CEDARHURST OF COLUMBIA.

PRINTED: 08/12/2024 FORM APPROVED (X1) PROVIDER/SUPPLIERICLIA. IDENTIFICATION NUMBER STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X2} MULTIPLE CONSTRUCTION ABULOING (X3) DATE SURVEY COMPLETED Cc 08/01/2024 29874 BWING NAME OF PROVIDER OR SUPPLIER STREET ADORESS. CITY. STATE. ZIP CONE 2333 CHAPEL HILL ROAD CEDARHURST OF COLUMBIA COLUMBIA, MO 85203 (x4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION 5 PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PRErIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR (SC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A4778 19 CSR 30-86.047(37} Appropriate Action & ASTTB Notification i in case of behaviors that present a reasonable iikelihood of serious harm to himseff or herself or others, serious iliness, significant change in condition, injury or death, staff shail take appropriate action and shall promptly attempt to contact the person listed in the resident's record as the legally authorized representative, designee or placement authority. The facility shall contact — the attending physician or designee and notify the | local corones or medical examiner immediately upon the death of any resident of the facility prior ; to transferring the deceased resident to a funeral | home. if! ; This regulation is not met as evidenced by: Class Hi Based on interview and record review, facility staff faited to notify one resident (Resident #1) family member when the resident had a fall with injury. The facility census was 83. 1. Review of the facility policy titled, "Fall Risk,” undated, showed facility staff were directed to notify the family when a resident falls. 2. Review of Resident # 1's medical racord : showed the rasident admitted to the facility on i 11/22/21 with diagnoses of osteoporosis : (decreased bone density), osteoarthritis difficulty | walking, muscle weakness, and low back pain. Review showed the residents family member to be contacted first. Review of the residents individual service plan, dated 01/09/24, shawed staff assessed the resident with a history of falls and at risk for fails. tgsoun Oepartment of Health and Server Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE {X6} DATE 4 contauatas sheel tofd Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER CEDARHURST OF COLUMBIA (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) PRINTED: 11/12/2024 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED Cc 08/01/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 2333 CHAPEL HILL ROAD COLUMBIA, MO 65203 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A4778 19 CSR 30-86.047(37) Appropriate Action & Notification In case of behaviors that present a reasonable likelihood of serious harm to himself or herself or others, serious illness, significant change in condition, injury or death, staff shall take appropriate action and shall promptly attempt to contact the person listed in the resident ' s record as the legally authorized representative, designee or placement authority. The facility shall contact the attending physician or designee and notify the local coroner or medical examiner immediately upon the death of any resident of the facility prior to transferring the deceased resident to a funeral home. I/II This regulation is not met as evidenced by: Class II Based on interview and record review, facility staff failed to notify one resident (Resident #1) family member when the resident had a fall with injury. The facility census was 83. 1. Review of the facility policy titled, "Fall Risk,” undated, showed facility staff were directed to notify the family when a resident falls. 2. Review of Resident # 1's medical record showed the resident admitted to the facility on 11/22/21 with diagnoses of osteoporosis (decreased bone density), osteoarthritis difficulty walking, muscle weakness, and low back pain. Review showed the residents family member to be contacted first. Review of the residents individual service plan, dated 01/09/24, showed staff assessed the resident with a history of falls and at risk for falls. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 9H9011 If continuation sheet 1 of 3 PRINTED: 11/12/2024 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 Cc 08/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2333 CHAPEL HILL ROAD COLUMBIA, MO 65203 (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 COLUMBIA Continued From page 1 Review of the resident's nurse notes, dated 07/28/24 at 1:38 A.M., showed staff documented an incident report created for an unwitnessed fall. Review of the resident's incident report, dated 07/28/24 at 2:28 A.M., showed facility staff documented they walked past the residents room and found the resident on the floor with a "big" bump on the residents back of head. Review showed staff documented the resident said he/she did not want to go to the hospital. Review showed staff documented they did not call family or representative and did have an injury. Review of the resident's nurses notes, dated 07/28/24 at 8:45 P.M., showed facility staff documented the resident with more confusion. During an interview on 08/01/24 at 2:20 P.M., shift manager A said he/she was in the facility at the time of incident. He/She said Level One Medication Aide (L1MA) B was instructed to contact the family before the end of the night shift assignment. He/She said L1MAB had affirmed he/she would contact the family. During an interview on 08/01/24 at 2:28 P.M., the interim Director of Nursing said he/she was notified the resident fell at 1:38 A.M. on 07/28/24. He/She said the post fall monitoring policy instructs facility staff to notify the family when a resident falls. During an interview on 08/01/24 at 2:56 P.M., L1MAB said on 07/28/24 around 1:40 A.M., found the resident on the floor. L1MAB said the resident had a big bump on the back of his/her head. He/She said the resident did not want to go to the hospital. He/She said shift manager A instructed him/her to contact the family. L1MAB Missouri Department of Health and Senior Services STATE FORM 6899 9H9011 If continuation sheet 2 of 3 PRINTED: 11/12/2024 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 Cc 08/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2333 CHAPEL HILL ROAD COLUMBIA, MO 65203 (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 COLUMBIA Continued From page 2 said the family was not contacted during the shift because the shift got busy in the morning. During an interview on 08/01/24 at 3:20 P.M., the administrator said he/she had spoken to the residents family member and the family member was not contacted regarding the resident's fall until 07/29/24, when the resident was sent to the hospital for evaluation related to increased confusion and the bump on the resident's head. He/She said L1MA B was the facility staff person who was responsible for family notification of the residents fall that occurred on 07/28/24 at 1:38 A.M. M000239749 Missouri Department of Health and Senior Services STATE FORM 6899 9H9011 If continuation sheet 3 of 3 PLAN OF CORRECTION Provider/Supptier Name: Cedarhurst of Columbia Street Address, City, Zip: 2333 Chapel Hil Rd Columbia, MO 65203 Date of Survey: | 8/1/2024 PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER ttisher erent JOPREFIXTAG , PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION | COMPLETION ‘i. i SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) «DATE ' | A Clinical staff in-service completed to review the Accidents & i ' AA77B } H 4 ——— .....)./Mtidents Policy and Procedure — 2 eave i | On-Call procedure reviewed and revised to streamiine communications of falis and incidents with attention to overnight hours. On-Call ceil phone number provided to all staff for ; Feporting of incidents. it is the responsibility of the reporting staff : Member on duty fo make an inthal notification to the resident's |; i | lagally authorized representative, designee, or piacemnent | j AAT76 , authority. On-Call clinical manager to keep log of calis received a/15/2024 | | gnd follow up needed. Call log wil be reviewed at daily stand up | meetings to facilitate communications and delegate a second follow up call with the resident's representative to a manager. { On call clinical managers inciude: Director of Nursing, Memory | ‘ | Care Director, and Resident Care Manager. If the on calt | eeaneigtie ts not the Director of Ping the manager on cali will The iirnindiaine signing and dating the first page of the CMS-2567/State Farm Is pacating thelr approval of the plan of correction being submitted on this form.

Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER CEDARHURST OF COLUMBIA (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) PRINTED: 01/11/2024 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED 12/29/2023 STREET ADDRESS, CITY, STATE, ZIP CODE 2333 CHAPEL HILL ROAD COLUMBIA, MO 65203 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 19 CSR 30-86.022(2)(D) Inspection Rights, No Fire Hazard General Requirements. (D) The department shall have the right of inspection of any portion of a building in which a licensed facility is located unless the unlicensed portion is separated by two- (2-) hour fire-resistant construction. No section of the building shall present a fire hazard. I/II This regulation is not met as evidenced by: Class II Based on observation and interview on December 29, 2023 the facility failed to keep the facility in a condition to not present a fire hazard. The facility census was eighty two. This deficiency affects eighty two of eighty two residents. Observation at 10:28 A.M. showed the vent tube for the clothes dryer in basement laundry room was ripped half way open near the top of the vent. The vent tube being damaged allows lint and heat from the dryer to vent directly into the laundry area. Observation at 10:48 A.M. showed the fire doors leading into the memory care side of the building did not fully close and latch on their own. Observation at 1:20 P.M. showed the fire doors seperating the theater assembly room fom the care facility did not fully close and latch on their own. During an interview at 3:00P.M. the maintenance manager stated he was not aware the vent tube was damaged and would get it fixed as soon as Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 S2ZW11 If continuation sheet 1 of 18 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 2333 CHAPEL HILL ROAD CEDARHURST OF COLUMBIA COLUMBIA, MO 65203 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 possible. He also stated he would make adjustments to both sets of fire doors that needed to close and latch properly. 19 CSR 30-86.022(3)(C)(1)(2) Fire Extinguishers-Rating Fire Extinguishers. (C) Fire extinguishers shall have a rating of at least: 1. Ten pounds (10 Ibs.), ABC-rated or the equivalent, in or within fifteen feet (15') of hazardous areas as defined in 19 CSR 30-83.010; and 2. Five pounds (5 Ibs.), ABC-rated or the equivalent, in other areas. II This regulation is not met as evidenced by: Class III Based on observation and interview on December 29, 2023, the facility failed to ensure fire extinguishers shall have a rating of at least ten pounds (10 Ibs.), ABC-rated or the equivalent, in or within fifteen feet (15') of the laundry room or any hazardous areas as defined in 19 CSR 30-83.010. Entinguishers shall be five pounds (5 Ibs.), ABC-rated or the equivalent, in other areas. The facility census was 82. This deficiency affects 82 out of 82 residents. Observation at 1:21 P.M., showed a fire entinguisher that was less than five pounds mounted in the fitness room on the second floor. During an interview, at the time of discovery, it was determined that a second extinguisher was not required in this area and this smaller one could be removed and no longer maintained. Missouri Department of Health and Senior Services STATE FORM 6899 S2ZW11 PRINTED: 01/11/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 12/29/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 2 of 18 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 2333 CHAPEL HILL ROAD CEDARHURST OF COLUMBIA COLUMBIA, MO 65203 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) 19 CSR 30-86.022(5)(A) Fire Drill/Evacuation Plan, Consultation Fire Drills and Emergency Preparedness. (A) All facilities shall have a written plan to meet potential emergencies or disasters and shall request consultation and assistance annually from a local fire unit for review of fire and evacuation plans. If the consultation cannot be obtained, the facility shall inform the state fire marshal in writing and request assistance in review of the plan. An up-to-date copy of the facility 's entire plan shall be provided to the local jurisdiction 's emergency management director. I/II This regulation is not met as evidenced by: Class III Based on records review and interview, during the the fire safety inspection on December 29, 2023 the facility failed to request consultation and assistance annually or provide documentation the consultation had been scheduled from the local fire unit for review of fire and evacuation plans. The facility census was eighty two. This deficiency affects eighty two of eighty two residents. Record review at 2:00 P.M., showed no record of the Fire Department consultation being completed, or requested from the local fire department. During an interview on at 3:00 P.M., the maintenance director stated he will inform the owner of the violation and call to get a local inspection scheduled. 19 CSR 30-86.022(5)(D) Fire Drill Requirements, Missouri Department of Health and Senior Services STATE FORM 6899 S2ZW11 PRINTED: 01/11/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 12/29/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 3 of 18 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 2333 CHAPEL HILL ROAD CEDARHURST OF COLUMBIA COLUMBIA, MO 65203 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 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. II/Ill This regulation is not met as evidenced by: Class III Based on records review and an interview during the fire safety portion of the licensure inspection on December 29, 2023. The facility management failed to conduct one fire drill monthly for the past twelve months, with one being on each shift every three months and two full evacuations performed. The facility census on December 29, 2023 was eighty two. This violaion affects eighty two of eighty two residents. Records review at 2:00 P.M. showed no fire drills were performed or recorded for the months of January through June as well as the month of December 2023. (refer to fire drill list on inspection records) Records review at 2:00 P.M. showed, two full evacuation drills were not executed in the past twelve months. Only one full evacuation was performed and recorded during the July 2023 drill. During the exit interview at 3:00 P.M., the maintinance manager stated he had just started this job aproximately six months prior to this Missouri Department of Health and Senior Services STATE FORM 6899 S2ZW11 PRINTED: 01/11/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 12/29/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 4 of 18 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 2333 CHAPEL HILL ROAD CEDARHURST OF COLUMBIA COLUMBIA, MO 65203 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 inspection and was not sure why the previouse maintinance manager did not record the drills. 19 CSR 30-86.022(6)(A)(1 - 3) Fire Safety Training Requirements-employees Fire Safety Training Requirements. (A) The facility shall ensure that fire safety training is provided to all employees: 1. During employee orientation; 2. At least every six (6) months; and 3. When training needs are identified as a result of fire drill evaluations. II/III This regulation is not met as evidenced by: Class III Based on record review and interview on December 29, 2023 the facility failed to complete employee fire safety training upon initial hiring and/or at least every six months. The facility census was eighty two. This deficiency affects eighty two of eighty two residents. Record review on December 29, 2023 at 2:00 P.M. showed no records of required employee fire safety training being completed in the past 6 months. No documentation was located showing the employees had any fire safety training after their original orientation training. During an interview at 3:00 P.M. the maintenance director stated he did not recieve any previosly logged paperwork after he started at this location approximately 6 months prior to this inspection, therfore the only records he has is the ones he has logged since starting. He stated he will make note of the violation and begin the training sessions. Missouri Department of Health and Senior Services STATE FORM 6899 S2ZW11 PRINTED: 01/11/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 12/29/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 5 of 18 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 2333 CHAPEL HILL ROAD CEDARHURST OF COLUMBIA COLUMBIA, MO 65203 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG 19 CSR 30-86.022(9)(D) Fire Alarm System Inspections/Certifications Complete Fire Alarm Systems. (D) All facilities shall have inspections and written certifications of the complete fire alarm system completed by an approved qualified service representative in accordance with NFPA 72, 1999 edition, at least annually. I/II This regulation is not met as evidenced by: Class II Based on record review and interview during a fire safety inspection on Decemeber 29, 2023 the facility failed to insure the complete fire alarm system was tested and maintained in accordance with National Fire Protection Association (NFPA) 72, 1999 ed. All facilities shall have inspections and written certifications of the complete fire alarm system completed by an approved qualified service representative at least annually. Thorough visual inspections and physical testing of the fire alarm systems components must occur weekly, monthly, quarterly, semi-annually, annually, every five and ten years according to NFPA statndards. The facility census was eighty two. This deficiency affects eighty two of eighty two residents as well as all employees. Records review at 2:00 P.M. showed the monthly fire alarm system testing documentation had not been kept for and entire year. Only the five months of logged fire drill records showed when the system had been tested. Record review at 2:00 P.M., showed no annual inspection had been done on the fire alarm system as required by National Fire Protection Association (NFPA) 72, 1999 ed. Table 7-3.1. The last semi-annual alarm test was performed on Missouri Department of Health and Senior Services STATE FORM 6899 S2ZW11 PRINTED: 01/11/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 12/29/2023 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 18 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 2333 CHAPEL HILL ROAD CEDARHURST OF COLUMBIA COLUMBIA, MO 65203 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 6 June 28, 2023. During an interview at 3:00 P.M. the Maintenance director stated he recieved no prior paperwork from before his hire date aproximately six months prior to this inspection date. He also stated he would let management know of the violations. 19 CSR 30-86.022(10)(A) Hazardous Area Requirements Protection from Hazards. (A) In assisted living facilities and residential care facilities licensed on or after November 13, 1980, for more than twelve (12) beds, hazardous areas shall be separated by construction of at least a one- (1-) hour fire-resistant rating. In facilities equipped with a complete fire alarm system, the one- (1-) hour fire separation is required only for furnace or boiler rooms. Hazardous areas equipped with a complete sprinkler system are not required to have this one- (1-) hour fire separation. Doors to hazardous areas shall be self-closing and shall be kept closed unless an electromagnetic hold-open device is used which is interconnected with the fire alarm system. When the sprinkler option is chosen, the areas shall be separated from other spaces by smoke-resistant partitions and doors. The doors shall be self-closing or automatic-closing. Facilities formerly licensed as residential care facility | or Il, and existing prior to November 13, 1980, shall be exempt from this requirement. II This regulation is not met as evidenced by: Class II Based on observation and interview on December 29, 2023, the facility failed to ensure Missouri Department of Health and Senior Services STATE FORM 6899 S2ZW11 PRINTED: 01/11/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 12/29/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 7 of 18 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 2333 CHAPEL HILL ROAD CEDARHURST OF COLUMBIA COLUMBIA, MO 65203 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 7 that doors to hazardous areas shall be self-closing and shall be kept closed unless an electromagnetic hold-open device is used which is interconnected with the fire alarm system, and that the storage of unnecessary combustible materials in any part of a building in which a licensed facility is located is prohibited. The facility census was 82. This deficiency affects 82 of 82 residents. Observation at 10:27 A.M. showed a staff access basement laundry room did not have a self-closing or automatic-closing door to assist with smoke seperation from the rest of the building. Observation at 10:29 A.M., showed several one gallon and a five gallon paint cans stored ina storage room int he basement on the facility. Observation throughout the inspection showed multiple pulic and staff access laundry rooms, on multiple floors, that did not have a self-closing or automatic-closing door to assist with smoke seperation from the rest of the building. During an exit interview at 3:00 P.M., the maintinance manager stated he will advise the management of the violations sand see they get fixed. Protection from Hazards. (A) In assisted living facilities and residential care facilities licensed on or after November 13, 1980, for more than twelve (12) beds, hazardous areas shall be separated by construction of at least a one- (1-) hour fire-resistant rating. In facilities equipped with a complete fire alarm system, the one- (1-) hour fire separation is required only for Missouri Department of Health and Senior Services STATE FORM 6899 S2ZW11 PRINTED: 01/11/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 12/29/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 8 of 18 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 2333 CHAPEL HILL ROAD CEDARHURST OF COLUMBIA COLUMBIA, MO 65203 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 8 furnace or boiler rooms. Hazardous areas equipped with a complete sprinkler system are not required to have this one- (1-) hour fire separation. Doors to hazardous areas shall be self-closing and shall be kept closed unless an electromagnetic hold-open device is used which is interconnected with the fire alarm system. The doors shall be self-closing or automatic-closing. 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, shall install and maintain a complete sprinkler system in accordance with NFPA 13, 1999 edition. I/II This regulation is not met as evidenced by: Class II Based on record review, observation and interview during the fire safety inspection process on December 29, 2023 the facility failed to install and maintain a complete sprinkler system in accordance with NFPA 13, 1999 edition. The facility census was 82, This deficiency affects 82 of 82 residents. Observation at 10:37 A.M. showed no sprinkler head located inside of the furnace room in the basement, resident storage room. During further investigation at the time of observation, the maintinance manager obtained a ladder and searched the entire furnace closet. No sprinkler head was located. Missouri Department of Health and Senior Services STATE FORM 6899 S2ZW11 PRINTED: 01/11/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 12/29/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 9 of 18 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 2333 CHAPEL HILL ROAD CEDARHURST OF COLUMBIA COLUMBIA, MO 65203 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 9 During interview at 3:00 P.M. the maintinance manager stated he would have a sprinkler head mounted in the furnace room. 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/II This regulation is not met as evidenced by: Class II Based on record review, observation and interview on December 29, 20223, the facility failed to inspect and/or maintain the sprinkler system in accordance with NFPA 13, 1999 edition, or NFPA 13R, 1999 edition,. The facility census was eighty two. This deficiency affects eighty two of eighty two residents. Observation at 12:46 P.M. showed the unapproved placement of a sprinkelr escutcheon plate in the game room on the 2nd floor of the main building. Record review begining at 2:00 P.M. showed no documentation of the sprinkler system being visually inspected monthly for the past twelve months. During an interview at 3:00 P.M. the maintenance manager stated he will be sure to document the monthly inspections of the sprinkler system and Missouri Department of Health and Senior Services STATE FORM 6899 S2ZW11 PRINTED: 01/11/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 12/29/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 10 of 18 PRINTED: 01/11/2024 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 12/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2333 CHAPEL HILL ROAD COLUMBIA, MO 65203 (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 COLUMBIA Continued From page 10 guages. He also stated he would get a ladder and fix the escutcheon plate in the game room fixed and appropriately mounted back onto the wall. 19 CSR 30-86.022(12)(C) Emergency Lighting -Battery Powered, 1.5 hrs Emergency Lighting. (C) If battery-powered lights are used, they shall be capable of operating the light for at least one and one-half (1 1/2) hours. II This regulation is not met as evidenced by: Class II Based on observation and interview during the fire safety inspection process on December 29, 2023 the facility failed to maintain the facilities main emergency lighting in good repair. The facility census on was eighty two. This deficiency affects eighty two of eighty two residents. Observation at 10:31 A.M. showed the emergency lighting located in the basement stairwell failed to function when the test button was depressed. Observation at 12:11 P.M. showed the emergency lighting located in the south stairwell failed to function when the test button was depressed. During an interview at 3:00 P.M. the maintinance manager stated he will have the lighting corrected. 19 CSR 30-86.022(13)(D) Curtains/Drapes, Flame Resistant Missouri Department of Health and Senior Services STATE FORM 6899 S2ZW11 If continuation sheet 11 of 18 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 2333 CHAPEL HILL ROAD CEDARHURST OF COLUMBIA COLUMBIA, MO 65203 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 11 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. || This regulation is not met as evidenced by: Class II Based on observation and record review during the fire safety inspection process on December 29, 2023 the facility failed to ensure all curtains and drapes in a licensed facility are certified or treated with flame-resistant material, and showed no documentation as defined in NFPA 101, 2000 edition. The facility census was eighty two. This deficiency affects eighty two of eighty two residents. Observation showed several drapes and curtains used in the 127 bed capacity facility. A records review begining at 2:00 P.M. showed no documentation that the curtains or draps being used are being manufactured with, or being treated with a flame resistant material. During an interview begining at 3:00 P.M. the maintinance manager stated he had the treatment formula on site and would look into getting the documentation together from his last treatment. 19 CSR 30-86.022(14)(A) Smoking in Designated Areas & Supervised Smoking. (A) Smoking shall be permitted in designated areas only. Areas where smoking is permitted shall be designated as such and shall be Missouri Department of Health and Senior Services STATE FORM 6899 S2ZW11 PRINTED: 01/11/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 12/29/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 12 of 18 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 2333 CHAPEL HILL ROAD CEDARHURST OF COLUMBIA COLUMBIA, MO 65203 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 12 supervised either directly or by a resident informing an employee of the facility that the area is being used for smoking. II/III This regulation is not met as evidenced by: Class III Based on observation and interview, during the fire safety inspection process on December 29, 2023, the facility failed to identify in writing the designated smoking areas. Areas where smoking is permitted shall be designated as such and shall be supervised either directly or by a resident informing an employee of the facility that the area is being used for smoking. During the records review that begun at 2:00 P.M. no documentation in the employee rules and regulations book to clarify the rules and regulations for employees or residents smoking policies and/or marked designated smoking areas was located. During an interview at 3:00 P.M., the maintenance supervisor stated he would notify the owners of the violation. 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 during the fire safety inspection process on Decmber 29, Missouri Department of Health and Senior Services STATE FORM 6899 S2ZW11 PRINTED: 01/11/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 12/29/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 13 of 18 PRINTED: 01/11/2024 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 12/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2333 CHAPEL HILL ROAD COLUMBIA, MO 65203 (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 COLUMBIA Continued From page 13 2023 the facility failed to ensure only metal or UL- or FM-fire-resistant rated wastebaskets were being used for trash. Facility census was eighty two. This deficiency affects eighty two of twenty eighty two residents. Observation through out the fire inspection showed more than sixty unapproved plastic wastebaskets in use throughout the building. The following rooms were noted with one to five violations each during the inspection. Rooms 105, 107, 112, 113, 116, 201, 211, 216, 218, 219, 220, 222, 223, 224, 226, 228, 230, 231, 232, 234, 235, 236, 238, 300, 302, 303, 305, 307, 314, 318, 319. During an interview at 3:00 P.M. the maintinance manager expressed his appologies and stated he had not been around to the rooms to check for trash cans since his hire date and would get them on order as soon as possible. He also stated a written reminder would be sent to all residents families reminding them of the regulation and rules. 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 II Based on observation and interview during the Missouri Department of Health and Senior Services STATE FORM 6899 S2ZW11 If continuation sheet 14 of 18 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 2333 CHAPEL HILL ROAD CEDARHURST OF COLUMBIA COLUMBIA, MO 65203 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 14 fire safety inspection process on December 29, 2023 the facility failed to maintain Oxygen storage and usage in accordance with NFPA 99, 1999 Edition. The facility census was 82. This deficiency affects 82 of 82 residents. Observation at 10:25 A.M. showed three,size-D, oxygen cylinders lying in the floor of the maintinance office. These cyliders were not stored in an approved rack, or secured by chain or band. Observation at 10:55 A.M. showed the proper oxygen signage was not displayed outside the residents door on room 117 even though oxygen was in use inside the residence. Observation at 12:33 P.M. showed the proper oxygen signage was not displayed outside the residents door on room 207 even though an oxygen purifying machine was in use inside the residence. Observation at 01:42 P.M. showed three, size-M, oxygen cylinders were lying on the floor of room 313. These cylinders were not stored in an approved rack, or secured by chain or band. Improperly stored or secured pressurized tanks create a life safety hazard. If a tank falls and damages the extruding valve causing pressurized oxygen to escape rapidly. The rapid release may cause the tank or vessel to fly through the air with tremendous force or rupture. During an interview at 3:00 P.M. the Maintinance Manager stated he would make sure to have the oxygen cylinders properly stored and reiterate to the residents to keep all oxygen tanks stored properly. Missouri Department of Health and Senior Services STATE FORM 6899 S2ZW11 PRINTED: 01/11/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 12/29/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 15 of 18 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 2333 CHAPEL HILL ROAD CEDARHURST OF COLUMBIA COLUMBIA, MO 65203 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) 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 shall 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. II/III This regulation is not met as evidenced by: Class II Based on observation and interview during the fire safety inspection process on December 29, 2023 the facility failed to properly maintain the buildings electrical wiring and not cause a safety or fire hazard. The facility census was eighty two. This deficiency affects eighty two of eighty two residents. In facilities that are constructed or have plans approved after July 1, 2005, electrical wiring shall be installed and maintained in accordance with Missouri Department of Health and Senior Services STATE FORM 6899 S2ZW11 PRINTED: 01/11/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 12/29/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 16 of 18 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 2333 CHAPEL HILL ROAD CEDARHURST OF COLUMBIA COLUMBIA, MO 65203 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 16 the requirements of the National Electrical Code, 1999 edition, National Fire Protection Association, Inc. Facilities built between September 28, 1979 and July 1, 2005 shall be maintained in accordance with the requirements of the National Electrical Code, which was in effect at the time of construction. All facilities shall have wiring inspected every two (2) years by a qualified electrician. Observation at 11:26 A.M. showed an unapproved multiplug electrical adapter in use in resident room 101. Observation at 11:40 A.M. showed the unapproved piggy backing of a extension cord into a power strip which was then plugged into another power strip, and all avaliable plugs were being occupied by devices in the bedroom of room 107. Observation at 11:41 A.M. showed an unapproved extension cord in use in the kitchen of room 107. Observation at 12:14 P.M. showed a power chair in room 220 was not plugged directly into the wall outlet. Observation at 12:27 P.M. showed a power chair in room 211 was not plugged directly into the wall outlet. Observation at 12:59 P.M. showed a comercial juice machine and a large comercial coffee machine were not plugged directly into the wall outlet in the Memory Care, 2nd floor kitchen. A records review begining at 3:00 P.M. showed no current two year electrical wiring inspection Missouri Department of Health and Senior Services STATE FORM 6899 S2ZW11 PRINTED: 01/11/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 12/29/2023 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 17 of 18 PRINTED: 01/11/2024 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 12/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2333 CHAPEL HILL ROAD COLUMBIA, MO 65203 (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 COLUMBIA Continued From page 17 documentation could be produced. No previous date of inspection could be produced or proven. During an interview at 3:00 P.M. the maintenance manager stated he was not aware the electrical issues were happening and he would see that they were fixed. He also stated he was not given any paperwork from the previous maintenance manager upon his hire date, aproximately six months prior, and had no previous records to refer to. Missouri Department of Health and Senior Services STATE FORM 6899 S2ZW11 If continuation sheet 18 of 18 THE FACILITY DID NOT RETURN A PLAN OF CORRECTION THEREFORE, NO POC IS INCLUDED WITH THE STATEMENT OF DEFICIENCIES (2567 FORM)