CEDARHURST OF WEST PLAINS.

“Prior to or upon admission and at least annually after that, each resident or his or her next of kin, legally authorized representatives or designees shall be informed of facility policies regarding provision of emergency and life-sustaining care, of an individual's right to make treatment decisions for himself or herself and of state laws related to advance directives for health-care decision making. The annual discussion may be handled either on a group or on an individual basis. Residents' next of kin, legally authorized representatives or designees shall be informed, upon request, regarding state laws related to advance directives for health-care decision making as well as the facility's policies regarding the provision of emergency or life-sustaining medical care or treatment. If a resident has a written advance health-care directive, a copy shall be placed in the resident's medical record and reviewed annually with the resident unless, in the interval, he or she has been determined incapacitated, in accordance with section 475.075 or 404.825, RSMo. Residents' next of kin, legally authorized representatives or designees shall be contacted annually to assure their accessibility and understanding of the facility policies regarding emergency and life-sustaining care. II/III”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“Each resident admitted to the facility, or his or her next of kin, legally authorized representative or designee, shall be fully informed of the individual's rights and responsibilities as a resident. These rights shall be reviewed annually with each resident, and/or his or her next of kin, legally authorized representative or designee, either in a group session or individually. II/III”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“The food-contact surfaces of grills, griddles and similar cooking devices and the cavities and door seals of microwave ovens shall be cleaned at least once a day, except that this shall not apply to hot oil-cooking equipment and hot oil-filtering systems. The food-contact surfaces of all cooking equipment shall be kept free of encrusted grease deposits and other accumulated soil. III”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“The facility shall screen residents and staff for tuberculosis as required for long-term care facilities by 19 CSR 20-20.100. II”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“The facility shall encourage and assist each resident based on his or her individual preferences and needs to be clean and free of body and mouth odor. II”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“Rooms shall be neat, orderly and cleaned daily. II/III”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“The administrator shall develop and implement a safe and effective system of medication control and use, which assures that all residents ' medications are administered by personnel at least eighteen (18) years of age, in accordance with physicians ' instructions using acceptable nursing techniques. The facility shall employ a licensed nurse eight (8) hours per week for every thirty (30) residents to monitor each resident ' s condition and medication. Administration of medication shall mean delivering to a resident his or her prescription medication either in the original pharmacy container, or for internal medication, removing an individual dose from the pharmacy container and placing it in a small cup container or liquid medium for the resident to remove from the container and self-administer. External prescription medication may be applied by facility personnel if the resident is unable to do so and the resident ' s physician so authorizes. All individuals who administer medication shall be trained in medication administration and, if not a physician or a licensed nurse, shall be a certified medication technician or level I medication aide. I/II”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“The facility may admit or retain an individual for residency in an assisted living facility only if the individual does not require hospitalization or skilled nursing placement as defined in this rule, and only if the facility: (G) Develops an individualized service plan (ISP), which means the planning document prepared by an assisted living facility which outlines a resident ' s needs and preferences, services to be provided, and goals expected by the resident or the resident ' s legal representative in partnership with the facility; II”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“The facility shall encourage and assist each resident based on his or her individual preferences and needs to be clean and free of body and mouth odor. II”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“The requirements of subsections (29)(D), (E) and (F) shall not apply to a resident receiving hospice care, provided the resident, his or her legally authorized representative or designee, or both, and the facility, physician and licensed hospice provider all agree that such program of care is appropriate for the resident. II”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“The administrator shall develop and implement a safe and effective system of medication control and use, which assures that all residents ' medications are administered by personnel at least eighteen (18) years of age, in accordance with physicians ' instructions using acceptable nursing techniques. The facility shall employ a licensed nurse eight (8) hours per week for every thirty (30) residents to monitor each resident ' s condition and medication. Administration of medication shall mean delivering to a resident his or her prescription medication either in the original pharmacy container, or for internal medication, removing an individual dose from the pharmacy container and placing it in a small cup container or liquid medium for the resident to remove from the container and self-administer. External prescription medication may be applied by facility personnel if the resident is unable to do so and the resident ' s physician so authorizes. All individuals who administer medication shall be trained in medication administration and, if not a physician or a licensed nurse, shall be a certified medication technician or level I medication aide. I/II”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“Based on observation and interview on April 23, 2025, the facility, licensed after August 28, 2007, failed to ensure doors in a smoke partition shall be self-closing. The facility census was 67. This | deficiency potentially affects 67 out of 67 residents. 1. Observation on April 23, 2025, at 11:12 A.M., showed a required smoke door located in the corridor of the north side of the Memory Care unit that did not clase completely in five (5) of six (6) attempts when the door was released from the electro-magnetic hold-open device (a device that holds the door in the open position and releases the door from the open position upon activation of the fire alarm). Further observation showed when the door completely clased and latched, an excessive amount of force was required to open | the doar. Smoke doors failing to close will allow | smoke and toxic gases to spread to other areas Missouri Deparment of Health and Senior Services eecutre Direct Y - 30-257 2L6R11 If continuation sheet 1 of 4 CEDARHURST OF WEST PLAINS WEST PLAINS, MO 65775 of the building in the event of a fire. 2. Observation on April 23, 2025, at 11:20 A.M., showed a required smoke door located in the corridor of the south side of the Memory Care unit. Observation showed an electro-magnetic hold-open device holding the door in the open position. Further observation showed a rubber door stop also holding the door in the open position. The rubber door stop would prevent the door from closing upon activation of the fire alarm. 3. Observation on April 23, 2025, at 11:29 A.M., showed a required smoke door located in the corridor by resident room 45 that did not close completely close in six (6) of six (6) attempts when the door was released from the electro-magnetic hold-open device. 4. Observation on April 23, 2025, at 11:41 A.M., showed a required smoke door located in the corridor by resident room 12 that did not close completely in six (6) of six (6) attempts when the door was released from the electro-magnetic hold-open device. Further observation showed two (2) wood screws designed to hold the latch to the door had been pulled out of the door preventing the door from completely closing and latching. During an interview on April 23, 2025, at 1:10 P.M., the Environmental Services Director said he/she was not aware the doors would not close properly, but would have them all repaired immediately.”

“Based on document review and interview on April 23, 2025, the facility failed to ensure the facility's electric wiring was inspected every two (2) years by a qualified electrician. The facility census on April 23, 2025, was 67. This deficiency affects 67 of 67 residents. Review on April 23, 2025, at 12:40 P.M., showed the last electrical wiring inspection by a qualified electrician had been completed on March 30, 2023. During an interview on April 23, 2025, at 1:02 6899 2L6R11 COMPLETED 04/23/2025 1521 US HIGHWAY 63 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE 1521 US HIGHWAY 63 CEDARHURST OF WEST PLAINS WEST PLAINS, MO 65775 COMPLETED 04/23/2025 A3214 | Continued From page 3 P.M., the Environmental Services Director said he/she had been trying to get the inspection completed, but all electricians were busy in the area with recent storm damage. ID PREFIX TAG Provider/Supplier Name: Date of Survey/Inspection: PLAN OF CORRECTION Cedarhurst of West Plains 1521 U.S. Hwy 63 West Plains MO, 65775 4/23/2025 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS- | COMPLETION REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE A2264 19 CSR 30- 86.022(10)(1) Smoke Section Partitions > than 20 beds “Protection from Hazards. (I) In facilities whose plans were approved or which were initially licensed after December 31, 1987, for more than twenty (20) beds and all facilities licensed after August 28, 2007, each smoke section Shall be separated by one- (1-) hour fire-rated smoke partitions. The smoke partitions shail be continuous from outside wall-to- outside wail and from floor-to-floor or floor-to-roof deck. All doors in this wall shall be at least twenty- (20-) minute fire- rated or its equivalent, self- closing, and may be held open only if the door closes automatically upon activation of the complete fire alarm system. II" O) What corrective action(s) will be accomplished for those areas found to have been affected by the deficient practice; » Effective 4/24/25, Environmental Service Director (Randall Wilson) Repaired all doors and components of doors that were found to be out of compliance during inspection. QO How you will identify other areas having the potential to be affected by the same deficient practice > Effective 4/24/25, Environmental Service Director (Randall Wilson) did an audit of all other doors in the community to ensure that they were functioning properly, and all components were in good repair. O What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur » Effective 4/24/25, Environmental Service Director (Randall Wilson) using the TELs audit/scheduling software, added weekly scheduled tasks for 3 times per week instead of 2 times per week. Scheduled for Monday, Wednesday and Friday. On these days, the Environmental Service Director (Randall Wilson) will complete the scheduled audit of all the doors. > Environmental Service Director (Randall Wilson) will provide 5-20-25 education to all staff present at our Monthly All Staff Meeting scheduled for 5/20/25 on the importance of not placing door stops in front of fire safety doors and also the importance of reporting immediately if they notice any doors that are broken or not working appropriately. 0 What corrective action(s) will be accomplished for those areas found to have been affected by the deficient practice; > Effective 4/30/25, Environmental Service Director (Randall Wilson) confirmed with Current Electric Inc that the electrical! inspection was completed on 4/30/25. Please see attached copy of the inspection. O What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur >» Effective 4/24/25, Environmental Service Director (Randall Wilson) using the TELs audit/scheduling software, added the mites scheduled tasks for every 2 years with next audit due in April of 19 CSR 30- 2026. The Environmental Service Director (Randall Wilson) will 86.032(13) complete monitor the scheduled tasks in TELs on a Weekly basis to Electrical see what items are coming due in the upcoming month and Wiring, schedule inspections accordingly. Maintained, | inspected ‘In facilities that are constructed or have plans approved after July 1, 2005, 4-30-25 electrical wiring shall be installed and maintained in accordance with the requirements of the National Electrical Code, 1999 edition, National Fire Protection Association, ine” 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. oma”

“General Requirements. (A) If the facility admits or retains any individual needing more than minimal assistance due to having a physical, cognitive or other impairment that prevents the individual from safely evacuating the facility, the facility shall: 10. Comply with all requirements of this rule. I/II”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“The administrator shall develop and implement a safe and effective system of medication control and use, which assures that all residents ' medications are administered by personnel at least eighteen (18) years of age, in accordance with physicians ' instructions using acceptable nursing techniques. The facility shall employ a licensed nurse eight (8) hours per week for every thirty (30) residents to monitor each resident ' s condition and medication. Administration of medication shall mean delivering to a resident his or her prescription medication either in the original pharmacy container, or for internal medication, removing an individual dose from the pharmacy container and placing it in a small cup container or liquid medium for the resident to remove from the container and self-administer. External prescription medication may be applied by facility personnel if the resident is unable to do so and the resident ' s physician so authorizes. All individuals who administer medication shall be trained in medication administration and, if not a physician or a licensed nurse, shall be a certified medication technician or level I medication aide. I/II”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“Protective oversight shall be provided twenty-four (24) hours a day. For residents departing the premises on voluntary leave, the facility shall have, at a minimum, a procedure to inquire of the resident or resident ' s guardian of the resident ' s departure, of the resident ' s estimated length of absence from the facility, and of the resident ' s whereabouts while on voluntary leave. I/II”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.