2) MULTIPLE CONSTRUCTION PRINTED: 10/17/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/03/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY (x5) COMPLETE DATE If continuation sheet 2 of 13 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 31581 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 10/17/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/03/2023 STREET ADDRESS, CITY, STATE, ZIP CODE 20551 E TRINITY PLACE BLUE SPRINGS, MO 64015 CEDARHURST OF BLUE SPRINGS (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 total building evacuation. This phased response part of the plan shall be consistent with the direction of the local fire unit or state fire marshal and appropriate for the fire or emergency; 2. Written instructions for evacuation of each floor including evacuation to areas of refuge, if applicable, and a floor plan showing the location of exits, fire alarm pull stations, fire extinguishers, and any areas of refuge; 3. Evacuating residents, if necessary, from an area of refuge to a point of safety outside the building; 4. The location of any additional water sources on the property such as cisterns, wells, lagoons, ponds, or creeks; 5. Procedures for the safety and comfort of residents evacuated; 6. Staffing assignments; 7. Instructions for staff to call the fire department or other outside emergency services; 8. Instructions for staff to call alternative resource(s) for housing residents, if necessary; 9. Administrative staff responsibilities; and 10. Designation of a staff member to be responsible for accounting for all residents ' whereabouts. II/III This regulation is not met as evidenced by: Class III Based on record review and interview on 10/3/23 this facility failed to produce a written plan for fire evacuation and drills that included responding to and using the areas of refuge. The facility census was seventy (70). This potentially affected seventy (70) of seventy (70) residents. Observation on 10/3/23 at 1:23 P.M. when the Missouri Department of Health and Senior Services STATE FORM 6899 ID PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY 01X311 If continuation sheet 3 of 13 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 31581 NAME OF PROVIDER OR SUPPLIER 20551 E TRINITY PLACE BLUE SPRINGS, MO 64015 SUMMARY STATEMENT OF DEFICIENCIES ID (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CEDARHURST OF BLUE SPRINGS (X4) ID PREFIX TAG Continued From page 3 area of refuge button was tested there was no immediate response from the facility personnel. The fire alarm monitoring company did call the facility and indicated there was a supervisory signal from a kitchen duct detector fault. Observation on 10/3/23 at 1:39 P.M. further showed when the area of refuge button was reset down stairs at the main panel the duct detector fault code also cleared up. During an interview on 10/3/23 at 1:39 P.M. the Environmental Services Director stated he/she would look into finding or establishing a response and usage procedure for the areas of refuge and check with the fire alarm company to see whether the areas of refuge notifications are programmed wrong in the fire alarm system. 19 CSR 30-86.022(5)(D) Fire Drill Requirements, Evacuation Fire Drills and Emergency Preparedness. (D) A minimum of twelve (12) fire drills shall be conducted annually with at least one (1) every three (3) months on each shift. At least four (4) of the required fire drills must be unannounced to residents and staff, excluding staff who are assigned to evaluate staff and resident response to the fire drill. The fire drills shall include a resident evacuation at least once a year. IlI/Ill This regulation is not met as evidenced by: Class III Based on record review and interview on 10/3/23 this facility failed to produce documentation of at Missouri Department of Health and Senior Services STATE FORM 6899 01X311 (X2) MULTIPLE CONSTRUCTION PRINTED: 10/17/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/03/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY (x5) COMPLETE DATE If continuation sheet 4 of 13 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 31581 NAME OF PROVIDER OR SUPPLIER 20551 E TRINITY PLACE BLUE SPRINGS, MO 64015 SUMMARY STATEMENT OF DEFICIENCIES ID (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CEDARHURST OF BLUE SPRINGS (X4) ID PREFIX TAG Continued From page 4 least 12 fire drills being conducted within the last year, the facility further failed to produce documentation of at least one fire drills being conducted on each shift every three months within the last year and the facility failed to include at least one resident evacuation during the last 12 months. The facility census was seventy (70). This potentially affected seventy (70) of seventy (70) residents. Record review on 10/3/23 at 3:50 P.M. showed no scheduled fire drills recorded for the last year. During an interview on 10/3/23 at 3:50 P.M. the Environmental Services Director stated he/she was hired in May of 2022 and had not done any scheduled fire drills. He/she further stated he/she would look up the state rules and become familiar with all the requirements, that the facility didn ' t have an Environmental Services Director for almost six months before he/she started. 19 CSR 30-86.022(7)(D)(1 - 8) Area of Refuge Requirements Exits, Stairways, and Fire Escapes. (D) An " area of refuge " shall have- 1. An area separated by one- (1-) hour rated smoke walls, from the remainder of the building. This area must have direct access to the exit stairway or access the stair through a section of the corridor that is separated by smoke walls from the remainder of the building. This area may include no more than two (2) resident rooms; 2. A two- (2-) way communication or intercom system with both visible and audible signals between the area of refuge and the bottom landing Missouri Department of Health and Senior Services STATE FORM 6899 01X311 (X2) MULTIPLE CONSTRUCTION PRINTED: 10/17/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/03/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY (x5) COMPLETE DATE If continuation sheet 5 of 13 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 31581 NAME OF PROVIDER OR SUPPLIER 20551 E TRINITY PLACE CEDARHURST OF BLUE SPRINGS BLUE SPRINGS, MO 64015 SUMMARY STATEMENT OF DEFICIENCIES ID (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) TAG (X4) ID PREFIX TAG Continued From page 5 of the exit stairway, attendants’ work area, or other primary location as designated in the written plan for fire drills and evacuation; 3. Instructions on the use of the area during emergency conditions that are located in the area of refuge and conspicuously posted adjoining the communication or intercom system; 4. Asign at the entrance to the room that states AREA OF REFUGE IN CASE OF FIRE" and displays the international symbol of accessibility; 5. An entry or exit door that is at least a one and three-fourths inch (1 3/4") solid core wood door or has a fire protection rating of not less than twenty (20) minutes with smoke seals and positive latching hardware. These doors shall not be lockable; 6. Asign conspicuously posted at the bottom of the exit stairway with a diagram showing each location of the areas of refuge; 7. Emergency lighting for the area of refuge; and 8. The total area of the areas of refuge on a floor shall equal at least twenty (20) square feet for each resident who is blind or requires the use of a wheelchair or walker housed on the floor. II This regulation is not met as evidenced by: Class II Based on observations and an interview on 10/3/23 this facility failed to post proper signage "AREA OF REFUGE IN CASE OF FIRE" and display the international symbol of accessibility at the entrances for the areas of refuge. This facility further failed to have instructions on the use of the area during emergency conditions that are located in the area of refuge and conspicuously posted adjoining the communication or intercom system Missouri Department of Health and Senior Services STATE FORM 6899 01X311 (X2) MULTIPLE CONSTRUCTION PRINTED: 10/17/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/03/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY (x5) COMPLETE DATE If continuation sheet 6 of 13 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 31581 NAME OF PROVIDER OR SUPPLIER 20551 E TRINITY PLACE BLUE SPRINGS, MO 64015 SUMMARY STATEMENT OF DEFICIENCIES ID (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CEDARHURST OF BLUE SPRINGS (X4) ID PREFIX TAG Continued From page 6 on the second floor. The facility census was seventy (70). This potentially affected seventy (70) of seventy (70) residents. Observations during the fire safety inspection walkthrough on 10/3/23 showed no signage on the corridor doors that separate the two areas of refuge from the rest of the corridor on the second floor. There were also no instructions for use posted in the corridor by the area or refuge intercom panels. During an interview on 10/3/23 at 1:39 P.M. the Environmental Services Director stated he/she would get the appropriate signs up on the area of refuge doors and get usage instructions and procedures posted by the corridor intercom panels. 19 CSR 30-86.022(9)(E) Fire Alarm System Monthly Test Complete Fire Alarm Systems. (E) Facilities shall test by activating the complete fire alarm system at least once a month. 1/Il This regulation is not met as evidenced by: Class II Based on record review and an interview on 10/3/23 this facility failed to show proof they had activated the fire alarm system at least once each and every month. The facility census was seventy (70). This potentially affected seventy (70) of seventy (70) residents. Record review on 10/3/23 at 3:50 P.M. showed no Missouri Department of Health and Senior Services STATE FORM 6899 01X311 (X2) MULTIPLE CONSTRUCTION PRINTED: 10/17/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/03/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY (x5) COMPLETE DATE If continuation sheet 7 of 13 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 31581 NAME OF PROVIDER OR SUPPLIER 20551 E TRINITY PLACE BLUE SPRINGS, MO 64015 SUMMARY STATEMENT OF DEFICIENCIES ID (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CEDARHURST OF BLUE SPRINGS (X4) ID PREFIX TAG Continued From page 7 scheduled monthly fire alarm system activations recorded. During an interview on 10/3/23 at 3:50 P.M. the Environmental Services Director stated he/she was hired in May of 2022 and had not done any scheduled fire alarm activations. He/she further stated he/she would look up the state rules and become familiar with all the requirements, that the facility didn ' t have an Environmental Services Director for almost six months before he/she started. 19 CSR 30-86.022(10)(C) Clothes Dryers Vented, Lint Traps Protection from Hazards. (C) Electric or gas clothes dryers shall be vented to the outside. Lint traps shall be cleaned regularly to protect against fire hazard. II/III This regulation is not met as evidenced by: Class Ill Based on observation and an interview on 10/3/23 this facility failed to keep the dryer vent hose attached and in good repair so it could properly vent outside. The facility census was seventy (70). This potentially affected seventy (70) of seventy (70) residents. Observation on 10/3/23 at 11:56 A.M. showed noticeable lint build up behind a dryer located in the Memory Cares laundry area. Further observation showed the dryer vent hose detached from the back of one of the clothes dryers. Missouri Department of Health and Senior Services STATE FORM 6899 01X311 (X2) MULTIPLE CONSTRUCTION PRINTED: 10/17/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/03/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY (x5) COMPLETE DATE If continuation sheet 8 of 13 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 31581 NAME OF PROVIDER OR SUPPLIER 20551 E TRINITY PLACE BLUE SPRINGS, MO 64015 SUMMARY STATEMENT OF DEFICIENCIES ID (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CEDARHURST OF BLUE SPRINGS (X4) ID PREFIX TAG Continued From page 8 During an interview on 10/3/23 at 11:56 A.M. the Environmental Services Director stated he/she would get the hose hooked back up, that they have a problem of the dryers walking out and pulling the hoses loose. 19 CSR 30-86.022(10)(F) Atriums Protection from Hazards. (F) Atriums open between floors will be permitted if resident room corridors are separated from the atrium by one- (1-) hour rated smoke walls. These corridors must have access to at least one (1) of the required exits without traversing any space opened to the atrium. II This regulation is not met as evidenced by: Class II Based on observation and interview on 10/3/23 this facility failed to ensure the door providing separation between the resident's rooms and the atrium was closing fully to provide a one- (1-) hour rated smoke separation. The facility census was seventy (70). This potentially affected seventy (70) of seventy (70) residents. Observation on 10/3/23 at 1:32 P.M. showed the Atrium smoke separation door by Room 201 not closing and latching properly. During an interview on 10/3/23 at 1:32 P.M. the Environmental Services Director stated he/she would get the doors adjusted so they would properly close and latch. Missouri Department of Health and Senior Services STATE FORM 6899 01X311 (X2) MULTIPLE CONSTRUCTION PRINTED: 10/17/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/03/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY (x5) COMPLETE DATE If continuation sheet 9 of 13 PRINTED: 10/17/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 31581 $$$ i$ 10/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 20551 E TRINITY PLACE BLUE SPRINGS, MO 64015 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE DATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY CEDARHURST OF BLUE SPRINGS Continued From page 9 19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing Sprinkler Systems. (B) Facilities that have a sprinkler system installed prior to August 28, 2007, shall inspect, maintain, and test these systems in accordance with the requirements that were in effect for such facilities on August 27, 2007. I/Il This regulation is not met as evidenced by: Class II Based on observation, interview and record review on 10/3/23 this facility failed to record monthly pressure gage readings and valve position checks of the sprinkler system. The facility census was seventy (70). This potentially affected seventy (70) of seventy (70) residents. Observation on 10/3/23 at 12:12 P.M. showed no monthly sprinkler valve check sheets in the sprinkler room or on the annual tags on the sprinkle riser. Record review on 10/3/23 at 3:50 P.M. showed no records or indication monthly valve position and pressure gauge readings were being done. During an interview on 10/3/23 at 3:50 P.M. the Environmental Services Director stated he/she would put together a sheet to hang in the sprinkler riser room and start doing the monthly checks. 19 CSR 30-86.022(13)(D) Curtains/Drapes, Flame Resistant Missouri Department of Health and Senior Services STATE FORM oeee 01X311 If continuation sheet 10 of 13 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 31581 NAME OF PROVIDER OR SUPPLIER 20551 E TRINITY PLACE BLUE SPRINGS, MO 64015 SUMMARY STATEMENT OF DEFICIENCIES ID (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CEDARHURST OF BLUE SPRINGS (X4) ID PREFIX TAG Continued From page 10 Interior Finish and Furnishings. (D) All curtains and drapes in a licensed facility shall be certified or treated to be flame-resistant as defined in NFPA 101, 2000 edition. II This regulation is not met as evidenced by: Class II Based on observation, and interview on 10/3/23 this facility failed to insure certified flame-retardant curtains or chemically treat ones with a flame retardant were going to be used. The facility census was seventy (70). This potentially affected seventy (70) of seventy (70) residents. Observation on 10/3/23 at 12:12 P.M. showed some large curtains laying on the floor inside the sprinkler riser room. During an interview on 10/3/23 at 12:12 P.M. the Environmental Services Director stated he/she was not aware the curtains had to be flame retardant and was getting ready to purchase new curtains for the dining room. He/she stated he/she would be sure to get the proper curtains. 19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements Trash and Rubbish Disposal. (A) Only metal or UL- or FM-fire-resistant rated wastebaskets shall be used for trash. II This regulation is not met as evidenced by: Class II Based on observation and interview on 10/3/23 this Missouri Department of Health and Senior Services STATE FORM 6899 01X311 (X2) MULTIPLE CONSTRUCTION PRINTED: 10/17/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/03/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY (x5) COMPLETE DATE If continuation sheet 11 of 13 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 31581 NAME OF PROVIDER OR SUPPLIER 20551 E TRINITY PLACE BLUE SPRINGS, MO 64015 SUMMARY STATEMENT OF DEFICIENCIES ID (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CEDARHURST OF BLUE SPRINGS (X4) ID PREFIX TAG Continued From page 11 facility failed to insure all of the wastebaskets were the approved types allowed. The facility census was seventy (70). This potentially affected seventy (70) of seventy (70) residents. Observations during the fire safety inspection walkthrough on 10/3/23 showed the following rooms with un-approved types in them, many of which were removed but not replaced at the time of inspection; Room 117 had one, Room 102 had one, Room 104 had three, Room 213 had two, Room 212 had one, Room 216 had two, Room 227 had one, Room 223 had two and Room 220 had one. During an interview on 10/3/23 at 12:16 P.M. the Environmental Services Director stated he/she would get all of them replaced and discuss with house keeping on what to check for to ensure the wrong ones are not used again. 19 CSR 30-86.022(17) Oxygen Storage Requirements Oxygen storage shall be in accordance with NFPA 99, 1999 Edition. II/III This regulation is not met as evidenced by: Class Ill Based on observation and interview on 10/3/23 this facility failed to provide a proper oxygen storage room in accordance with NFPA 99, 1999 Edition, which requires a constantly on ventilation fan. The Missouri Department of Health and Senior Services STATE FORM 6899 01X311 (X2) MULTIPLE CONSTRUCTION PRINTED: 10/17/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/03/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY (x5) COMPLETE DATE If continuation sheet 12 of 13 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 31581 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 10/17/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/03/2023 STREET ADDRESS, CITY, STATE, ZIP CODE 20551 E TRINITY PLACE BLUE SPRINGS, MO 64015 CEDARHURST OF BLUE SPRINGS (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) A2298 | Continued From page 12 facility census was seventy (70). This potentially affected seventy (70) of seventy (70) residents. Observation on 10/3/23 at 11:58 A.M. showed the oxygen storage had no ventilation fan within it. During an interview on 10/3/23 at 11:58 A.M. the Environmental Services Director stated he/she would see about getting a fan installed into the room. Missouri Department of Health and Senior Services STATE FORM 6899 ID PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY 01X311 If continuation sheet 13 of 13 PLAN OF CORRECTION Provider/Supplier CEDARHURST OF BLUE SPRINGS Name: Street Address, 20551 E TRINITY PLACE City, Zip: BLUE SPRINGS, MO 64015 Date of Survey: 10/3/2023 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 26D2173029 ID PREFIX TAG A2210 A2211 PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE Fire extinguishers UL/FM, Maintain/Checks Based on observations and an interview on 10/3/23 this facility failed to document and date all of the fire extinguishers being checked monthly. The facility census was seventy (70). This potentially affected seventy (70) of seventy (70) residents. All fire extinguishers checked by ESD/designee and 10/6/23 documented completed by 10/6/23. Then all fire extinguishers will be checked by ESD/designee by the 5' of every month going forward. Outlook calendar alarm set up and in place to alert ESD/designee the 5" of every month to check each extinguisher within the community. Range hood Based on observation, record review and interview on 10/3/23 this facility had failed to have the range hood extinguishing system maintained in accordance with NFPA 96, 1998 edition which in part requires the hood extinguishing system to be certified at least twice annually by a qualified person. The facility census was seventy (70). This potentially affected seventy (70) of seventy (70) residents. 10/6/23 Range hood suppression system check completed by Prodigy Fire Systems by 10/6/23. Then range haad suppression system check will be completed by April 30 and October 30 annually. Outlook calendar alarm set up and in place to alert ESD/designee the first of the month due. A2217 Fire drill/Evacuation plan Based on record review and interview on 10/3/23 this facility failed to produce a written plan for fire evacuation and drills that included responding to and using the areas of refuge. The 40/25/23 facility census was seventy (70). This potentially affected seventy (70) of seventy (70) residents. See attached policy and procedure Fire drill requirements, evacuation 10/25/23 A2228 Based on record review and interview on 10/3/23 this facility failed to produce documentation of at least 12 fire drills being conducted within the last year, the facility further failed to produce documentation of at least one fire drills being conducted on each shift every three months within the last year and the facility failed to include at least one resident evacuation during the last 12 months. The facility census was seventy (70). This potentially affected seventy (70) of seventy (70) residents. Fire drill completed by ESD/designee and documented by 10/25/23. Then fire drill will be completed by the end of every month with alternating shift times to ensure fire drill being conducted on each shift every three months, completed by EDS/designee. At least one fire drill will include resident evacuation annually. Outlook calendar alarm set up and in place to alert ESD/designee the first and end of every month to complete fire drills. Qullook calendar alarm set up and in place to alert ESD/designee at the first and end of every month to ensure fire drill set up and confirm alternating shift. Area of refuge Based on observations and an interview on 10/3/23 this facility failed to post proper signage "AREA OF REFUGE IN CASE OF FIRE" and display the international symbol cf accessibility at the entrances for the areas of refuge. This facility further failed to have instructions on the use of the area during emergency conditions that are located in the area of refuge and conspicuously posted adjoining the communication or intercom system on the second floor. The facility census was seventy (70). This potentially affected seventy (70) of seventy (70) residents. 10/27/23 Area of Refuge Sign posted on corridor door stating "Area of refuge in case of fire” A2251 Fire alarm system monthly test Based on record review and an interview on 10/3/23 this facility failed to show proof they had activated the fire alarm system at least once each and every month. The facility census was seventy (70). This potentially affected seventy (70) of seventy (70) residents. Fire alarm system activation completed by ESD/designee and documented by 10/25/23. Then fire alarm system test will be completed during or just after fire drill that will be completed by the end of every month completed by EDS/designee. Outlook calendar alarm set up and in place to alert ESD/designee at the first and end of every month to ensure fire alarm system activation was completed. 10/25/23 A2258 | Clothes Dryers Vented, Lint Traps Based on observation and an interview on 10/3/23 this facility 10/6/23 failed to keep the dryer vent hose attached and in good repair so — it could properly vent outside. The facility census was seventy (70). This potentially affected seventy (70) of seventy (70) residents. All dryer vent hoses checked for attachment and in good repair completed by ESD/designee by 10/6/23. Then dryer vent hoses will be checked monihly for attachment and in good repair by the end of every month by ESD/designee. Outlook calendar alarm set up and in place to alert ESD/designee at the end of every month to alert ESD/designee to complete monthly dryer vent checks. Atriums Based on observation and interview on 10/3/23 this facillty falled to ensure the door providing separation between the resident's rooms and the atrium was closing fully to provide a one- (1-) hour rated smoke separation. The facility census was seventy (70). This potentially affected seventy (70) of seventy (70) residents. mene All fire doors checked for proper closure completed by ESD/designee by 10/6/23. All fire doors will be checked monthly for proper closure by ESD/designee by the end of every month. Outlook calendar alarm set up and in place to alert ESD/designee at the end of every month to complete fire door closure checks. 10/6/23 Sprinkler System Maintenance/Testing Based on observation, interview and record review on 10/3/23 this facility failed to record monthly pressure gage readings and valve position checks of the sprinkler system. The facility census was seventy (70). This potentially affected seventy (70) of seventy (70) residents. Recording of pressure gauge and valve position check completed by 10/6/23 by ESD/designee. Then pressure gauge and valve position checks to be performed monthly by ESD/designee by the end of every month. Outlook calendar alarm set up and in place to alert ESD/designee at the end of every month to complete pressure gauge and valve position checks. A2269 10/6/23 Curtains/Drapes, Flame Resistant Based on observation, and interview on 10/3/23 this facility failed to insure certified flame-retardant curtains or chemically treat ones with a flame retardant were going to be used. The A2282 facility census was seventy (70). This potentially affected seventy (70) of seventy (70) residents. Forcefield Fire Spray purchased. | A2286 Wastebaskets 10/6/23 Based on observation and interview on 10/3/23 this facility failed to insure all of the wastebaskets were the approved types allowed. The facility census was seventy (70). This potentially affected seventy (70) of seventy (70) residents. All wastebaskets checked to ensure they are the approved types allowed completed by 10/6/23 by ESD/designee. Then room checks to be completed monthly to ensure that all wastebaskets are of the approved types by the end of every month by ESD/designee. Outlook calendar alarm set up and in place to alert ESD/designee at the end of every month to complete wastebasket checks. Oxygen Storage Based on observation and interview on 10/3/23 this facility failed to provide a proper oxygen storage room in accordance with NFPA 99, 1999 Edition, which requires a constantly on ventilation fan. The facility census was seventy (70). This 10/25/23 potentially affected seventy (70) of seventy (70) residents. PM Contracting completed installation of oxygen storage room ventilation fan on 10/25/23. The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approval of the plan of correction being submitted on this form.