Deficiencies (last 5 years)
Deficiencies (over 5 years)
5.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
2% better than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
74% occupied
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Plan of Correction
Census: 66
Deficiencies: 6
Date: Apr 30, 2025
Visit Reason
The inspection was conducted to identify deficiencies in compliance with applicable laws and regulations at Cedarhurst of Blue Springs and to document the facility's plan of correction for those deficiencies.
Findings
The facility was found non-compliant with regulations regarding operator/administrator responsibilities, tuberculosis screening for residents and staff, food safety and labeling, food storage, ventilation hood cleanliness, and resident rights annual review. The facility census was 66 residents at the time of inspection.
Deficiencies (6)
19 CSR 30-86.047(6) Operator/Administrator Responsibilities: The operator failed to assure compliance with laws when placing two residents in a room licensed for one bed, lacking a policy on resident room placement.
19 CSR 30-86.047(19) TB Screen Residents & Staff: The facility failed to ensure required two-step tuberculosis screening and annual evaluations for sampled residents.
19 CSR 30-87.030(11) Food-Safe, Obtain From Appropriate Sources: The facility failed to ensure food was obtained from compliant sources, with unlabeled raw chicken, ground beef, and sour cream found.
19 CSR 30-87.030(14) Food-Clean Containers, Storage, Covers: Food was not stored in clean covered containers; uncovered prepared foods were observed in the kitchen.
19 CSR 30-87.030(55) Ventilation Hoods, Clean, Filters Removable: Ventilation hood filters were caked with grease and not properly cleaned, risking contamination.
19 CSR 30-88.010(4) Resident Rights-Admission/Annual Review: The facility failed to ensure resident rights were reviewed annually for five of six sampled residents.
Report Facts
Facility census: 66
Completion date for plan of correction: Scheduled completion date for corrective actions is 2025-05-29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hannah Brown | Executive Director | Named in plan of correction for TB screening and food safety audits |
| Chris Beckham | Dietary Services Director | Named in plan of correction for kitchen cleanliness and food labeling |
| Rae Buxton | Assistant Executive Director | Named in plan of correction for resident rights annual review monitoring |
Inspection Report
Plan of Correction
Census: 38
Deficiencies: 1
Date: Mar 7, 2024
Visit Reason
The inspection was conducted to assess compliance with protective oversight regulations, specifically regarding the use of gait belts during resident transfers.
Findings
The facility failed to provide protective oversight by not ensuring staff used gait belts during resident transfers, as evidenced by observations and interviews. The facility census was 38 residents at the time of inspection.
Deficiencies (1)
19 CSR 30-86.047(35) Protective Oversight: The facility failed to ensure staff used gait belts during resident transfers for one sampled resident. Staff were observed transferring the resident without a gait belt, contrary to policy.
Report Facts
Facility census: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mark Holleday | Executive Director | Signed the statement of deficiencies and plan of correction |
Inspection Report
Plan of Correction
Census: 70
Deficiencies: 12
Date: Oct 3, 2023
Visit Reason
This document is a Plan of Correction submitted by Cedarhurst of Blue Springs following a state inspection conducted on 10/03/2023. The plan addresses multiple deficiencies found during the inspection related to fire safety and facility maintenance.
Findings
The inspection identified multiple deficiencies including failure to document monthly fire extinguisher checks, inadequate range hood extinguishing system maintenance, lack of a written fire evacuation plan, insufficient fire drill documentation, missing proper signage for areas of refuge, failure to activate fire alarm systems monthly, dryer vent issues, improper fire door separation, lack of certified flame-retardant curtains, unapproved wastebaskets, and improper oxygen storage ventilation.
Deficiencies (12)
A2210 Fire extinguishers were not documented and dated as checked monthly. The facility census was seventy (70).
A2211 The range hood extinguishing system was not maintained or certified twice annually as required. The facility census was seventy (70).
A2215 The facility failed to produce a written fire evacuation plan including use of areas of refuge and staff responsibilities. The facility census was seventy (70).
A2217 The facility failed to document at least 12 fire drills annually, including one resident evacuation drill. The facility census was seventy (70).
A2228 The facility failed to post proper signage for areas of refuge and provide instructions for their use. The facility census was seventy (70).
A2251 The facility failed to show proof of monthly fire alarm system activation. The facility census was seventy (70).
A2258 The facility failed to keep dryer vent hoses attached and in good repair to prevent fire hazards. The facility census was seventy (70).
A2261 The facility failed to ensure fire doors provided proper separation and closed fully. The facility census was seventy (70).
A2269 The facility failed to record monthly pressure gauge and valve position checks for the sprinkler system. The facility census was seventy (70).
A2282 The facility failed to insure all curtains and drapes were certified flame-retardant or chemically treated. The facility census was seventy (70).
A2286 The facility failed to insure all wastebaskets were approved fire-resistant types. The facility census was seventy (70).
A2298 The facility failed to provide proper oxygen storage room ventilation with a constant fan. The facility census was seventy (70).
Report Facts
Facility census: 70
Number of fire drills required annually: 12
Fire drills frequency: 4
Fire drills frequency: 1
Inspection Report
Annual Inspection
Census: 54
Deficiencies: 7
Date: Jan 7, 2020
Visit Reason
The inspection was the fire safety portion of the licensure inspection conducted on 01/07/2020.
Findings
The facility failed to properly maintain multiple fire safety systems including the range hood extinguishing system, fire alarm system, clothes dryers venting and lint traps, smoke section partitions, sprinkler system, wastebaskets, and building maintenance. The administrator acknowledged the issues and scheduled repairs or replacements.
Deficiencies (7)
19 CSR 30-86.022(4)(C) Range Hood Certification. The facility failed to properly maintain the range hood and extinguishing system and lacked documentation of required semi-annual inspections.
19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain. The facility failed to provide documentation of testing and maintaining the complete fire alarm system as required.
19 CSR 30-86.022(10)(C) Clothes Dryers Vented, Lint Traps. The facility failed to properly maintain the clothes dryers and lint traps, allowing lint discharge into the laundry room.
19 CSR 30-86.022(10)(I) Smoke Section Partitions > than 20 beds. The facility failed to maintain required smoke partitions; doors did not close and latch properly.
19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing. The facility failed to properly maintain the sprinkler system and lacked documentation of monthly gauge readings.
19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements. The facility failed to ensure the use of metal or fire-resistant wastebaskets; unapproved wastebaskets were observed in multiple locations.
19 CSR 30-86.032(2) Substantially Constructed & Maintained. The facility failed to maintain the building in good repair; an access panel was disconnected and held by glue.
Report Facts
Facility census: 54
Inspection Report
Plan of Correction
Census: 42
Deficiencies: 1
Date: Aug 9, 2019
Visit Reason
The inspection was conducted to assess compliance with minimum square footage requirements per resident in multiple occupancy bedrooms at Cedarhurst of Blue Springs.
Findings
The facility failed to ensure that rooms housing multiple residents met the required minimum square footage per resident, negatively affecting six residents. The facility's census was 42 residents at the time of inspection.
Deficiencies (1)
19 CSR 30-86.012(6) Minimum Square Feet Per Resident was not met as rooms housing multiple residents did not meet the required minimum square footage, affecting six residents.
Report Facts
Residents affected: 6
Rooms reviewed: 38
Rooms with double occupancy: 6
Census: 42
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