CEDARHURST OF LEBANON ASSISTED LIVING & MEMORY CARE.

PRINTED: 11/21/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (K1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED R-C 31890 B. WING 10/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 842 LYNN STREET LEBANON, MO 66536 (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 LEBANON ASSISTED LIVIN: A4778 19 CSR 30-86.047(37) Appropriate Action & A4778 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 ta a funeral home. HiIl This regulation is not met as evidenced by: | Class Il Based on interview and record review, facility staff failed to take appropriate action and promptly attempt to contact the person listed in the resident's record as the legally authorized representative for a change of condition when staff failed to notify one resident's (Resident #1) family when staff noted a large blister on the | resident's right heel. The facility census was 59. Review showed the facility did not provide a policy regarding notifications with changes of condition. 1. Review of Resident #1's face sheet (basic information sheet) showed the following: | -Admission date of 11/09/23; -Diagnoses included vascular dementia (a general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE C4 pe Duster (1/22/2024 STATE FORM eee C40G611 If continuation sheet 1 of 4 PRINTED: 11/21/2024 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 R-C 31890 B. WING 10/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 842 LYNN STREET LEBANON, MO 65536 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 LEBANON ASSISTED LIVIN‘ Continued From page 1 impaired blood flow to your brain); -A Power of Attorney (POA) listed for health care. Review of the resident's physician order, dated 10/01/24 at 10:00 P.M., showed staff to clean the right heel with wound cleanser, cover with foam dressing, and change two times weekly by the hospice nurse. Staff to keep pressure relieving boots on while in bed. Review of the resident's nursing note dated 10/01/24, at 10:45 P.M., showed the following: -A large blister was discovered covering the resident's right heel: -Staff notified hospice; -The hospice nurse came to evaluate the resident's right heel; -The Director of Nursing (DON) was notified; -A new order received was follows to clean right heel with wound cleanser, pat dry, cover with foam dressing, change twice a week by hospice nurse. Staff to keep pressure relieving boots on when in bed. Left heel noted to be "boggy" but no visible breakdown observed; -Staff instructed to keep heel protectors on and turn every two hours when in bed. Staff to apply only loose fitting footwear when out of bed. (Staff did not document notification of the resident's POA of the blister). Review of the resident's nursing note dated 10/02/24, at 11:15 A.M., showed the following: -Staff spoke with a family member regarding the blister to resident's right heel and treatment plan; -The family member reported the family was not notified by hospice last night regarding the blister; -Staff discussed with the family member the causes of skin break down on heels could be Missouri Department of Health and Senior Services STATE FORM 6899 C40G611 If continuation sheet 2 of 4 PRINTED: 11/21/2024 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 R-C 31890 B. WING 10/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 842 LYNN STREET LEBANON, MO 65536 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 LEBANON ASSISTED LIVIN‘ Continued From page 2 from multiple factors in the resident's health, diet, and decreased mobility. During an interview on 10/23/24, at 2:37 P.M., Level One Medication Aide (LIMA) B said for a change of condition, including a wound or sore, he/she would report it to the charge nurse. The charge nurse makes the family notifications. During an interview on 10/23/24, at 2:11 P.M., Licensed Practical Nurse (LPN) A said the following: -On 10/01/24, a hospice nurse came to the facility; -The hospice nurse brought a dressing and applied it to the resident's right heel; -The resident did not have an open wound on either heel; -The blister was raised; -LPN A Instructed staff about the resident's treatment and heel protectors and documented the same in the staff report book; -No one called the resident's family/POA that night; -Family would be notified with a change of condition like a health decline; -LPN A asked the Director of Nursing if he/she should call the resident's family so late and the DON said either her or the hospice nurse would call in the morning. During an interview on 10/23/24, at 4:19 P.M., the Hospice Nurse said the following: -He/She reviewed the hospice nurse's documentation from 10/01/24; -The hospice nurse did not document the POA was notified; -On 10/03/24, he/she notified the POA about the Missouri Department of Health and Senior Services STATE FORM 6899 C40G611 If continuation sheet 3 of 4 PRINTED: 11/21/2024 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 R-C 31890 B. WING 10/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 842 LYNN STREET LEBANON, MO 65536 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 LEBANON ASSISTED LIVIN‘ Continued From page 3 blister and the treatment ordered; -Typically the family would be notified by the next day; -He/She recalled on 10/02/24, about dinner time, he/she spoke with the resident's POA on an unofficial visit and the POA wanted to look at the blister. During interviews on 10/23/24, at 11:11 A.M. and 4:10 P.M., the DON said the following: -The charge nurse notifies the family of a change of condition; -If the resident has hospice, then hospice will update the family and let the facility know; -The onset date of the resident's blister was 10/01/24; -On 10/01/24, hospice came to the facility and started the resident's treatment; -On 10/02/24, a family member said the POA was not notified of the resident's blister; -There is no documentation in the resident's record that hospice or staff notified the POA; -On 10/02/24, she found out hospice did not notify the POA; -It's hospice responsibility to notify the POA. MO00243116 Missouri Department of Health and Senior Services STATE FORM 6899 C40G611 If continuation sheet 4 of 4 PLAN OF CORRECTION Provider/Supplier Name: Cedarhurst Senior Living (Assisted Living & Memory Care) Street Address, City, Zip: 842 Lynn St. Lebanon, Mo 65536 Date of Survey: 10/23/2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER | | ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE AA778 All Staff Monthly Inservice covered change of Condition- (Skin 40/30/2024 issues/Falls/Incidents -When to notify and who to notify (POA) i -Discussed when a resident is on hospice, we have protective oversight of every resident and it is our responsibility to notify legally authorized representative, designee or placement authority not hospice or outside providers when there is a change in condition. Notification should happen immediately regardiess of time of day followed by documentation of notification in residents EHR. DON or delegated person will follow up on documentation after 10/31/2024 incidents to ensure both POA and PCP are notified. Managers Meeting 10/31/2024 reviewed with all managers policy and procedures of change in Condition (Skin Issues/Falls/Incidents) -reviewed with all managers Progress Note documentation policy and procedures. All Staff Monthly Inservice covered Progress Note documentation policy and procedures Covered this topic at both times with staff @ 7:20am & 2:30pm 11/22/2024 Progress Note Documentation policy & Change in Condition osted in both nursing stations for review as needed Change in Condition covering topics such as Skin Issues, Falls, Incidents) Change in Condition and Documentation Process covered in all 44/1/2024 11/22/2024 niin new hire orientation (on-going Quarterly -All Staff Inservice covering Change of Condition and 4/1/2025- A4778 Documentation process will be conducted for continuing 42131-2025 education 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: 05/16/2024 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 G 31890 B. WING 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 842 LYNN STREET LEBANON, MO 65536 (4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (XS) 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 LEBANON ASSISTED LIVIN: A8023) 19 CSR 30-88.010(23) Develop/Implement A/N A8023 Policies The facility shall develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of any resident and misappropriation of resident property and funds, and develop and implement policies that require a report to be made to the department for any resident or to both the department and the Department of Mental Health for any vulnerable person whom the administrator or employee has reasonable cause to believe has been abused or neglected. II/III This regulation is not met as evidenced by: Class II* Based on interview and record review, facility staff failed to implement abuse policies and procedures when staff failed to ensure a complete and timely investigation was completed according to facility policy following an allegation of resident to resident abuse involving two residents (Resident #1 and Resident #2). The facility census was 59. Review of the facility's policy titled “Abuse, Neglect and Exploitation Prevention, Prohibition, and Investigation,” dated 03/14/22, showed the following: -All allegations of abuse will be treated as serious and will be investigated, documented, and reported as per the standards set forth in this policy and procedure, or per State or Federal definitions and regulations, whichever is more stringent; -Abuse means any act or failure to act performed intentionally or recklessly that causes or is likely to cause harm to a resident. Any physical or Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (%6) DATE — CQ. Acti slailad STATE FOR 6699 URJC11 If continuation sheet 1 of 22 PRINTED: 05/16/2024 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 C 31890 B. WING 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 842 LYNN STREET LEBANON, MO 65536 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 LEBANON ASSISTED LIVIN‘ Continued From page 1 mental injury or sexual assault inflicted on a resident, other than by accidental means. Sexual contact including fondling of a resident by an employee, agent, or other resident by force, threat, duress or coercion, or sexual contact with a resident who has no ability to consent; -Witnessed or suspected abuse, neglect, and exploitation procedures include ensuring the safety of the resident and staff will immediately initiate the investigation; -If the allegation is a crime or the abuse is of a sexual nature, or theft of a controlled substance, notify local law enforcement; -An investigation shall be started immediately when the Executive Director or designee receives notification of an alleged violation and thoroughly investigated and reported to the appropriate state agency within the corresponding timeframes; -Interview all staff who may have witnessed or may have knowledge of the alleged abuse; -Interview the resident, or any other resident(s) who may have knowledge of any similar actions; - Executive Director, Director of Wellness, & Regional Team and others, as deemed appropriate will review the documentation and determine if the investigation was thorough and complete. -If allegation of abuse is substantiated, the Executive Director will establish an Abuse Investigation File that includes a copy of the incident report and all alleged abuse investigation documentation. 1. Review of Resident #1's face sheet (a document that gives a patient's information at a quick glance) showed the following: -Admission date of 01/15/21; -The resident had a responsible party; -Diagnoses included anxiety and mild cognitive Missouri Department of Health and Senior Services STATE FORM 6899 URJC11 If continuation sheet 2 of 22 PRINTED: 05/16/2024 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 C 31890 B. WING 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 842 LYNN STREET LEBANON, MO 65536 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 LEBANON ASSISTED LIVIN‘ Continued From page 2 impairment Review of the resident's Individual Service Plan (ISP- plan put in place to indicate the care needs of the resident), dated 01/10/24, showed the following: -The resident had impaired ability to perform activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting). The resident required one person providing moderate to maximum time for cuing and hands-on assistance with some activities of daily care; -The resident had cognitive impairment; -The resident had a diagnoses of dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors), and recent cerebral vascular accident (CVA- an interruption in the flow of blood to cells in the brain). Review of the resident's nurse's progress note dated 04/09/24, at 11:30 P.M., showed the following: -The licensed nurse called the resident's family member and notified him/her of an incident that occurred at approximately 9:20 P.M. between Resident #1 and Resident #2. Resident #2 entered Resident #1's apartment while Resident #1 was resting in bed. Resident #2 was observed by Resident Aide (RA) B standing at Resident #1's bedside and leaning down appearing to kiss Resident #1's face. Resident #2 was removed Missouri Department of Health and Senior Services STATE FORM 6899 URJC11 If continuation sheet 3 of 22 PRINTED: 05/16/2024 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 C 31890 B. WING 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 842 LYNN STREET LEBANON, MO 65536 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 LEBANON ASSISTED LIVIN‘ Continued From page 3 from Resident #1's room promptly. The licensed nurse spoke with Resident #1 and asked him/her what happened. Resident #1 did not appear frightened or tearful. Resident #1 said "a person came in here and tried to kiss me." The licensed nurse attempted to provide assurance to Resident #1 and explained the other resident was confused. The licensed nurse asked Resident #1 if Resident #2 kissed him/her, to which he/she replied "no." However, Resident #1 later told another RA that he/she had been kissed on the cheek. The licensed nurse had previously been in Resident #1's apartment at approximately 9:00 P.M. administering prescribed eye drops. The licensed nurse called the Director of Nursing (DON) and notified the DON of the incident. Resident #2 was sent to Mercy Emergency Department (ED) for evaluation and treatment of inappropriate behaviors and physical combativeness. Resident #1's family member thanked the licensed nurse for notification of the incident. 2. Review of Resident #2's face sheet showed the following: -Admission date of 2/07/24- -The resident had a responsible party; -Diagnoses included Parkinson's Disease, anxiety, and depression. Review of the resident's ISP, dated 02/08/24, showed the following: -The resident had impaired ability to perform ADL's. The resident required one person providing moderate to maximum time for cuing and hands-on assistance with some activities of daily care; -The resident had cognitive impairment; Missouri Department of Health and Senior Services STATE FORM 6899 URJC11 If continuation sheet 4 of 22 PRINTED: 05/16/2024 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 C 31890 B. WING 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 842 LYNN STREET LEBANON, MO 65536 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 LEBANON ASSISTED LIVIN‘ Continued From page 4 -The resident had a diagnosis of dementia, Alzheimer's disease, Parkinson's disease, and recent CVA. Review of the resident's nurse's progress note dated 04/09/24, at 11:15 P.M., showed the following: -At approximately 9:20 P.M., the licensed nurse was Called to Resident #1's apartment where RA B had discovered Resident #2 standing at the bedside of Resident #1 who was resting in bed, leaning over him/her and appearing to kiss his/her face. RA entered room promptly and told Resident #2 to leave the room immediately. Resident #2 responded "I wasn't doing anything." Resident #2 had to be physically escorted out of the apartment and tried to force his/her way back into the room several times and became verbally and physically hostile with staff when staff would not allow him/her to do so. The licensed nurse convinced the resident to come to the nurses’ station to call his/her family member while a RA remained at Resident #1's apartment to ensure the resident's safety. Resident #2's family member answered the phone and the licensed nurse explained the situation. The family member said he/she would be unable to come in and try to calm Resident #2 down but agreed to talk to Resident #2 on the phone. Resident #2 spoke briefly with the family member and then set the phone down and started walking back to Resident #1's apartment. The licensed nurse followed the resident. The resident tried to physically plow his/her way back in past the RAs to Resident #1's apartment and when he/she was unsuccessful, he/she tried to enter other residents' rooms and physically shove past staff blocking his/her way. RAB went to check on other residents while another RA remained at Resident #1's apartment. Missouri Department of Health and Senior Services STATE FORM 6899 URJC11 If continuation sheet 5 of 22 PRINTED: 05/16/2024 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 C 31890 B. WING 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 842 LYNN STREET LEBANON, MO 65536 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 LEBANON ASSISTED LIVIN‘ Continued From page 5 As RAB was in another resident's apartment, Resident #2 entered that apartment and had to be physically blocked from approaching that resident. RAB reported Resident #2 rubbed his/her genitals on the RA and was observed touching his/her genitals. Resident #2 was then observed by the licensed nurse attempting to enter another apartment and physically shoving the other RA. The licensed nurse was on the phone with Resident #2's family member at the time and notified the family member we would have to call 911 as Resident #2 was posing a serious threat to other residents and staff members. The family member verbalized understanding and agreement. The licensed nurse called 911 at approximately 9:40 P.M. Two Emergency Medical Services (EMS) and a police officer arrived. Resident #2 willingly went onto the stretcher and said "| want to go home." The licensed nurse gave verbal report to EMS and the officer about the resident's behaviors. Resident #2 left the facility via gurney to Mercy Lebanon ED. The licensed nurse called in report to Mercy Lebanon ED nurse. Review of the resident's nurses' progress notes dated 04/10/24 showed the following: -At 3:45 A.M., the resident came back from the emergency room (ER) at 2:30 A.M. and went to sleep. No new medication orders received; -At 7:15 A.M., the resident returned from the ER at about 1:30 A.M. The resident was given no medications at the ER. ER staff said he/she was calm and well behaved the whole time he/she was there. The resident was put to bed when he/she returned to the facility and had been sleeping since; -At 9:15 A.M., staff called geriatric wellness unit for possible bed availability due to recent Missouri Department of Health and Senior Services STATE FORM 6899 URJC11 If continuation sheet 6 of 22 PRINTED: 05/16/2024 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 C 31890 B. WING 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 842 LYNN STREET LEBANON, MO 65536 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 LEBANON ASSISTED LIVIN‘ Continued From page 6 behaviors and no beds were available at this time. Staff will continue contact for availability and resident to be sent to ER for medical clearance once bed becomes available. DON spoke with the resident's family member and he/she is in agreement. Left message with neurologist regarding possible medication adjustment as establishment appointment with new primary care provider is at later date, awaiting return call. Resident has been pacing this morning but no behaviors noted at this time. Staff will continue to monitor. During an interview on 04/12/24, at 9:04 A.M., the resident said he/she wandered into a room and kissed another resident awhile ago and he/she was not supposed to do that. 3. Review of a facility grievance, dated 04/12/24, showed the following: -The Resident #1's family member came in to speak with the Executive Director regarding an incident between Resident #1 and Resident #2 on 04/09/24. The family member had also spoken with the DON the night before regarding his/her concerns. He/she continued to state that Resident #1 had been molested and that he/she did not want Resident #2 back here. The family member said he/she knew Resident #2 had been sent out but, could not understand why Resident #2 was back in the building the next day and that he/she hoped Resident #2 would be gone for at least a couple of days. The Executive Director informed the family member that the facility cannot determine how long a hospital will keep someone or what they will do when someone is there. The Executive Director also stated that it is not uncommon for someone with dementia to be confused about who an individual was and to Missouri Department of Health and Senior Services STATE FORM 6899 URJC11 If continuation sheet 7 of 22 PRINTED: 05/16/2024 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 C 31890 B. WING 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 842 LYNN STREET LEBANON, MO 65536 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 LEBANON ASSISTED LIVIN‘ Continued From page 7 think someone might be a spouse, daughter, neighbor, etc. The Executive Director informed the family member that the Executive Director could not speak specifically regarding Resident #2's care but that when the facility had someone who has exhibited a behavior that staff will place them on 15 min checks, staff may notify the resident's doctor to suggest a medication adjustment and/or recommend a resident go to a geriatric psychiatric unit for medication adjustment. The Executive Director stated that behaviors can escalate for individuals with dementia due to urinary tract infections (UTI's), visits from certain family members, etc. The Executive Director also stated that when those behaviors occur that staff monitor the person and do everything that the Executive Director had just stated. The family member said he/she should be able to go home at night and worry about Resident #1 being molested; -The Executive Director offered to move Resident #1 to the assisted living side and explained that the resident could still go to the unit during the daytime since the resident usually sits in the day area where he/she can be observed. It was also offered to have the resident's door locked at night so that no one could wander into his/her room. The family member said he/she had a lot to think about and that he/she would let me know. 4. Review showed on 04/12/24, the facility did not provide any documentation of an investigation completed or in progress. During an interview on 04/12/24, at 9:51 A.M., the ED said he/she had not started an investigation. 5. During an interview on 04/12/24, at 9:18 A.M., RAA said the following: Missouri Department of Health and Senior Services STATE FORM 6899 URJC11 If continuation sheet 8 of 22 PRINTED: 05/16/2024 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 C 31890 B. WING 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 842 LYNN STREET LEBANON, MO 65536 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 LEBANON ASSISTED LIVIN‘ Continued From page 8 -He/she was told in report that Resident #2 kissed Resident #1; -Staff redirected Resident #2 and kept their eyes on him/her; -Staff communicated Resident #2's whereabouts with each other; -Resident #2 was on fifteen minute checks. 6. During interviews on 04/12/24, at 9:38 A.M. and 12:12 P.M., Certified Nursing Assistant (CNA) C said the following: -He/she heard Resident #2 wandered into Resident #1's room and kissed the resident; -Resident #2 was on fifteen minute checks; -The DON and Executive Director investigated allegations of abuse; -He/she did not consider Resident #2 kissing Resident #1 abuse and just considered it an innocent kiss. 7. During an interview on 04/12/24, at 11:01 A.M., RAB said the following: -On 04/09/24, he/she completed his/her fifteen minute checks when he/she noticed Resident #2 in Resident #1's room leaning over Resident #1 and kissing the resident's face; -He/she told Resident #2 they could not be in there and escorted the resident out of the room as he/she radioed for another staff member; -He/she asked Resident #1 if Resident #2 did anything and Resident #1 said Resident #2 was kissing him/her; -The other RA came to assist him/her with escorting Resident #2 out of the room because the resident was resisting; -He/she asked the nurse to take Resident #2 so he/she and the other RA could care for Resident #1; Missouri Department of Health and Senior Services STATE FORM 6899 URJC11 If continuation sheet 9 of 22 PRINTED: 05/16/2024 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 C 31890 B. WING 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 842 LYNN STREET LEBANON, MO 65536 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 LEBANON ASSISTED LIVIN‘ Continued From page 9 -Resident #2 again attempted to reenter the room and he/she assisted the nurse in taking Resident #2 to the TV room and then Resident #2 attempted to head to another resident's room; -He/she attempted to redirect the resident and the resident pushed him/her back and rubbed his/her leg; -Resident #2 then attempted to go back into Resident #1's room and as staff attempted to redirect the resident, the resident became combative; -The charge nurse called the DON and Resident #2 calmed down right before EMS arrived; -Resident #2 went to the ER and came back the next morning; -He/she considered Resident #2 kissing Resident #1 physical or sexual abuse. 8. During an interview on 04/12/24, at 12:18 P.M., Level One Medication Aide (LIMA) D said the following: -The DON and Executive Director completed an investigation on allegations of abuse; -Resident #2 was on fifteen minute checks. 9. During an interview on 04/12/24, at 12:52 P.M., Licensed Practical Nurse (LPN) E said the following: -He/she learned about the incident between Resident #1 and Resident #2 during report; -lf Resident #1 did not want the kiss, he/she would consider it sexual abuse, but would have to take into consideration Resident #2's dementia diagnosis as well; -He/she did not know if the incident required an investigation; -He/she did not know if Resident #2 was on fifteen minute checks or not. Missouri Department of Health and Senior Services STATE FORM 6899 URJC11 If continuation sheet 10 of 22 PRINTED: 05/16/2024 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 C 31890 B. WING 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 842 LYNN STREET LEBANON, MO 65536 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 LEBANON ASSISTED LIVIN‘ Continued From page 10 10. During an interview on 04/12/24, at 1:13 P.M., the DON said the following: -The DON started an investigation immediately on allegations of abuse; -Resident #2 had dementia and was confused about who he/she was kissing; -Resident #1 said Resident #2 kissed him/her on the cheek; -He/she did not consider Resident #2 kissing Resident #1 abuse; -Resident #1's family member was fine when the nurse first told him/her about the incident, but after the family member slept on it, he/she said the incident was molestation. 10. During an interview on 04/12/24, at 1:13 P.M., the Executive Director said the following: -He/she did not consider the incident abuse; -He/she did not consider a kiss on the cheek to be a sexual advance; -The resident's family member said the incident was molestation; -At times, residents in the memory care unit think other residents are their mothers or wives; -Resident #2 did not forcibly kiss Resident #1. If he/she would have, he/she would consider that abuse. *The higher classification merited due to the extent of the violation. M000234509 19 CSR 30-88.010(25) Report A/N to DHSS/DMH When Needed Missouri Department of Health and Senior Services STATE FORM 6899 URJC11 If continuation sheet 11 of 22 PRINTED: 05/16/2024 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 C 31890 B. WING 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 842 LYNN STREET LEBANON, MO 65536 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 LEBANON ASSISTED LIVIN‘ Continued From page 11 If the administrator or other employee of a long-term care facility has reasonable cause to believe that a resident of the facility has been abused or neglected, the administrator or employee shall immediately report or cause a report to be made to the department. Any administrator or other employee of a long-term care facility having reasonable cause to suspect that a vulnerable person has been subjected to abuse or neglect or observes such a person being subjected to conditions or circumstances that would reasonably result in abuse or neglect shall immediately report or cause a report to be made to the department and to the Department of Mental Health. I/II This regulation is not met as evidenced by: Class II Based on interview and record review, facility Staff failed to report an incident of resident-to-resident abuse involving two residents (Resident #1 and #2) to the Department of Health & Senior Services (DHSS). The facility census was 59. Review of the facility's policy titled "Abuse, Neglect and Exploitation Prevention, Prohibition, and Investigation," dated 03/14/22, showed the following: -All staff members and residents will be educated about what constitutes abuse, neglect, and exploitation, that they are all considered mandated reporters, and to err on reporting anything they see or hear that does not seem appropriate towards a resident; -All allegations of abuse will be treated as serious and will be investigated, documented, and reported as per the standards set forth in this Missouri Department of Health and Senior Services STATE FORM 6899 URJC11 If continuation sheet 12 of 22 PRINTED: 05/16/2024 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 C 31890 B. WING 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 842 LYNN STREET LEBANON, MO 65536 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 LEBANON ASSISTED LIVIN‘ Continued From page 12 policy and procedure, or per State or Federal definitions and regulations, whichever is more stringent; -Abuse means any act or failure to act performed intentionally or recklessly that causes or is likely to cause harm to a resident. Any physical or mental injury or sexual assault inflicted on a resident, other than by accidental means. Sexual contact including fondling of a resident by an employee, agent, or other resident by force, threat, duress or coercion, or sexual contact with a resident who has no ability to consent; -Immediately report the alleged abuse to your supervisor and Executive Director by phone call. Your State agency will be notified by Executive Director or designee per State guidelines; -lf allegation of abuse is substantiated, Executive Director will immediately notify your state agency and appropriate law enforcement agencies as indicated and notify the conclusion. 1. Review of Resident #1's face sheet (a document that gives a patient's information at a quick glance) showed the following: -Admission date of 01/15/21; -The resident had a responsible party; -Diagnoses included anxiety and mild cognitive impairment Review of the resident's Individual Service Plan (ISP- plan put in place to indicate the care needs of the resident), dated 01/10/24, showed the following: -The resident had impaired ability to perform activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting). The resident required one person providing moderate to maximum time for cuing and hands-on Missouri Department of Health and Senior Services STATE FORM 6899 URJC11 If continuation sheet 13 of 22 PRINTED: 05/16/2024 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 C 31890 B. WING 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 842 LYNN STREET LEBANON, MO 65536 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 LEBANON ASSISTED LIVIN‘ Continued From page 13 assistance with some activities of daily care; -The resident had cognitive impairment; -The resident had a diagnoses of dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors), and recent cerebral vascular accident (CVA- an interruption in the flow of blood to cells in the brain). Review of the resident's nurse's progress note dated 04/09/24, at 11:30 P.M., showed the following: -The licensed nurse called the resident's family member and notified him/her of an incident that occurred at approximately 9:20 P.M. between Resident #1 and Resident #2. Resident #2 entered Resident #1's apartment while Resident #1 was resting in bed. Resident #2 was observed by Resident Aide (RA) B standing at Resident #1's bedside and leaning down appearing to kiss Resident #1's face. Resident #2 was removed from Resident #1's room promptly. The licensed nurse spoke with Resident #1 and asked him/her what happened. Resident #1 did not appear frightened or tearful. Resident #1 said "a person came in here and tried to kiss me." The licensed nurse attempted to provide assurance to Resident #1 and explained the other resident was confused. The licensed nurse asked Resident #1 if Resident #2 kissed him/her, to which he/she replied "no." However, Resident #1 later told another RA that he/she had been kissed on the cheek. The licensed nurse had previously been in Missouri Department of Health and Senior Services STATE FORM 6899 URJC11 If continuation sheet 14 of 22 PRINTED: 05/16/2024 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 C 31890 B. WING 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 842 LYNN STREET LEBANON, MO 65536 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 LEBANON ASSISTED LIVIN‘ Continued From page 14 Resident #1's apartment at approximately 9:00 P.M. administering prescribed eye drops. The licensed nurse called the Director of Nursing (DON) and notified the DON of the incident. Resident #2 was sent to Mercy Emergency Department (ED) for evaluation and treatment of inappropriate behaviors and physical combativeness. Resident #1's family member thanked the licensed nurse for notification of the incident. 2. Review of Resident #2's face sheet showed the following: -Admission date of 2/07/24- -The resident had a responsible party; -Diagnoses included Parkinson's Disease, anxiety, and depression. Review of the resident's ISP, dated 02/08/24, showed the following: -The resident had impaired ability to perform ADL's. The resident required one person providing moderate to maximum time for cuing and hands-on assistance with some activities of daily care; -The resident had cognitive impairment; -The resident had a diagnosis of dementia, Alzheimer's disease, Parkinson's disease, and recent CVA. Review of the resident's nurse's progress note dated 04/09/24, at 11:15 P.M., showed the following: -At approximately 9:20 P.M., the licensed nurse was Called to Resident #1's apartment where RA B had discovered Resident #2 standing at the bedside of Resident #1 who was resting in bed, Missouri Department of Health and Senior Services STATE FORM 6899 URJC11 If continuation sheet 15 of 22 PRINTED: 05/16/2024 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 C 31890 B. WING 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 842 LYNN STREET LEBANON, MO 65536 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 LEBANON ASSISTED LIVIN‘ Continued From page 15 leaning over him/her and appearing to kiss his/her face. RA entered room promptly and told Resident #2 to leave the room immediately. Resident #2 responded "I wasn't doing anything." Resident #2 had to be physically escorted out of the apartment and tried to force his/her way back into the room several times and became verbally and physically hostile with staff when staff would not allow him/her to do so. The licensed nurse convinced the resident to come to the nurses' station to call his/her family member while a RA remained at Resident #1's apartment to ensure the resident's safety. Resident #2's family member answered the phone and the licensed nurse explained the situation. The family member said he/she would be unable to come in and try to calm Resident #2 down but agreed to talk to Resident #2 on the phone. Resident #2 spoke briefly with the family member and then set the phone down and started walking back to Resident #1's apartment. The licensed nurse followed the resident. The resident tried to physically plow his/her way back in past the RAs to Resident #1's apartment and when he/she was unsuccessful, he/she tried to enter other residents' rooms and physically shove past staff blocking his/her way. RAB went to check on other residents while another RA remained at Resident #1's apartment. As RAB was in another resident's apartment, Resident #2 entered that apartment and had to be physically blocked from approaching that resident. RAB reported Resident #2 rubbed his/her genitals on the RA and was observed touching his/her genitals. Resident #2 was then observed by the licensed nurse attempting to enter another apartment and physically shoving the other RA. The licensed nurse was on the phone with Resident #2's family member at the time and notified the family member we would have to call 911 as Resident #2 was posing a Missouri Department of Health and Senior Services STATE FORM 6899 URJC11 If continuation sheet 16 of 22 PRINTED: 05/16/2024 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 C 31890 B. WING 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 842 LYNN STREET LEBANON, MO 65536 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 LEBANON ASSISTED LIVIN‘ Continued From page 16 serious threat to other residents and staff members. The family member verbalized understanding and agreement. The licensed nurse called 911 at approximately 9:40 P.M. Two Emergency Medical Services (EMS) and a police officer arrived. Resident #2 willingly went onto the stretcher and said "| want to go home." The licensed nurse gave verbal report to EMS and the officer about the resident's behaviors. Resident #2 left the facility via gurney to Mercy Lebanon ED. The licensed nurse called in report to Mercy Lebanon ED nurse. Review of the resident's nurses' progress notes dated 04/10/24 showed the following: -At 3:45 A.M., the resident came back from the emergency room (ER) at 2:30 A.M. and went to sleep. No new medication orders received; -At 7:15 A.M., the resident returned from the ER at about 1:30 A.M. The resident was given no medications at the ER. ER staff said he/she was calm and well behaved the whole time he/she was there. The resident was put to bed when he/she returned to the facility and had been sleeping since; -At 9:15 A.M., staff called geriatric wellness unit for possible bed availability due to recent behaviors and no beds were available at this time. Staff will continue contact for availability and resident to be sent to ER for medical clearance once bed becomes available. DON spoke with the resident's family member and he/she is in agreement. Left message with neurologist regarding possible medication adjustment as establishment appointment with new primary care provider is at later date, awaiting return call. Resident has been pacing this morning but no behaviors noted at this time. Staff will continue to monitor. Missouri Department of Health and Senior Services STATE FORM 6899 URJC11 If continuation sheet 17 of 22 PRINTED: 05/16/2024 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 C 31890 B. WING 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 842 LYNN STREET LEBANON, MO 65536 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 LEBANON ASSISTED LIVIN‘ Continued From page 17 During an interview on 04/12/24, at 9:04 A.M., the resident said he/she wandered into a room and kissed another resident awhile ago and he/she was not supposed to do that. 3. Review of a facility grievance, dated 04/12/24, showed the following: -The Resident #1's family member came in to speak with the Executive Director regarding an incident between Resident #1 and Resident #2 on 04/09/24. The family member had also spoken with the DON the night before regarding his/her concerns. He/she continued to state that Resident #1 had been molested and that he/she did not want Resident #2 back here. The family member said he/she knew Resident #2 had been sent out but, could not understand why Resident #2 was back in the building the next day and that he/she hoped Resident #2 would be gone for at least a couple of days. The Executive Director informed the family member that the facility cannot determine how long a hospital will keep someone or what they will do when someone is there. The Executive Director also stated that it is not uncommon for someone with dementia to be confused about who an individual was and to think someone might be a spouse, daughter, neighbor, etc. The Executive Director informed the family member that the Executive Director could not speak specifically regarding Resident #2's care but that when the facility had someone who has exhibited a behavior that staff will place them on 15 min checks, staff may notify the resident's doctor to suggest a medication adjustment and/or recommend a resident go to a geriatric psychiatric unit for medication adjustment. The Executive Director stated that behaviors can escalate for individuals with Missouri Department of Health and Senior Services STATE FORM 6899 URJC11 If continuation sheet 18 of 22 PRINTED: 05/16/2024 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 C 31890 B. WING 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 842 LYNN STREET LEBANON, MO 65536 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 LEBANON ASSISTED LIVIN‘ Continued From page 18 dementia due to urinary tract infections (UTI's), visits from certain family members, etc. The Executive Director also stated that when those behaviors occur that staff monitor the person and do everything that the Executive Director had just stated. The family member said he/she should be able to go home at night and worry about Resident #1 being molested; -The Executive Director offered to move Resident #1 to the assisted living side and explained that the resident could still go to the unit during the daytime since the resident usually sits in the day area where he/she can be observed. It was also offered to have the resident's door locked at night so that no one could wander into his/her room. The family member said he/she had a lot to think about and that he/she would let the home know. (Staff did not document reporting the allegation of abuse to the DHSS.) 4. Review of DHSS records showed the facility did not self-report the abuse. 5. During an interview on 04/12/24, at 9:18 A.M., RAA said the following: -If he/she observed a resident enter another resident's room and kiss that resident, he/she separated the residents and reported to the charge nurse; -The DON reported to DHSS immediately; -He/she was told in report that Resident #2 kissed Resident #1. 6. During interviews on 04/12/24, at 9:38 A.M. and 12:12 P.M., Certified Nursing Assistant (CNA) C said the following: -If he saw a resident kissing another resident, he/she separated the residents and reported to Missouri Department of Health and Senior Services STATE FORM 6899 URJC11 If continuation sheet 19 of 22 PRINTED: 05/16/2024 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 C 31890 B. WING 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 842 LYNN STREET LEBANON, MO 65536 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 LEBANON ASSISTED LIVIN‘ Continued From page 19 the charge nurse immediately; -He/she did not know if the facility reported this to DHSS; -He/she heard Resident #2 wandered into Resident #1's room and kissed the resident; -He/she did not consider Resident #2 kissing Resident #1 abuse, just considered it an innocent kiss. 7. During an interview on 04/12/24, at 11:01 A.M., RAB said the following: -If he/she witness one resident kissing another resident, he/she separated the residents and reported to the charge nurse immediately; -The staff member in charge at the time reported to DHSS immediately; -He/she considered Resident #2 kissing Resident #1 physical or sexual abuse. 8. During an interview on 04/12/24, at 12:18 P.M., Level One Medication Aide (LIMA) D said the following: -If he/she witness a resident kissing another resident, he/she separated them and reported to the charge nurse and DON immediately; -The DON or Executive Director reported to DHSS within twenty-four hours. 9. During an interview on 04/12/24, at 12:52 P.M., Licensed Practical Nurse (LPN) E said the following: -If aides witnessed a resident kissing another resident, they should separate the residents and report to the charge nurse immediately; -The charge nurse assessed the resident and reported to the DON or Executive Director immediately and notified the resident's Missouri Department of Health and Senior Services STATE FORM 6899 URJC11 If continuation sheet 20 of 22 PRINTED: 05/16/2024 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 C 31890 B. WING 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 842 LYNN STREET LEBANON, MO 65536 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 LEBANON ASSISTED LIVIN‘ Continued From page 20 responsible party and physician; -lf Resident #1 did not want the kiss, he/she would consider it sexual abuse, but would have to take into consideration Resident #2's dementia diagnosis as well; -The DON reported allegations of abuse to DHSS, but he/she did not know when. 10. During an interview on 04/12/24, at 1:13 P.M., the DON said the following: -If aides witnessed a resident kissing another resident, they should separate the residents and report to the charge nurse immediately; -The charge nurse called the resident's responsible party and physician, placed the resident kissing the other resident on fifteen minute checks and notified the DON; -The DON notified the Executive Director immediately; -The DON or Executive Director reported to DHSS if the allegation warranted a report and was an abuse situation. 11. During an interview on 04/12/24, at 1:13 P.M., the Executive Director said the following: -He/she did not consider the incident abuse; -He/she did not consider a kiss on the cheek to be a sexual advance; -The resident's family member said the incident was molestation; -At times, residents in the memory care unit think other residents are their family members or significant others; -Resident #2 did not forcibly kiss Resident #1. If he/she would have, he/she would consider that abuse. MO000234509 Missouri Department of Health and Senior Services STATE FORM 6899 URJC11 If continuation sheet 21 of 22 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 31890 B. WING NAME OF PROVIDER OR SUPPLIER CEDARHURST OF LEBANON ASSISTED LIVIN‘ SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Missouri Department of Health and Senior Services STATE FORM 6899 (X2) MULTIPLE CONSTRUCTION A. BUILDING: CROSS-REFERENCED TO THE APPROPRIATE URJC11 PRINTED: 05/16/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/12/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 842 LYNN STREET LEBANON, MO 65536 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE (x5) COMPLETE DATE DEFICIENCY) If continuation sheet 22 of 22 Cedarhurst of Lebanon Assisted Living and Memory Care 842 Lynn St. Lebanon, MO 65536 Plan of Correction Survey Completed 04/12/2024 Provider Identification Number 31890 This plan of correction is submitted as required under State and Federal law and policies. The submission of this plan does not constitute an admission on the part of Cedarhurst of Lebanon Assisted Living (“Facility”) as to the accuracy of the surveyor’s findings or the conclusions drawn there from. The plan of correction does not constitute an admission on the part of the facility that the findings cited are accurate, that the findings constitute a deficiency or the scope and severities regarding any of the deficiencies cited are correctly applied. The facility submits this plan of correction with the intention that it be inadmissible by any third party in any civil action against the facility or any employee, agent, officer, director, or shareholder of the facility. Any changes to facility policies and procedures should be subsequent remedial measures as that concept is employed in Rule 407 of the Federal Rules of Evidence and should be inadmissible in any proceeding on that basis. 19 CSR 30-88.010(23) The facility does and will continue to ensure that a written policy and procedure that prohibits mistreatment, neglect, and abuse of any resident and misappropriation of resident property and funds, and develops and implements policies that require a report to be made to the department for any resident or fo both the department and the Department of Mental Health for any vulnerable person whom the administrator or employee has reasonable cause to believe has been abused or neglected. The facility submits the following as its plan of correction. Plan of Correction On 4/19/2024 the facility completed an in-service for all staff regarding implementing abuse policies and procedures, including immediately reporting abuse or neglect if the administrator or employee has reasonable cause to believe it occurred, that the administrator shall immediately report or case a report to me made to the appropriate state department and, ensuring a timely and through investigation is completed by the facility. Resident number 1 was re-assessed by the DON and determined to have no lasting negative outcome as a result of the alleged deficiency. Resident number 1 will continue to be monitored by the DON and charge nurse for any adverse effects of the alleged incident. Resident 2 was immediately placed on 15 minutes checks to monitor his behavior and location. The Administrator, DON and charge nurses will review the status of all residents to make certain that all reasonable measures are taken to ensure that care is in accordance with individual needs and current plan of care and that any allegations of abuse are investigated and reported immediately to the department for any vulnerable person whom the administrator or employee has reasonable cause to believe has been abused or neglected. Current policies and procedures will be reviewed, and changes will be made to ensure policies are in accordance to meet professional standards of practice. Revisions will be made as indicated. Additionally, to monitor the correction, the Administrator and DON or designee will review all residents daily to ensure compliance. Any abnormalities will be reported immediately to the Administrator and subsequent actions will be taken to ensure the proper implementation of the policies set forth to maintain ongoing compliance. Date of Completion: 4/19/2024 19 CSR 30-88.010(25) Report Abuse or Neglect to Department of Health and Senior Services or Department of Mental Health When Needed The facility does and will continue to ensure that if the administrator or other employee has reasonable cause to believe that a resident of the facility has been abused or neglected, the administrator or employee shall immediately report or cause a report to be made to the department. The facility will also ensure that the administrator or other employee having reasonable cause to suspect that a vulnerable person has been subjected to abuse or neglect or observes such a person being subjected to conditions or circumstances that would reasonably result in abuse or neglect shall immediately report or cause a report to be made to the department and to the Department of Mental Health per 19 CSR 30-88.010(25). The facility submits the following as its plan of correction in order to enhance the proper implementation of the facility's policy and procedures concerning reporting potential abuse, neglect, or exploitation. Plan of Correction On 4/19/2024 the facility completed an in-service for all staff regarding implementing abuse policies and procedures, ensuring a timely investigation and reporting abuse or neglect to the department and the Department of Mental Health. Resident number 1 was re-assessed by the DON and determined to have no lasting negative outcome as a result of the alleged deficiency. Resident number 1 will continue to be monitored by the DON and charge nurse for any adverse effects of the alleged incident. Resident 2 was immediately placed on 15 minutes checks to monitor his behavior and location. The Administrator, DON and charge nurses will review the status of all residents to make certain that all reasonable measures are taken to ensure that care is in accordance with individual needs and current plan of care and that any allegations of abuse are investigated and reported immediately to the department for any resident or vulnerable person whom the administrator or employee has reasonable cause to believe has been abused or neglected. Current policy and procedures will be reviewed, and changes will be made to ensure policies are in accordance to meet professional standards of practice. Revisions will be made as indicated. Additionally, to monitor the correction, the Administrator and DON or designee will review all residents daily to ensure compliance. Any abnormalities will be reported immediately to the Administrator and subsequent actions will be taken to ensure the proper implementation of the policies set forth to maintain ongoing compliance. Date of Completion: 4/19/2024

PRINTED: 12/13/2023 . 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 (DENTIFICATION NUMBER: A. BUILDING: COMPLETED 31890 8. WING 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 842 LYNN STREET LEBANON, MO 65536 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE oa. | | TAG REGULATORY OR LSC IDENTIFYING INFORMATION) | CROSS-REFERENCED TO THE APPROPRIATE CEDARHURST OF LEBANON ASSISTED LIVING & ME DEFICIENCY A2258 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-apen 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, 7980, shall be exempt from this , requirement. II This regulation is not met as evidenced by: Class II Based on observation and interview during the fire safety inspection process on November 15, 2023 the facility failed ta maintain self closing smoke partition doors that separate the laundry rooms from the residential spaces. The facility census November 15, 2023 was sixty-six (66). This deficiency affects sixty-six (66) of sixty-six (66) residents. Observation on November 15, 2023 at 0959 Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE valiant’ If continuation sheet 1 of 5 GOT4114 PRINTED: 12/13/2023 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 31890 B. WING 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 842 LYNN STREET LEBANON, MO 65536 (xay 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 ie TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE | CEDARHURST OF LEBANON ASSISTED LIVING & ME = | A2256 | Continued From page 1 revealed the self-closure devices on the laundry | room smoke partition doors were not adjusted to | clase the door. | During the exit interview on November 15, 2023 at | 1130 the administrator stated that they have always been this way, but that she would have maintenance adjust the doors on all the laundry | rooms. 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 Il | Based on observation and interview during the fire safety inspection process on November 15, 2023, the facility failed to maintain a complete sprinkler system in accordance with NFPA 13, 1999 edition. The facility census November 15, 2023 was sixty-six (66). This deficiency affects sixty-six (66) of sixty-six (66) residents. | Observation on November 15, 2023 at 1108 revealed a sprinkler head dropped down from the ceiling in room 175. Observation on November 15, 2023 at 1112 revealed a sprinkler head dropped down from the Missouri Department of Health and Senior Services STATE FORM ee GOT411 if continuation sheet 2 of S PRINTED: 12/13/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 31890 B. WING 11/15/2023 NAME OF PROVIOER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 842 LYNN STREET T OF LEBANON ASSISTED LIVIN ME SEDARHURS ee LEBANON, MO 65536 SUMMARY STATEMENT OF DEFICIENCIES | {D PROVIDER'S PLAN OF CORRECTION {X5} (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE acy REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY: Continued From page 2 ceiling in room 112. | Observation on November 15, 2023 at 1122 | revealed a sprinkler head dropped down from the ceiling in room 101. These penetrations would allow smoke, fire and toxic gases to travel to unaffected areas on the | building | During the exit interview on November 15, 2023 at 1135 the administrator stated they had just had | insulation placed in the attic and that the heads must have been pushed down during the process, but she would have maintenance correct the situation. /19CSR 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 Missouri Department of Health and Seniar Services STATE FORM S999 GOT411 If continuation sheet 3 of § PRINTED: 12/13/2023 ' 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 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 842 LYNN STREET LEBANON, MO 65536 (x4) 1D | 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 ae” TAG | REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE CEDARHURST OF LEBANON ASSISTED LIVING & ME | A3214| Continued From page 3 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. I/II | This regulation is not met as evidenced by: | Class III Based on observation and interview during the fire safety inspection process on November 15, 2023 the facility failed to ensure the facility's electric wiring was properly maintained. The facility census | November 15, 2023 was sixty-six (66). This | deficiency affects sixty-six (66) of sixty-six (66) residenis. Observation on November 15, 2023 at 1055 revealed an extension cord being used as permanent wiring in the kitchen. Extension cords _ are not permitted as permanent wiring. | During the exit interview on November 15, 2023 at 4140 the administrator stated she would have the extension cord removed. | 19 CSR 30-87 .020(25) Plumbing per Code Plumbing shall be sized, installed and maintained | according to the National Plumbing Code. II/III | This regulation is not met as evidenced by: Class Ill | Based on observation and interview during the fire safety inspection process on November 15, 2023, the facility failed to maintain plumbing in | Missouri Department of Health and Senior Services STATE FORM Bae GOT411 If continuation sheet 4 of 5 PRINTED: 12/13/2023 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 31890 B. WING 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 842 LYNN STREET LEBANON, MO 65536 4) 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 ee TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE CEDARHURST OF LEBANON ASSISTED LIVING & ME | A6025 Continued From page 4 | accordance to the National Plumbing Cade. The facility census November 15, 2023 was sixty-six | (66). This deficiency affects sixty-six (66) of | sixty-six (66) residents. | Observation on November 15, 2023 at 0958 revealed a water heater, in the mechanical room, , with a drip leg that terminated more than a foot | above the floor. Drip legs should terminate less than six (6) inches above the floor. | During the exit interview on October 30, 2023 at , 1145 the administrator stated she would have | maintenance extend or replace the drip leg. Missouri Department of Health and Senior Services STATE FORM Goes GOT411 If continuation sheet 5 of 5 Cedarhurst of Lebanon Assisted Living and Memory Care 842 Lynn St. Lebanon, MO 65536 Plan of Correction Survey Completed 11/15/2023 Provider Identification Number 31890 This plan of correction is submitted as required under State and Federal law and policies. The submission of this plan does not constitute an admission on the part of Cedarhurst of Lebanon Assisted Living (“Facility”) as to the accuracy of the surveyor’s findings or the conclusions drawn there from. The plan of correction does not constitute an admission on the part of the facility that the findings cited are accurate, that the findings constitute a deficiency or the scope and severities regarding any of the deficiencies cited are correctly applied. Exhibits referenced in the Plan of Correction may contain confidential resident medical record information and are submitted as an addendum. The Exhibits will not be made available to residents, families, and the public. Unauthorized release would violate the Federal Health Insurance Portability and Accountability Act (HIPAA). The facility assumes that the State and Federal agencies that receive copies of the documents will similarly maintain the Exhibits in a confidential file. The facility submits this plan of correction with the intention that it be inadmissible by any third party in any civil action against the facility or any employee, agent, officer, director, or shareholder of the facility. Any changes to facility policies and procedures should be subsequent remedial measures as that concept is employed in Rule 407 of the Federal Rules of Evidence and should be inadmissible in any proceeding on that basis. 19 CSR 30-86.022(10)(A) A2256 Plan of Correction All laundry doors are self-closing smoke partition doors that separate the laundry rooms from the residential spaces. All required inspections have been reviewed for compliance and the Administrator and Environmental Services Director will meet monthly to ensure continued compliance in accordance with 19 CSR 30-86.022(10)(A) Hazardous Area Requirements. Date of Completion: 11/16/2023 19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing A2269 Plan of Correction Sprinkler heads dropped down from the ceiling in room 115, 112, and 101 are secured and are in accordance with NFPA 13, 1999 edition. All required inspections have been reviewed for compliance and the Administrator and Environmental Services Director will meet monthly to ensure continued compliance in accordance with NFPA 13, 1999 edition. Date of Completion: 12/18/2023 19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected A3214 Plan of Correction Electrical wiring, including the wiring in the kitchen, is installed and maintain in accordance with the requirements of the National Electrical Code, 1999 edition, NFPA, Inc. All wiring will be monitored weekly by all staff and the Administrator and Environmental Services Director will meet monthly to ensure continued compliance in accordance. Date of Completion: 12/18/23 19 CSR 30-87.020(25) Plumbing per Code A6025 Plan of Correction All water heater drip legs terminate less than six (6) inches above the floor. All required inspections have been reviewed for compliance and the Administrator and Environmental Services Director will meet monthly to ensure continued compliance in accordance with the National Plumbing Code. Date of Completion: 12/18/23