SAGEGROVE AT RAYMORE.

PRINTED: 11/15/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A. BUILDING: B. WING 11/14/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 2100 JOHNSTON DRIVE RAYMORE, MO 64083 NAME OF PROVIDER OR SUPPLIER BENTON HOUSE OF RAYMORE PROVIDER'S PLAN OF CORRECTION (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A2268 19 CSR 30-86.022(11)(A) Complete Sprinkler System-NFPA 13 Sprinkler Systems. (A) Facilities licensed on or after August 28, 2007, or any section of a facility in which a major renovation has been completed on or after August 28, 2007, shall install and maintain a complete sprinkler system in accordance with NFPA 13, 1999 edition. 1/II This regulation is not met as evidenced by: Class II Based on observation and interview on November 13, 2024, the facility failed to install and maintain a complete sprinkler system in accordance with NFPA 13, 1999 edition. The facility census on November 13, 2024 was sixty-seven (67). This deficiency potentially affected sixty-seven (67) of sixty-seven (67) residents. Observation from 2:33 P.M. to 4:14 P.M., showed several sprinkler heads in the facility that were missing or have a space around the escutcheon ring in the following resident rooms, corridors and other spaces in the building. (AL laundry room, Orchord laundry room, in hallway near the by Groves' wing, hallway outside of Director of Nursing and storage room, resident room 401, resident room 214, and outside of resident room 106) (These missing and spaces around the escutcheon rings can and will allow smoke to travel to other parts of the facility) During an interview on November 13, 2024 at 6:25 P.M., the Maintenance Director said, they would get them fixed. Missouri Department of Health and Senior Services R PROVJDER/SUPPLIER REPRESENTATIVE'S SIGNATURE (X6) DATE 3W0S11 PRINTED: 11/15/2024 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: < SUILBING: COMPLETED Ee ae 11/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2100 JOHNSTON DRIVE RAYMORE, MO 64083 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) BENTON HOUSE OF RAYMORE A3214; 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 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/III This regulation is not met as evidenced by: Class III Based on record review and interview on November 13, 2024, the facility failed to ensure electrical wiring was maintained in good repair and did not present a safety hazard. The facility census on November 13, 2024 was six-seven (67). This deficiency potentially affected -seven (67) of -seven (67) residents. Record review at 4:27 P.M. showed there was not a current Electrical Wiring Inspection, which is required every two (2) years. Missouri Department of Health and Senior Services STATE FORM 6899 3W0S11 If continuation sheet 2 of 3 PRINTED: 11/15/2024 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, BUI BIRE COMPLETED NIN 11/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2100 JOHNSTON DRIVE RAYMORE, MO 64083 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) BENTON HOUSE OF RAYMORE Continued From page 2 During an interview on November 13, 2024 at 2:00 P.M., the Maintenance Director said, they thought it was done but cannot find the paperwork, but it will be scheduled next week. Missouri Department of Health and Senior Services STATE FORM 6899 3W0S11 If continuation sheet 3 of 3 a PLAN OF CORRECTION Provider/Supplier Benton House of Raymore Name: City, Zip: ey iia 2100 Johnston Drive Raymore, MO 64083 Date of Survey: 11/14/24 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER COMPLETION DATE ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) The facility will maintain a complete Sprinkler System in accordance with NFPA 13 1999 edition. The sprinkler heads identified will have the space surrounding the Escutcheon rings repaired by Keller Fire to prevent the potential passage of smoke to other parts facility (AL Laundry room, Orchard Laundry room, hallway near Groves, hallway outside Director of Nursing/storage room, resident room 401, resident room 214, and outside resident room 106). The facility will complete an audit of sprinkler heads and escutcheon rings to prevent potential smoke to other parts of the facility. The facility Maintenance Director will ensure the scope of work is performed correctly by Keller Fire for the sprinkler heads identified and address any new concerns identified through the facility audit appropriately. The facility Maintenance Director or designee will complete a monthly audit of these Sprinkler heads for the next 3 months and bring the findings to the Executive Director for further action if needed. The facility will maintain the electrical wiring in accordance with the requirements of the National Electrical Code and National Fire Protection Association by having an Electrical wiring inspection completed every two years. The facility has a completed and current “Certificate of Electrical Wiring” completed by a Licensed Electrician (Mike Hagen Electric Inc) on 11/19/24. The facility will maintain proper documentation of the Certification of Electric Wiring. The facility Maintenance Director will ensure this inspection is completed every 2 years or more, any new Electrical Wiring issues will be brought to the Executive Director for further action if needed. A2268 12/20/24 A3214 12/14/24 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: 12/14/2023 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 Cc 29896 B. WING ____. 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2100 JOHNSTON DRIVE RAYMORE, MO 64083 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x8) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) BENTON HOUSE OF RAYMORE 19 CSR 30-86.047(35) Protective Oversight 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 regulation is not met as evidenced by: Class I Based on observation, interview and record review, the facility failed to ensure side rail assessments were completed for two sampled residents (Residents #1, and #2,), to ensure physician's orders for two residents with side rails (Residents #1 and #2), and to ensure staff were appropriately trained on the risk of side rails for two sampled residents (Residents #1, and #2) out of five sampled residents. The facility census was 59 residents. Review of undated policy entitled “Use of Bed Side Rail Guidelines" showed: -It is the policy to allow the use of bed side rails only if ordered by a Resident's physician. -Regardless, only half be side rails were permitted. -Use of side rules are only approved after other options have been considered, and the responsible party had been made aware of the potential risk of use. -A copy of the physician's order for half bed side rails was kept in the resident's file. -A copy of the completed bed side rail assessment was completed and signed by the reviewer and Missouri Department of Health and Senior Services OR PRO¥IDER/SUPPLIER REPRESENTATIVE'S SIGNATURE ITLE (X6) DATE Wiww11 if continuation sheet 1 of 4 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 29896 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 2100 JOHNSTON DRIVE BENTON HOUSE OF RAYMORE RAYMORE, MO 64083 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG (x4) ID PREFIX TAG Continued From page 1 responsible party. -Care plans were updated to reflect the use of half bed side rails in the Ambulation section of the care plan. -Continued use of half be side rails was confirmed during the regular assessment(s) or as needs change. -Confirmed continued use was documented on the care plan. -Regional Director and Director of Quality Assurance was alerted prior to approval of use of half bed side rails. -Regional Director approved all use of half bed side rails. 1. Review of Resident #1's Face Sheet showed he/she was admitted on 4/19/23 with diagnosis of: -Dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). -Osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes). -High blood pressure. Review of the resident's Status and Care Plan, undated showed he/she did not have side rails. Review of the resident's active physician's orders as of 11/27/23 showed no physician's order for side rails. Review of the resident's complete medical record on 11/28/23 showed there was no Risk Assessment for the use of side rails. Observation on 11/28/23 at 9:22 A.M., showed: Missouri Department of Health and Senior Services STATE FORM 6899 w1wwi1 PRINTED: 12/14/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 12/05/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (x5) COMPLETE DATE If continuation sheet 2 of 4 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 29896 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 2100 JOHNSTON DRIVE BENTON HOUSE OF RAYMORE RAYMORE, MO 64083 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG (x4) ID PREFIX TAG Continued From page 2 -There were 1/2 side rails (side rails one half the length of the bed) on both sides of the resident's bed. -He/she was unable to answer questions. 2. Review of Resident #2's Face Sheet showed he/she was admitted on 2/23/21 with diagnosis of: -Dementia. -Poor short term memory. -Confusion. Review of the resident's Status and Care Plan, undated showed he/she did not have side rails. Review of the resident's active physician's orders as of 11/27/23 showed no physician's order for side rails. Record review of the resident's complete medical record on 11/28/23 showed there was no Risk Assessment for the use of side rails. Observation on 11/28/23 at 9:43 A.M., showed: -There were half side rails on both sides of the resident's bed. -He/she was unable to answer questions. 3. During an interview on 12/5/23 at 9:40 A.M. P.M., Certified Medication Technician (CMT) A said: -Resident #1 was the only resident with bed rails. -The bed rails were to assist the resident when getting him/her out of bed. -He/she did not do anything with the bed rails. -The bed rails were affixed to the bed and did not move. During an interview on 12/5/23 at 9:43 A.M., Missouri Department of Health and Senior Services STATE FORM 6899 w1wwi1 PRINTED: 12/14/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 12/05/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (x5) COMPLETE DATE If continuation sheet 3 of 4 PRINTED: 12/14/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 29896 — 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2100 JOHNSTON DRIVE RAYMORE, MO 64083 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) BENTON HOUSE OF RAYMORE Continued From page 3 Certified Nurse's Aide (CNA) A said: -Resident #1 was the only resident that had side rails on his/her bed. -The side rails were to help the resident maneuver and get out of bed. -He/she did not do anything with the side rails. During an interview the Regional Service Director (RSD) said: -No residents had side rails. -The facility did not use side rails. -There would be an order by the doctor for a resident to have side rails. -The side rails would be documented in the resident's status care plan. -Side rails were a hazard and caused falls and allowed resident to get trapped in them. -No one had been notified of the resident's use of side rails. Missouri Department of Health and Senior Services STATE FORM 6e98 wiwwt11 If continuation sheet 4 of 4 PLAN OF CORRECTION Provider Name: Benton House of Raymore Street Address, City, Zip: 2100 Johnston Dr. Raymore, MO 64083 Date of Survey: 12/05/2023 Provider number: | 29896 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE A47T76 The facility will provide Protective Oversight 24 hours a day for all residents. The facility will provide a side rail assessment for residents that require a full or half bedrail prior to installation. Each resident requiring a side or half bedrail will have a written physician‘s order documented in the resident record. Bedrails for resident's #1 and #2 have been removed. The facility will perform an audit of current resident beds pertaining to full or half bedrails and address appropriately according to Benton House A6.2.10 “Use of Bed Side Rails” policy. All new full or half rails coming into the facility will be compliant with A6.2.10 “Use of Bed Side Rails” policy prior to installation or admission. Facility will notify third party agreements with our outside vendors that full or half rails are not allowed unless Executive Director or Resident Services Director has approved their installation in accordance with A6.2.10 “Use of Bed Side Rails” policy. The facility Maintenance Director or designee will complete a monthly bedrail audit for the next 3 months and bring the findings to the Executive Director and Resident Services Director for further action if needed. Resident Services Director will in-service clinical team members A6.2.10 “Use of Bed Side Rails” policy and the risks associated with full or half rails. Corrective Action will be completed by 1/14/2024 1/14/2024 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.