Sagegrove at Blue Springs.

PRINTED: 08/08/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN QF CORRECTION IDENTIFICATION NUMBER; (X2) MULTIPLE CONSTRUCTION A.BUILDING: (X3) DATE SURVEY COMPLETED B. WING 29729 07/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1701 NW JEFFERSON STREET BENTON HOUSE OF BLUE SPRINGS BLUE SPRINGS, MO 64018 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE GROS8-REFERENCED TO THE APPROPRIATE DEFICIENCY) SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x6) COMPLETE DATE (4) ID PREFIX TAG A2214! 19 CSR 30-86.022(5)(A) Fire Drill/Evacuation Plan, Consultation Fire Drills and Emergency Preparedness. (A) All facllities shall have a written plan to meet potential emergencies or disasters and shail request consultation and assistance annually from a local fire unit for review of fire and evacuation plans, If the consultatton cannot be obtatned, the faaility shall inform the state fire marshal in writing and request assistance In review of the plan. An up-to-date capy of the facility's entire plan shall be provided to the local Jurisdiction ' s emergency management director. WAN : This regulation Is not met as evidenced by: Clase III Based on record review and an interview on 7/31/24 this facility failed to provide documentation a request was made for consultation and assistance annually from a local fire unit. The facility census was 66. This potentially affected 66 of 66 residents. Record review on 7/31/24 at 12:44 P.M. showed no documentation asking for and/or receiving consultation and assistance annually from a local fire unit. During an interview on 7/31/24 at 12:44 P.M. the maintenance director sald he/she had been in contact with the local fire marshal and he had said he was going to be cut In July instead of later in the year, but never showed up. 19 CSR 30-86.022(13)(D) Curtains/Drapes, Flame Resistant Interlor Finish and Furnishings. Missourl Department of Health and Senlar Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE a “Tan, TITLE Eye ened Art “ay MO DATE rr tN I STATE FORM e008 3x1211 I continuation sheet 1 of 3 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xt) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 29729 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A, BUILDING: B, WING 1704 NW JEFFERSON STREET BENTON HOUSE OF BLUE SPRINGS (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX {EACH DEFIOIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC [DENTIFYING INFORMATION) Continued From page 1 (D) All curtains and drapes In a licensed facility shall be certified or treated to be flame-resistant as defined In NFPA 101, 2000 edition. II This regulation is not met as evidenced by: Class Il Based on observation and an interview on 7/31/24 thla facility falled to show documentation on the fire resistance rating of all the drapes and/or curtains from the time of purchase and installation in the faclilty. The facility census was 66. This potentially affected 66 of 66 residents, Observation on 7/31/24 at 11:52 A.M. showed curtains over the windows in Room 402 with no flame-retardant tags on them. During an Interview on 7/31/24 at 11:52 A.M. with the maintenance director sald he/she did not put them up. He/she indicated he/she would talk fo the famlly as they must be who put them up and explain curtains must be flame retardant material or treated to be such. 19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements Trash and Rubbleh Disposal. (A) Only metal or UL- or FM-fire-resistant rated wasiebaskets shall be used for trash. Il This ragutatian Is not met as evidenced by: Class Il Based on observation and interview on 7/31/24 this facility failed to insure all the wastebaskets were the approved types allowed. The facllity consus wag 66, This potentially affected 66 of 66 Missourl Department of Health and Senior Services STATE FORM 8899 BLUE SPRINGS, MO 64015 3X1211 PRINTED: 08/08/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 07/34/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (BACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) If continuation sheet 2 of 3 i | PRINTED: 08/08/2024 FORM APPROVED | and Senlor Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED -_ 29729 B. WING 07/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1701 NW JEFFERSON STREET i BENTON HOUSE OF BLUE SPRINGS BLUE SPRINGS, MO 64015 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION x6) PREEIX (EACH DEFICIENCY MUST BE PRECERED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE : TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENGED TO THE APPROPRIATE PATE DEFICIENCY) Contlnued From page 2 A2286 residents. Observation during the fire safety Inspection, walkthrough on 7/31/24. showed the following i rooms having non-fire rated or solid metal i wastebaskets; Room 102 had ane, Roam 104 : had two, Room 231 had two, Room 227 had two, ; Roam 216 had one, Room 211 had two, Room i 201 had three, Room 311 had one, Room 408 i had ong, and Roam 414 had three, During an interview on 7/31/24 at 11:19 A.M. the maintenance director stated he/she never got my inspectlon report from last year, but thought he got most of the wastebaskets changed out and again would get with the administrator to address this with staff and the residents. | | | i | | | Missouri Department of Health and Senior Services STATE FORM ans 3x1211 If continuation sheet 3 of 3 PLAN OF CORRECTION Provider/Supplier Name: Benton House of Blue Springs Street Address, City, Zip: 1701 NW Jefferson St, Blue Springs, Mo 64015 Date of Survey: 7/31/2024 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 Fire Drill and Emergency Preparedness- A drill consultation with A2214 Jackson County has been scheduled for 8/21/2024 and one 8/21/2024 will be scheduled by the maintenance director yearly. | sss The curtains were removed from 402 immediately. 7/31/2024 P| The maintenance director will inspect all move ins to ensure proper fire-retardant curtains are in use. | | Waste baskets in 102,104,211,216,227,231,311,408,414 | 7/31/2024 _ | «| Were removed immediately and family was notified. |__| Housekeeping will inspect rooms daily for proper trash cans. | | en | | a | PF a | Ps ee SS | 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.