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.

PRINTED: 07/18/2025 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 29729 B. WING 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1701 NW JEFFERSON STREET BLUE SPRINGS, MO 64015 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) BENTON HOUSE OF BLUE SPRINGS 19 CSR 30-86.022(9)(E) Fire Alarm System Monthly Test Complete Fire Alarm Systems. (E) Facilities shall test by activating the complete fire alarm system at least once a month. I/II This regulation is not met as evidenced by: Class II Based on record review and an interview on 8/24/23 the facility failed to show proof they had activated the fire alarm system at least once each month. The facility census was sixty-two (62). This potentially affected sixty-two (62) of sixty-two (62) residents. Record review on 8/24/23 at 3:42 P.M. showed no record or mention of the fire alarm being activated for the months of August 2022, September 2022, December 2022, February 2023, March 2023, May 2023, June 2023, and July 2023. During an interview on 8/24/23 at 3:42 P.M. the maintenance director stated he/she sets off the fire alarms with all fire drills except overnights. He/she further stated he/she will start documenting specifically on the fire drill sheets the fire alarm was set off and on the over nights will test the fire alarm the following day and document that on the overnight fire drill sheet. 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 Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 EL2P11 If continuation sheet 1 of 6 PRINTED: 07/18/2025 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 29729 B. WING 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1701 NW JEFFERSON STREET BLUE SPRINGS, MO 64015 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) BENTON HOUSE OF BLUE SPRINGS Continued From page 1 facilities on August 27, 2007. I/II This regulation is not met as evidenced by: Class II Based on observations, interview, and record review on 8/24/23 the facility failed to record monthly pressure gage readings and valve position checks of the sprinkler system. The facility census was sixty-two (62). This potentially affected sixty-two (62) of sixty-two (62) residents. Observation on 8/24/23 at 1:51 P.M. showed no current monthly sprinkler valve check sheets in the sprinkler room or on the annual tags on the sprinkler riser. Record review on 8/24/23 at 3:42 P.M. showed no records or indication monthly valve position and pressure gauge readings were being done. During an interview on 8/24/23 at 3:42 P.M. the maintenance director stated he/she would start recording them on a monthly log in the sprinkler riser room. 19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements Trash and Rubbish Disposal. (A) Only metal or UL- or FM-fire-resistant rated wastebaskets shall be used for trash. II This regulation is not met as evidenced by: Class II Based on observation and interview on 8/24/23 the facility failed to insure all the wastebaskets were the approved types allowed. The facility Missouri Department of Health and Senior Services STATE FORM 6899 EL2P11 If continuation sheet 2 of 6 PRINTED: 07/18/2025 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 29729 B. WING 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1701 NW JEFFERSON STREET BLUE SPRINGS, MO 64015 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) BENTON HOUSE OF BLUE SPRINGS Continued From page 2 census was sixty-two (62). This potentially affected sixty-two (62) of sixty-two (62) residents. Observation during the fire safety inspection walkthrough on 8/24/23 showed the following rooms having non-fire rated or solid metal wastebaskets; Room 101 had one, Room 104 had two, Room 114 had one, Room 302 had one, Room 402 had one, Room 225 had two, Room 217 had one, Room 216 had one, Room 212 had one, and Room 201 had one. During an interview on 8/24/23 at 11:51 A.M. the maintenance director stated he/she would get with the administrator to address this with staff and the residents. 19 CSR 30-86.032(2) Substantially Constructed & Maintained The building shall be substantially constructed and shall be maintained in good repair and in accordance with the construction and fire safety rules in effect at the time of initial licensing. II/III This regulation is not met as evidenced by: Class II Based on observation and interview on 8/24/23 the facility failed to maintain the building in good repair and in accordance with the construction and fire safety rules in effect at the time of initial licensing. The facility census was sixty-two (62). This potentially affected sixty-two (62) of sixty-two (62) residents. Observations during the 8/24/23 walk through showed the following resident room's doors mechanically blocked open with various items; Missouri Department of Health and Senior Services STATE FORM 6899 EL2P11 If continuation sheet 3 of 6 PRINTED: 07/18/2025 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 29729 B. WING 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1701 NW JEFFERSON STREET BLUE SPRINGS, MO 64015 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) BENTON HOUSE OF BLUE SPRINGS Continued From page 3 Room 403, Room 404, Room 405, and Room 406. Some rooms were unoccupied at the time with the doors blocked open. All these doors were originally constructed with door closers in place to help protect the resident (evacuation) corridors from the effects of fire. NOTE: NFPA 101 does permit these types of doors to be held open with friction type holders that release with a simple pull on the door handle. During an interview on 8/24/23 at 3:42 P.M. the maintenance director and administrator both stated they are in the process of putting magnetic hold opens on the resident rooms doors as required or requested by the residents who like to have their doors open. Observation on 8/24/23 at 3:04 P.M. showed the door knob on Resident Room 223 loose. During an interview on 8/24/23 at 3:04 P.M. the maintenance director stated he/she would get the door knob tightened up. 19 CSR 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 Missouri Department of Health and Senior Services STATE FORM 6899 EL2P11 If continuation sheet 4 of 6 PRINTED: 07/18/2025 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 29729 B. WING 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1701 NW JEFFERSON STREET BLUE SPRINGS, MO 64015 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) BENTON HOUSE OF BLUE SPRINGS Continued From page 4 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 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. II/IIl This regulation is not met as evidenced by: Class III Based on record review and an interview on 8/24/23 the facility failed to show documentation the electrical wiring had been inspected within the last two years by a qualified electrician. The facility census was sixty-two (62). This potentially affected sixty-two (62) of sixty-two (62) residents. Record review on 8/24/23 at 3:42 P.M. showed no current records of an electrical inspection being done. The last electrical inspection on file had expired on 7/14/23. During an interview on 8/24/23 at 3:42 P.M. the maintenance director stated he/she would get one set up. 19 CSR 30-86.032(18) Extension Cords/Duplex Receptacles If extension cords are used, they must be Underwriters ' Laboratory (UL)-approved or shall comply with other recognized electrical appliance approval standards and sized to carry the current required for the appliance used. Only one (1) appliance shall be connected to one (1) extension Missouri Department of Health and Senior Services STATE FORM 6899 EL2P11 If continuation sheet 5 of 6 PRINTED: 07/18/2025 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 29729 B. WING 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1701 NW JEFFERSON STREET BLUE SPRINGS, MO 64015 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) BENTON HOUSE OF BLUE SPRINGS Continued From page 5 cord and only two (2) appliances may be served by one (1) duplex receptacle. If extension cords are used, they shall not be placed under rugs, through doorways or located where they are subject to physical damage. II/III This regulation is not met as evidenced by: Class III Based on observation and an interview on 8/24/23 the facility failed to prevent extension cords, 3 way and six-way adapter from being used that allow more than two electrical items to be plugged into a duplex receptacle in resident's rooms. The facility census was sixty-two (62). This potentially affected sixty-two (62) of sixty-two (62) residents. Observations during the 8/24/23 walk through showed the following resident rooms that either had extension cords with more than one item plugged into them or that had multi-plug adapters plugged in; Room 108 had a six way and a three-way adapter, Room 405 had a six-way adapter, and Room 411 had an ungrounded extension cord with two items plugged into it, During an interview on 8/24/23 at 3:42 P.M. the maintenance director stated he/she would get power strips with surge protectors to replace all of those items. Missouri Department of Health and Senior Services STATE FORM 6899 EL2P11 If continuation sheet 6 of 6