Inspection Reports for
Cedarhurst of Lebanon Assisted Living & Memory Care

19 CSR 30-86.047(37) Appropriate Action & Notification: Based on interview and record review, facility staff failed to promptly notify the resident's legally authorized representative/POA of a change in condition when staff noted a large blister on Resident #1's right heel, and the facility did not have a policy regarding notifications for changes of condition.

19 CSR 30-88.010(23) Develop/Implement A/N Policies: Based on interview and record review, facility staff failed to implement abuse policies and ensure a complete and timely investigation following an alleged resident-to-resident abuse incident involving two residents.

19 CSR 30-88.010(25) Report A/N to DHSS/DMH When Needed: Based on interview and record review, facility staff failed to report an incident of resident-to-resident abuse to the Department of Health & Senior Services/Department of Mental Health as required.

19 CSR 30-86.022(10)(A) Hazardous Area Requirements: The self-closure devices on the laundry room smoke partition doors were not adjusted to close the doors, allowing the doors to remain open; the administrator stated maintenance would adjust the doors.

19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing: Sprinkler heads were observed dropped down from the ceilings in multiple resident rooms and these penetrations would allow smoke, fire and toxic gases to travel to unaffected areas.

19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected: An extension cord was observed being used as permanent wiring in the kitchen, indicating the facility failed to ensure electrical wiring was properly maintained.

19 CSR 30-87.020(25) Plumbing per Code: A water heater drip leg in the mechanical room terminated more than a foot above the floor rather than at the required termination height.

19 CSR 30-86.022(4)(C) Range Hood Certification: Based on record review and observation the facility failed to certify a hood extinguishing system in accordance with required inspection/certification procedures; the deficiency potentially affected sixty-one residents.

19 CSR 30-86.022(9)(D) Fire Alarm System Inspections/Certifications: Based on record review and interview the facility failed to have the complete fire alarm system inspected and certified as required; the deficiency potentially affected sixty-one residents.

19 CSR 30-86.032(18) Extension Cords/Duplex Receptacles: Based on observation and interview the facility failed to ensure extension cords being used were UL-approved and properly used; observation showed three homemade extension cords in a resident's room and the deficiency potentially affected sixty-one residents.

19 CSR 30-86.047(47)(B) Physicians Orders Requirements Medication Orders: Based on interview and record review, facility staff failed to ensure physicians' written and signed orders were completed for one newly admitted resident and were not renewed at least every three months for two residents; the facility did not provide a policy for physicians' written and signed orders.

19 CSR 30-88.010(10) Advance Directive Requirements: Based on interview and record review, facility staff failed to review advance directives with residents or their representatives upon admission and annually for three sampled residents and the facility did not provide a policy regarding advance directives.