GARDENS AT BARRY ROAD, THE.

PRINTED: 04/06/2026 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X1) PROVIDER/SUPPLIERJCLIA (X2) MULTIPLE CONSTRUCTION (X93) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED c B. WING 03/23/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8300 NW BARRY ROAD KANSAS CITY, MO 64153 (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) GARDENS AT BARRY ROAD, THE A8030 19 CSR 30-88,010(29) Dignity/Privacy Each resident shall be treated with consideration, respect, and full recognition of his or her dignity and individuatity, including privacy in treatment and care of his or her personal needs. All persons, other than the attending physician, the facility personnel necessary for any treatment or personal care, or the department or Department of Mental Health staff, as appropriate, shall be excluded from observing the resident during any time of examination, treatment, or care unless consent has been given by the resident. II/Ill This reguiation is not met as evidenced by: Class Ill Based on interview, and record review, the facility staff failed to treat one resident (Resident #1) of three sampled residents with consideration, dignity, and respect when Level One Medication Aide (L1MA) A yelled at and spoke disrespectfully to the resident. The facility census was 28. Review of the facility policy titled, "Resident Rights,” dated 6/2025 showed residents had the right to be accepted and treated with respect and dignity 1. Review of Resident #1's medical file showed: -Admit date was 03/28/25; -Diagnoses included: Dementia and history of stroke. Review of a video date and time stamped on 03/07/26 between 10:11 A.M. -10:17 A.M. in the resident's room showed: -L1MAA exited the resident's room and said that he/she was going to get gloves and would be back; Missouri Department of Health and Senior Senyice es LABORATORY DIRGCTOR'S OR PROVIDER/SPPLIER rf ESENTATIVE'S SIGNATURE TITLE . (X8) DAT! LAWS AAAS | A | \ Ig gp CKELADV LAVILTR STATE FOR LY 6889 LMEQ1 ’ continuation sheet 1 of 2 PRINTED: 04/06/2026 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 03/23/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8300 NW BARRY ROAD KANSAS CITY, MO 64153 (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) GARDENS AT BARRY ROAD, THE A8030 19 CSR 30-88.010(29) Dignity/Privacy Each resident shall be treated with consideration, respect, and full recognition of his or her dignity and individuality, including privacy in treatment and care of his or her personal needs. All persons, other than the attending physician, the facility personnel necessary for any treatment or personal care, or the department or Department of Mental Health staff, as appropriate, shall be excluded from observing the resident during any time of examination, treatment, or care unless consent has been given by the resident. II/III This regulation is not met as evidenced by: Class III Based on interview, and record review, the facility staff failed to treat one resident (Resident #1) of three sampled residents with consideration, dignity, and respect when Level One Medication Aide (L1MA) A yelled at and spoke disrespectfully to the resident. The facility census was 28. Review of the facility policy titled, "Resident Rights," dated 6/2025 showed residents had the right to be accepted and treated with respect and dignity 1. Review of Resident #1's medical file showed: -Admit date was 03/28/25: -Diagnoses included: Dementia and history of stroke. Review of a video date and time stamped on 03/07/26 between 10:11 A.M. -10:17 A.M. in the resident's room showed: -L1MAA exited the resident's room and said that he/she was going to get gloves and would be back; Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 LMEQ11 If continuation sheet 1 of 2 PRINTED: 04/06/2026 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 03/23/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8300 NW BARRY ROAD KANSAS CITY, MO 64153 (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) GARDENS AT BARRY ROAD, THE Continued From page 1 -At 10:14 A.M. L1MAA returned to the resident's room. As L1MAA walked into the room the L1MA said "He/She's just getting on my nerves. He/She just wants to push buttons, knowing | was already here": -L1MAA then walked over to where the resident was but was out of view on camera; -L1MAA and the resident could both be heard yelling at one another but the words they were saying could not be understood; -L1MAA then walked towards the door and said "Your running around here thinking you can talk smart to everybody. You got something to say about everything. Take care of you!". -L1MAA then walk out and slammed the door. During an interview on 3/23/26 at 2:10 P.M., the facility administrator said: -She expected all residents to be treated with dignity and respect; -The way LIMAA treated the resident in the video was unacceptable. MO261140 Missouri Department of Health and Senior Services STATE FORM 6899 LMEQ11 If continuation sheet 2 of 2 PLAN OF CORRECTION Provider/Supplier Nuiriey The Gardens at Barry Road Street Address, 8300 NW Barry Road City, Zip: Kansas City, MO 64153 Date of Survey: 3/23/2026 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 23774 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} DATE This plan of correction is submitted as required under State Law to correct noted deficient practices that could affect all residents. The submission of this plan shall not constitute or be construed as an admission by The Gardens at Barry Road of the allegations found by the surveyor(s) nor the conclusions drawn therefrom. This plan of correction shall serve as our credible letter alleging compliance, which will be effective by April 30, 2026. Compliance will be maintained as provided in the plan of correction. 19 CSR 30-88.010(29) Dignity/Privacy The Executive Director (ED) immediately suspended LIMA A pending investigation of the reported interaction with Resident #1, Following completion of the investigation, LIMA A’s employment was terminated for failure to treat the resident with dignity and respect in accordance with facility policy. A8030 4/30/26 The ED or designee will ensure all staff are educated on Resident Rights upon hire and at least annually thereafter, with emphasis on treating all residents with dignity, respect, and professionalism at all times, regardless of behaviors or circumstances. The ED, Health Services Director (HSD), and/or | Memory Care Director (MCD), or designee, will provide timely coaching and/or disciplinary action, up to and including termination, for any violations. L | | a! 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: 03/09/2026 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X17) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 23774 B.WING 02/24/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8300 NW BARRY ROAD KANSAS CITY, MO 64153 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) GROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) GARDENS AT BARRY ROAD, THE A8023 19 CSR 30-88.010(23) Develop/Implement A/N A8023 Policies The facility shall develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of any resident and misappropriation of resident property and funds, and develop and implement policies that require a report to be made to the department for any resident or to both the department and the Department of Mental Health for any vulnerable person whom the administrator or employee has reasonable cause to believe has been abused or neglected. IIItII This regulation is not met as evidenced by: Class II* *Higher class merited due to extent of violation. Based on interview and record review the facility failed to implement their written policies and procedures that prohibited abuse of any resident when staff failed to report the allegations to management immediately. In addition, the facility failed to keep the alleged person away from the resident (Resident #1) during the investigation into allegations of physical and sexual abuse, when they allowed the alleged person ta take the resident offsite the day after the allegations were made prior to the conclusion of the facility's investigation. The facility census was 31. Review of the facility policy titled, "Abuse and Neglect," revised 10/17/19 showed: -Staff were to immediately report any event or allegation so that it could be reported to DHSS. -Identification and removal of the alleged person was part of the facility's investigation; -If the alleged person was another resident or a visitor, during the investigation process, the Missouri Department of Health and Senior Servige SIGNATHYRE If continuation sheet 1 of 6 PRINTED: 03/09/2026 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 02/24/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8300 NW BARRY ROAD KANSAS CITY, MO 64153 (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) GARDENS AT BARRY ROAD, THE A8023 19 CSR 30-88.010(23) Develop/Implement A/N Policies The facility shall develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of any resident and misappropriation of resident property and funds, and develop and implement policies that require a report to be made to the department for any resident or to both the department and the Department of Mental Health for any vulnerable person whom the administrator or employee has reasonable cause to believe has been abused or neglected. II/III This regulation is not met as evidenced by: Class II* *Higher class merited due to extent of violation. Based on interview and record review the facility failed to implement their written policies and procedures that prohibited abuse of any resident when staff failed to report the allegations to management immediately. In addition, the facility failed to keep the alleged person away from the resident (Resident #1) during the investigation into allegations of physical and sexual abuse, when they allowed the alleged person to take the resident offsite the day after the allegations were made prior to the conclusion of the facility's investigation. The facility census was 31. Review of the facility policy titled, "Abuse and Neglect," revised 10/17/19 showed: -Staff were to immediately report any event or allegation so that it could be reported to DHSS. -ldentification and removal of the alleged person was part of the facility's investigation; -If the alleged person was another resident or a visitor, during the investigation process, the Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 Wwy9211 If continuation sheet 1 of 6 PRINTED: 03/09/2026 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 02/24/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8300 NW BARRY ROAD KANSAS CITY, MO 64153 (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) GARDENS AT BARRY ROAD, THE Continued From page 1 facility was to protect the resident which included removing the alleged abuser from the patient care setting, prohibiting a visitor from visiting the resident or having access to the facility; -All residents were to be protected from harm. Review of the facility's investigation dated 02/24/26 showed: - The resident made the allegations of abuse on 02/22/26 to Medication Aide A, Medication Aide B, and the Resident Care Coordinator (RCC); -The Memory Care Director and Administrator were not made aware of the allegations until 02/23/26 at which time the allegations were then reported to DHSS. 1. Review of Resident #1's record showed diagnoses included Alzheimer's (a progressive, irreversible neurodegenerative brain disorder). Review of a progress note documented by Medication Aide A on 02/22/26 at 9:30 A.M. showed: -While the Medication Aide A was assisting the resident with a shower, the resident repeatedly asked if Medication Aide A was going to hit him/her like his/her spouse did; -The resident told Medication Aide A that his/her spouse hit him/her when he/she didn't listen; -Upon Medication Aide A attempting to asssist the resident to clean his/her buttocks after having a bowel movement, the resident screamed and said stop, using both hands he/she pounded his/her fists on the shower bar stating that was what his/her spouse did to him/her. Review of a form titled " The Resident's Investigation Expectations” showed: -Interventions in place during the investigation of the abuse allegations included toileting and Missouri Department of Health and Senior Services STATE FORM 6899 Wwy9211 If continuation sheet 2 of 6 PRINTED: 03/09/2026 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 02/24/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8300 NW BARRY ROAD KANSAS CITY, MO 64153 (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) GARDENS AT BARRY ROAD, THE Continued From page 2 showering the resident with two staff present in the room, if the resident's spouse visited, it had to be in common areas, if family wanted to take resident offsite the resident was to be asked if they wanted to leave with that family member; -If the resident's spouse visited the resident in his/her apartment or took the resident offsite without agreeing first, the Administrator was to be notified immediately. During an interview on 02/24/26 at 1:57 P.M. the resident's spouse said: - He/She was confused about the allegations against him/her; -He/She would have expected the facility to protect his/her spouse from any alleged person whether the alleged person was himself/herself or anyone else, during the facility's investigation. During an interview on 02/24/26 at 12:14 P.M. Medication Aide A said: -On 02/22/26 while giving the resident a shower, he/she made statements that suggested his/her spouse physically and sexually abused him/her; -Upon completing the shower, he/she took the resident out to the commons area to find the Resident Care Coodinator (RCC) and Medication Aide B where the resident repeated these same statements, and demonstrated pounding his/her fists on the medication cart, and said pound pound like his/her spouse did; -He/She was made aware of the interventions in place on 02/23/25 while the facility's investigation was ongoing; -He/She was directed by the RCC to document the allegations and he/she would take care of letting the MCD know about the allegations; -He/She knew any allegations were supposed to be reported to the manager on duty, which would have been the RCC who would report on to Missouri Department of Health and Senior Services STATE FORM 6899 Wwy9211 If continuation sheet 3 of 6 PRINTED: 03/09/2026 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 02/24/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8300 NW BARRY ROAD KANSAS CITY, MO 64153 (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) GARDENS AT BARRY ROAD, THE Continued From page 3 management. During an interview on 02/24/26 at 12:00 P.M. the RCC said: -The resident made the allegations over the weekend, but could not remember what day it occurred; -He/She was made aware of the interventions in place on 02/23/25 while the facility's investigation was ongoing. -He/She thought he/she reported these allegations to the MCD the day of the allegations; -He/She knew to report any allegations of abuse to his/her supervisor immediately; -He/She expected care staff to report any allegations to him/her, so he/she could report to the MCD; During an interview on 02/24/26 at 12:47 P.M. Medication Aide B said: -Medication Aide A finished giving the resident a shower, and brought the resident to him/her where the resident repeated statements alleging his/her spouse physically and sexually abused him/her; -All allegations of abuse were to be reported to his/her manager on duty immediately; -He/She was made aware of the interventions in place on 02/23/25 while the facility's investigation was ongoing; -His/her manager on duty, the RCC was present when first hearing these allegations from the resident, so he/she assumed the RCC notified the MCD; -He/She was expected to report to the on duty manager who at that time would have been the RCC. During an interview on 02/24/26 at 12:25 P.M. the MCD said: Missouri Department of Health and Senior Services STATE FORM 6899 Wwy9211 If continuation sheet 4 of 6 PRINTED: 03/09/2026 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 02/24/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8300 NW BARRY ROAD KANSAS CITY, MO 64153 (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) GARDENS AT BARRY ROAD, THE Continued From page 4 -He/She was not aware of the allegations the resident made on 02/22/26, until 02/23/26 at which time he/she notified the Administrator; -Around the same time of becoming aware of the allegations on 02/23/26, the resident's spouse was already onsite getting ready to take the resident offsite; -He/She was unaware of what the facility's policy said about how to protect the resident if the alleged person was a family member or visitor; -He/She expected his/her staff to report any allegation of abuse to him/her immediately so it could be reported to DHSS and an investigation could be started immediately. During an interview on 02/24/26 at 4:22 P.M. the Administrator said: -He/She was not made aware of the abuse allegations until 02/23/26 at which time the resident's spouse was already onsite and preparing to take the resident offsite; -He/She intercepted the resident and his/her spouse as they were walking towards the front door to speak with the spouse about the allegations; -He/She then asked the resident if he/she was comfortable leaving with his/her spouse and he/she confirmed; -He/She was unaware of what his/her policy said regarding protection of the resident from the alleged person during their investigation; -Had he/she known about the allegations when they arose on 02/22/26, he/she would have had time to process everything, have guidance from corporate, and would not have let the resident leave the facility with his/her spouse as a precaution while they completed their investigation; -He/She expected all staff to report any allegation of abuse immediately so he/she could report to Missouri Department of Health and Senior Services STATE FORM 6899 Wwy9211 If continuation sheet 5 of 6 PRINTED: 03/09/2026 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 02/24/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8300 NW BARRY ROAD KANSAS CITY, MO 64153 (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) GARDENS AT BARRY ROAD, THE A8023 Continued From page 5 DHSS and begin his/her investigation into the allegations. -He/She expected all residents to be kept safe during their investigation into any and all abuse allegations. -No reeducation with staff on reporting abuse and neglect had been started yet. MO260901 Missouri Department of Health and Senior Services STATE FORM 6899 Wwy9211 If continuation sheet 6 of 6 i Supplier | The Gardens at Barry Road ame: PLAN OF CORRECTION Street Address, City, Zip: 8300 NW Barry Road Kansas City, MO 64153 Date of Survey: ID PREFIX TAG 2/24/26 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 23774 PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE A8023 This plan of correction is submitted as required under State Law te correct noted deficient practices that could affect all residents. The submission of this plan shall not constitute or be construed as an admission by The Gardens of Barry Road of the allegations found by the surveyor(s) nor the conclusions drawn there from. This plan of correction shall serve as our credible letter alleging compliance, which will be effective by March 30, 2026. Compliance will be maintained as provided in the plan of correction. 19 CSR 30-88.010(23) Develop/Implement A/N Policies Any supervisor or director who has completed A/N training and fails to immediately report suspected A/N to the Executive Director will be subject to disciplinary action, up to and including immediate termination, in accordance with existing facility policy. To ensure successful implementation of the existing A/N policy, the Executive Director, Memory Care Director, or designee will provide in-service training to all supervisors and department directors regarding the requirement to immediately report any suspected A/N to the Executive Director so that prompt action can be taken in accordance with the A/N policy. 3/30/26 All remaining staff will receive in-service training reinforcing the requirement to immediately report any suspected A/N to their supervisor, in accordance with the policy. All trainings will be completed and documented by March 30, 2026. To ensure ongoing compliance, all new hires will continue to receive A/N training at the time of hire in accordance with the facility's policy, which includes the requirement for immediate reporting of suspected A/N. In addition, all staff will continue to receive A/N training at least twice per year. All trainings will be documented. The Executive Director will review training documentation monthly to ensure completion and continued compliance with the facility's Abuse/Neglect policy. ITIL 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.

Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A, BUILDING: 23774 B. WING NAME OF PROVIDER OR SUPPLIER 8300 NW BARRY ROAD NS AT ROAD, THE SARDENSAT Beatie KANSAS CITY, MO 64153 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A8023) 19 CSR 30-88.010(23) Develop/Implement A/N Policies The facility shall develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of any resident and misappropriation of resident property and funds, and develop and implement policies that require a report to be made to the department for any resident or to both the department and the Department of Mental Health for any vulnerable person whom the administrator or employee has reasonable cause to believe has been abused or neglected. IIAlI This reguiation is not met as evidenced by: Class II* Based on interview and record review the facility failed to develop and implement written abuse policies and procedures when Resident #2's emergency contact was not notified when Resident #1 smacked Resident #2's arm with the back of his/her hand. This deficient practice affected one of two sampled residents. The facility census was 31 residents. Review of the facility's Abuse and Neglect policy revised on 10/17/19, showed that as part of the facility's investigation into any abuse or neglect allegation, notification to the resident's emergency contact was required. Review of the facility's Abuse and Neglect investigation dated 10/06/25 showed: -Resident #1 entered Resident #2's room through the open door, and when Resident #2 tald Resident #1 to leave his/her room, he/she refused, and then smacked Resident #2's arm with the back of his/her hand; -Residents were immediately separated by Level Missoul) Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROWIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE ATE FORM 6089 ‘t | OPIOt (X2) MULTIPLE CONSTRUCTION PRINTED: 10/21/2025 FORM APPROVED {X3) DATE SURVEY COMPLETED Cc 10/14/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETE DATE TITLE (X6) DATE Hf continuation sheet 1 of 4 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8300 NW BARRY ROAD GARDENS AT BARRY ROAD, THE KANSAS CITY, MO 64153 PRINTED: 10/21/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 10/14/2025 (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 A8023 19 CSR 30-88.010(23) Develop/Implement A/N Policies The facility shall develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of any resident and misappropriation of resident property and funds, and develop and implement policies that require a report to be made to the department for any resident or to both the department and the Department of Mental Health for any vulnerable person whom the administrator or employee has reasonable cause to believe has been abused or neglected. II/III This regulation is not met as evidenced by: Class II* Based on interview and record review the facility failed to develop and implement written abuse policies and procedures when Resident #2's emergency contact was not notified when Resident #1 smacked Resident #2's arm with the back of his/her hand. This deficient practice affected one of two sampled residents. The facility census was 31 residents. Review of the facility's Abuse and Neglect policy revised on 10/17/19, showed that as part of the facility's investigation into any abuse or neglect allegation, notification to the resident's emergency contact was required. Review of the facility's Abuse and Neglect investigation dated 10/06/25 showed: -Resident #1 entered Resident #2's room through the open door, and when Resident #2 told Resident #1 to leave his/her room, he/she refused, and then smacked Resident #2's arm with the back of his/her hand; -Residents were immediately separated by Level Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE STATE FORM 6399 OPI011 DEFICIENCY) (X6) DATE 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: NAME OF PROVIDER OR SUPPLIER GARDENS AT BARRY ROAD, THE (X2) MULTIPLE CONSTRUCTION A. BUILDING: KANSAS CITY, MO 64153 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 One Medication Aide (L1MA) A who was already in the room assisting Resident #2's roommate; -Both residents were assessed for injuries, no injuries were noted, physicians and responsible parties were notified. 1. Review of Resident #1's face sheet showed: - Diagnoses included: Major neurocognitive disorder (mental health disorders that primarily affect cognitive abilities including learning, memory, perception, and problem-solving), vascular dementia (a type of cognitive decline caused by damage to the blood vessels in the brain) with delusions, behavioral disturbance, impulse control disorder (difficulties in controlling impulsive behaviors, often leading to harmful or disruptive consequences), and anxiety. 2. Review of Resident #2's face sheet showed: - Diagnoses included: Dementia (a general term for a group of brain disorders that cause a gradual decline in cognitive abilities, such as memory, thinking, problem-solving, and language) and anxiety. Review of Resident #2's progress note entered by L1MAA, dated 10/06/25 at 8:20 P.M. showed: -At around 3:35 P.M. Resident #1 walked into Resident #2's room, when Resident #2 told Resident #1 to leave, Resident #1 refused to leave and then hit Resident #2 in the arm, with the back of his/her hand; -Staff separated the two residents immediately , vitals were obtained, and no complaints of pain or injuries noted; -All parties were notified. During an interview on 10/14/25 at 12:12 P.M. Resident #2's Emergency Contact said: -He/She was not aware of any altercation Missouri Department of Health and Senior Services STATE FORM 6899 OPI011 PRINTED: 10/21/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 10/14/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 8300 NW BARRY ROAD PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 2 of 4 PRINTED: 10/21/2025 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 Cc 10/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8300 NW BARRY ROAD KANSAS CITY, MO 64153 (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) GARDENS AT BARRY ROAD, THE Continued From page 2 involving his/her mother that took place on 10/06/25; -He/She was at the facility on 10/08/25 and was still never made aware of the incident; -He/She would have expected to be notified of this incident immediately. During an interview on 10/14/25 at 12:20 P.M. L1MAA said: -This was the first time completing an incident report, so L1MA B was helping him/her complete the report and he/she thought L1 MA B was going to make the phone call to Resident #2's family; -He/She did not call Resident #2's family after the incident on 10/06/25. During an interview on 10/14/25 at 12:26 P.M. L1MAB said: -He/She did not call Resident #2's family after the incident on 10/06/25, but thought other staff said they did; -L1MA's were responsible for notifying families of incidents that occurred. During an interview on 10/14/25 at 1:02 P.M. the Administrator said: -He/She was not aware that Resident #2's family was not notified of the 10/06/25 incident; -He/She contacted all staff that were working on 10/06/25 all of whom advised they did not call the family because they thought someone else was; -He/She expected whomever wrote the incident report to notify the resident's family; -In this incident, L1MAA was new and still being trained by L1MA B, there appeared to be a break down in the procedure as each staff thought the other was notifying the resident's family; -He/She expected families to be notified after any allegation or incident of abuse or neglect. Missouri Department of Health and Senior Services STATE FORM 6899 OPI011 If continuation sheet 3 of 4 PRINTED: 10/21/2025 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 Cc 10/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8300 NW BARRY ROAD KANSAS CITY, MO 64153 (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) GARDENS AT BARRY ROAD, THE A8023 Continued From page 3 *The higher classification merited due to the extent of the violation. MO258714 Missouri Department of Health and Senior Services STATE FORM 6899 OPI011 If continuation sheet 4 of 4 PLAN OF CORRECTION Provider/Supplier Rong The Gardens at Barry Road Street Address, 8300 NW Barry Road City, Zip: Kansas City, MO 64153 Date of Survey: 10/14/2025 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 23774 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE This plan of correction is submitted as required under State Law to correct noted deficient practices that could affect all residents. The submission of this plan shall not constitute or be construed as an admission by The Gardens of Barry Road of the allegations found by the surveyor(s) nor the conclusions drawn there from. This plan of correction shall serve as our credible letter alleging compliance, which will be effective on or before 10/14/25. Compliance will be maintained as provided in the plan of correction. 19 CSR 30-88.010(23) Develop/Implement A/N Policies. The facility shall develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of any resident and misappropriation of resident property and funds, and develop and implement policies that require a report to be made to the department for any resident or to both the department and the Department of Mental Health for any vulnerable person whom the administrator or employee has reasonable cause to believe has been abused or neglected. MAIL. The Gardens at Barry Road maintains written policies and procedures that strictly prohibit the mistreatment, neglect, or A8023 abuse of any resident, as well as the misappropriation of 10/17/25 resident property or funds. These policies require notification to the resident’s designated emergency contact or resident representative in the event of any incident involving potential harm, injury, or risk. During this recent incident, a new staff member was being trained on the procedure by another staff member. Implementation failed because it was unclear whether the trainer or the trainee was responsible for notifying the resident’s emergency contact. The Executive Director (ED), Health Services Director (HSD), and Memory Care Director (MCD) have clarified and redefined responsibilities to eliminate any ambiguity regarding notification duties for reportable incidents. Effective immediately, when MCD, HSD, or ED is notified of a reportable incident, the department director or designee (ED, HSD, or MCD) will personally ensure that the resident’s emergency contact is notified. ED will audit future reportable incidents to verify that required notifications are documented and completed. Ongoing compliance will be monitored through routine quality assurance meetings. 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: 04/05/2024 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. BUILDING: COMPLETED 23774 B. WING 03/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8300 NW BARRY ROAD KANSAS CITY, MO 64153 41D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x8) 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) GARDENS AT BARRY ROAD, THE A7013 19 CSR 30-87,.030(11) Food-Safe, Obtain From Appropriate Sources Food shall be in sound condition, free from spoilage, filth or other contamination and shall be safe for human consumption. Food shall be obtained from sources that comply with all laws relating to food and food labeling. The use of food in hermetically sealed containers that was not prepared in a food-processing establishment is prohibited. Nothing in this section shall prohibit facilities from using fresh vegetables or fruits purchased from farmers ' markets or obtained from the facility garden or residents ' family gardens. I/ll This regulation is not met as evidenced by: Class lk *Higher classification due to the extent of the violation. Based observation and interview, the facility failed to ensure food was in sound condition, free from spoilage, or other contamination and safe for human consumption, when facility staff did not date food when it was opened and did not dispose of outdated food. This had the potential to affect all residents. The facility census was 31. No policy was provided regarding food storage and labeling. 1. Observation of the preparation station refrigerator in the main kitchen on 03/27/24 at 10:11 A.M., showed: | -22 sandwiches wrapped in plastic, prepared on 03/19/24 with a use by date of 03/24/24; -A pitcher of what looked like tomato juice or | tomato sauce, was prepared on 03/21/24 and | was to be used by 03/26/24; Missouri Depgrtment of Health and Senior Services If c@ntinuation sheet 1 of § Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER GARDENS AT BARRY ROAD, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) PRINTED: 06/22/2024 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED 03/27/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 8300 NW BARRY ROAD KANSAS CITY, MO 64153 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A7013, 19 CSR 30-87.030(11) Food-Safe, Obtain From Appropriate Sources Food shall be in sound condition, free from spoilage, filth or other contamination and shall be safe for human consumption. Food shall be obtained from sources that comply with all laws relating to food and food labeling. The use of food in hermetically sealed containers that was not prepared in a food-processing establishment is prohibited. Nothing in this section shall prohibit facilities from using fresh vegetables or fruits purchased from farmers ' markets or obtained from the facility garden or residents ' family gardens. I/II This regulation is not met as evidenced by: Class II *Higher classification due to the extent of the violation. Based observation and interview, the facility failed to ensure food was in sound condition, free from spoilage, or other contamination and safe for human consumption, when facility staff did not date food when it was opened and did not dispose of outdated food. This had the potential to affect all residents. The facility census was 31. No policy was provided regarding food storage and labeling. 1. Observation of the preparation station refrigerator in the main kitchen on 03/27/24 at 10:11 A.M., showed: -22 sandwiches wrapped in plastic, prepared on 03/19/24 with a use by date of 03/24/24: -A pitcher of what looked like tomato juice or tomato sauce, was prepared on 03/21/24 and was to be used by 03/26/24; Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 04/16/24 STATE FORM 6899 DC8911 If continuation sheet 1 of 5 PRINTED: 06/22/2024 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. BUILDING: COMPLETED 03/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8300 NW BARRY ROAD KANSAS CITY, MO 64153 (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) GARDENS AT BARRY ROAD, THE Continued From page 1 -A package of hotdog's that were open to air. 2. Observation of the grill area in the main kitchen on 03/27/24 at 10:15 A.M., showed: -19 peanut butter and jelly sandwiches wrapped in plastic, unlabeled and undated on the preparation station counter; 3. Observation of the refrigerator in the memory care kitchen on 03/27/24 at 11:00 A.M. showed: -Chocolate pudding prepared on 03/16/24, with no discard date; -A container of peaches of cream prepared on 3/24/24, with no discard date; -Three sandwiches wrapped in plastic unlabeled and undated. During an interview on 3/27/24 2:03 P.M., the Culinary Services Director said: -All foods should be covered, labeled, and dated; -All foods should have been discarded in a timely manner after their use by date. During an interview on 03/27/24 at 2:53 P.M. the Executive Director said: -All foods in the refrigerator should be labeled and dated; -Outdated and spoiled foods should be disposed of; -It was the dietary manager's responsibility to ensure the refrigerator is cleaned out regularly. 19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS At all times, including while being stored, prepared, displayed, served or transported to or from the facility, food shall be protected from potential contamination, including dust, insects, Missouri Department of Health and Senior Services STATE FORM 6899 DC8911 If continuation sheet 2 of 5 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER GARDENS AT BARRY ROAD, THE (X2) MULTIPLE CONSTRUCTION A. BUILDING: KANSAS CITY, MO 64153 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 rodents, unclean equipment and utensils, unnecessary handling, coughs and sneezes, flooding, drainage and overhead leakage or overhead drippage from condensation. The temperature of potentially hazardous food shall be forty-five degrees Fahrenheit (45°F) or below or one hundred forty degrees Fahrenheit (140°F) or above at all times, except as otherwise provided in this section. In the event of a fire, flood, power outage or similar event that might result in the contamination of food, or that might prevent potentially hazardous food from being held at required temperatures, the person in charge shall immediately contact the Department of Health and Senior Services (the department). Upon receiving notice of this occurrence, the department shall take whatever action that it deems necessary to protect the residents. II/III This regulation is not met as evidenced by: Class II *Higher classification due to the extent of the violation. Based observation and interview, the facility failed to ensure food was stored and prepared in a way that protected the food from potential contamination, and stored at the appropriate temperature when the staff failed to keep all prepared food covered, and failed to ensure two refrigerators storing potentially hazardous food were 45 degrees or below. This had the potential to affect all residents. The facility census was 31. No policy was provided regarding food temperatures. 1. Observation of the preparation station refrigerator in the main kitchen on 03/27/24 at Missouri Department of Health and Senior Services STATE FORM 6899 DC8911 PRINTED: 06/22/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 03/27/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 8300 NW BARRY ROAD PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 3 of 5 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER GARDENS AT BARRY ROAD, THE (X2) MULTIPLE CONSTRUCTION A. BUILDING: KANSAS CITY, MO 64153 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 10:11 A.M., showed: -The thermometer located in the back (the coldest part) of the refrigerator read 50 degrees; -22 cheese sandwiches were prepared and wrapped in plastic; -A package of hotdog's that were open to air. 2. Observation of the grill area in the main kitchen on 03/27/24 at 10:15 A.M., showed: -A pan of bacon on the counter uncovered; -A pan of cornbread uncovered; -A pan of eggs uncovered; -A pan of baked beans in the steam table, uncovered. 3. Observation of the refrigerator in the memory care kitchen on 03/27/24 at 11:00 A.M. showed: -The thermometer located in the back of the refrigerator read 46 degrees; -A container chocolate pudding; -A container of peaches of cream; -Three sandwiches wrapped in plastic. During an interview on 03/27/24 2:03 P.M., the Culinary Services Director said: -All foods should be covered to prevent any dust or particles from contamination; -All refrigerators should be between 32 to 42 degrees, and if outside that range, she expected her staff to immediately discard all items inside the refrigerator. During an interview on 03/27/24 at 2:53 P.M. the Executive Director said: -All refrigerators should be kept within the appropriate range, less than 45 degrees; -Any refrigerator found to be outside the range should be reported to the Culinary Services Director, and the spoiled food should be discarded immediately; Missouri Department of Health and Senior Services STATE FORM 6899 DC8911 PRINTED: 06/22/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 03/27/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 8300 NW BARRY ROAD PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 4 of 5 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8300 NW BARRY ROAD GARDENS AT BARRY ROAD, THE KANSAS CITY, MO 64153 PRINTED: 06/22/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 03/27/2024 (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 Continued From page 4 -All food should be kept covered when not serving to prevent potential contamination; -It was the dietary manager's responsibility to ensure the refrigerators were in proper working condition, and all foods were kept covered. Missouri Department of Health and Senior Services STATE FORM oeee DC8911 DEFICIENCY) If continuation sheet 5 of 5 PLAN OF CORRECTION Provider/Supplier Name: The Gardens at Barry Road Street Address, 8300 NW Barry Road City, Zip: Kansas City, MO 64153 Date of Survey: 3/27/2024 ID PREFIX TAG PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 23774 COMPLETION DATE This plan of correction is submitted as required under State Law to correct noted deficient practices that could affect all residents. The submission of this plan shall not constitute or be construed as an admission by The Gardens of Barry Road of the allegations found by the surveyor(s) nor the conclusions drawn there from. This plan of correction shall serve as our credible letter alleging compliance, which will be effective by April 19, 2024. Compliance will be maintained as provided in the plan of correction. A?013 19 CSR 30-87.030(11) Food-Safe, Obtain From Appropriate Sources- Culinary Services Director, or designee, will train current and future dietary staff of proper food/drink labeling, when to discard expired food, and when to cover/seal food and drinks. Dietary staff in Memory Care will complete attached checklist and turn it into Culinary Services Director daily. This checklist includes lines for 1) labeling any food in fridge with what it is and the date and 2} Discarding any food or beverages in fridge that have expired or have no date. Ongoing compliance will be met by Culinary Services Director, or designee, reviewing checklists for completion and auditing MC kitchen for completion of all tasks and proper food coverage every working day for 30 days after In-Service training. Corrective action will be taken for any staff members not following set guidelines. After 30 days, CSD and ED will evaluate frequency of reviews and will adjust as necessary to a minimum of at least weekly. 4/19/24 A7015 19 CSR 30-87 .030(13) Food-Protected, Temp, Need to Contact DHSS -Culinary Services Director, or designee, will train current and future staff of proper refrigerator temperatures, where thermometer should be placed in the refrigerator, what to do if.a 4/19/24 refrigerator is above temperature, and when to cover/seal food and drinks. Dietary staff in Memory Care will complete attached checklist and turn it into Culinary Services Director daily. This checklist includes lines for 1) labeling any food in fridge with what it is and the date and 2) Discarding any food or beverages in fridge that logs above temp. Ongoing compliance will be met by Culinary Services Director, or designee, reviewing checklists for completion and auditing MC kitchen for completion of all tasks and proper food coverage every working day for 30 days after In-Service training. Corrective action will be taken for any staff members not following set guidelines. After 30 days, CSD and ED will evaluate frequency of reviews and will adjust as necessary to a minimum of at least weekly. 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.

Could not obtain an administrator signature, since a new administrator took over. PRINTED: 04/07/2025 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 23774 B. WING 12/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8300 NW BARRY ROAD KANSAS CITY, MO 64153 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) GARDENS AT BARRY ROAD, THE 19 CSR 30-86.022(12)(A) Emergency Lighting - locations Emergency Lighting. (A) Emergency lighting of sufficient intensity shall be provided for exits, stairs, resident corridors, and required attendants ' station. II This regulation is not met as evidenced by: Class II Based on observation and an interview on 12/28/23 the facility failed to maintain all the emergency lights in good repair. The facility census was 75. This potentially affected 75 of 75 residents. Observations on 12/28/23 during the fire safety inspection walkthrough showed the following emergency lights not working; In the corridor by Room 249, In the corridor by Room 230, In the corridor by Room 236, In the corridor by Room 127, and in the first-floor stairwell by Room 117. During an interview on 12/28/23 the Regional Maintenance Director said he/she would get the facility maintenance director to do an assessment and repair as needed on all the emergency lights in the facility. 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 observations and an interview on Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 LZRX11 If continuation sheet 1 of 3 PRINTED: 04/07/2025 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 23774 B. WING 12/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8300 NW BARRY ROAD KANSAS CITY, MO 64153 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) GARDENS AT BARRY ROAD, THE Continued From page 1 12/28/23 the facility failed to insure all of the wastebaskets were the approved types allowed. The facility census was 75. This potentially affected 75 of 75 residents. Observations on 12/28/23 during the fire safety inspection walkthrough showed the following rooms with non-approved wastebaskets; Room 239 had one, Room 238 had two, Room 235B had one, Room 202 had one, Room 204 had one, Room 207 had one, Room 208 had one, Room 210 had one, Room 218 had two, and Room 119 had one. During an interview on 12/28/23 the Regional Maintenance Director said he/she would get the facility maintenance director to remove the improper wastebaskets and be sure flame retardant or metal wastebaskets were put in their place. 19 CSR 30-86.032(10) Heaters-Approved Label, Venting, No Portable In newly licensed facilities or if a new heating system is installed in an existing licensed facility, the heating of the building shall be restricted to steam, hot water, permanently installed electric heating devices or a warm air system employing central heating plants with installation such as to safeguard the inherent fire hazard, or approved installation of outside wall heaters which bear the approved label of the American Gas Association or National Board of Fire Underwriters. The foregoing requirements are applicable to residential care facilities. In assisted living facilities, the heating of the building shall be restricted to steam, hot water, permanently installed electric heating devices or a warm air Missouri Department of Health and Senior Services STATE FORM 6899 LZRX11 If continuation sheet 2 of 3 PRINTED: 04/07/2025 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 23774 B. WING 12/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8300 NW BARRY ROAD KANSAS CITY, MO 64153 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) GARDENS AT BARRY ROAD, THE Continued From page 2 system employing central heating plants with installation such as to safeguard the inherent fire hazard, or approved installation of outside wall heaters which bear the approved label of the American Gas Association or National Board of Fire Underwriters. For all facilities, oil or gas heating appliances shall be properly vented to the outside and the use of portable heaters of any kind is prohibited. If approved wall heaters are used, adequate guards shall be provided to safeguard residents. I/II This regulation is not met as evidenced by: Class II Based on observation and an interview on 12/28/23 the facility failed to ensure the use of portable space heaters was prohibited. The facility census was 75. This potentially affected 75 of 75 residents. Observation on 12/28/23 at 1:20 P.M. showed a portable electric heater plugged directly into the electrical outlet with no cord, like a night light set at 90 degrees and running. NOTE: Portable heaters are dangerous because they get hot enough to ignite paper or cloth if either were to accidentally be placed over or too close to one. During an interview on 12/28/23 at 1:20 P.M. the Regional Maintenance Director said he/she would get the facility maintenance director to remove the portable heater and explain to the staff why they are not permitted. Missouri Department of Health and Senior Services STATE FORM 6899 LZRX11 If continuation sheet 3 of 3