MCCRITE PLAZA AT BRIARCLIFF ASSISTED LIVING.

PRINTED: 03/10/2026 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 B.WING 03/03/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1201 NW TULLISON RD KANSAS CITY, MO 64116 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x) 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 DEFICIENCY) MCCRITE PLAZA AT BRIARCLIFF ASSISTED LIVING 19 CSR 30-86.022(10)(B) Combustible Materiais, Unnecessary Storage Of Protection from Hazards. (B) The storage of unnecessary combustible materials in any part of a building in which a licensed facility is located is prohibited. {/Il | This regulation is not met as evidenced by: | Class {I | Based on observation and interview, the facility | failed to keep unnecessary combustibles properly | secured while stored in the facility. This violation ' had the potential to affect ail assisted living | residents. The census was 89. Observation on 03/03/26 at 11:20 A.M. of the | basement level food storage area showed there | were four bottles of charcoal lighter fluid, three | closed bottles stored on a metal shelf and one | opened bottle on top of the ice machine. During an interview on 03/03/26 at 11:24 A.M., the Director of Dining Services said the bottles of | charcoal lighter fluid should be stored in the fire ; DOX, During an interview on 3/3/2026 at 2:59 P.M., the | Administrator said he/she agreed with the i Director of Dining Services that the bottles of : charcoal lighter fluid should be stored in the fire : box. i A7003 19 CSR 30-87.030(3) Clean Clothing, Hair | Restraints i The outer clothing of ali employees shall be clean | and employees shall use effective hair restraints | to prevent the contamination of food or food-contact surfaces. III Missouri Department of Health and Senio LABORATORY DIRECTOR'S OR PROVI /SUPPLIER REPRESENTATIVE'S SIGNATURE {X6) DATE vA STATE FORM HB1M11 If continuation sheet 1 of 8 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 MCCRITE PLAZA AT BRIARCLIFF ASSISTED LIVING (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) PRINTED: 03/10/2026 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED 03/03/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 1201 NW TULLISON RD KANSAS CITY, MO 64116 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 19 CSR 30-86.022(10)(B) Combustible Materials, Unnecessary Storage Of Protection from Hazards. (B) The storage of unnecessary combustible materials in any part of a building in which a licensed facility is located is prohibited. I/II This regulation is not met as evidenced by: Class II Based on observation and interview, the facility failed to keep unnecessary combustibles properly secured while stored in the facility. This violation had the potential to affect all assisted living residents. The census was 89. Observation on 03/03/26 at 11:20 A.M. of the basement level food storage area showed there were four bottles of charcoal lighter fluid, three closed bottles stored on a metal shelf and one opened bottle on top of the ice machine. During an interview on 03/03/26 at 11:24 A.M., the Director of Dining Services said the bottles of charcoal lighter fluid should be stored in the fire box. During an interview on 3/3/2026 at 2:59 P.M., the Administrator said he/she agreed with the Director of Dining Services that the bottles of charcoal lighter fluid should be stored in the fire box. 19 CSR 30-87.030(3) Clean Clothing, Hair Restraints The outer clothing of all employees shall be clean and employees shall use effective hair restraints to prevent the contamination of food or food-contact surfaces. III Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 HB1M11 If continuation sheet 1 of 8 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 MCCRITE PLAZA AT BRIARCLIFF ASSISTED LIVING (X2) MULTIPLE CONSTRUCTION A. BUILDING: KANSAS CITY, MO 64116 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 This regulation is not met as evidenced by: Class Ill Based on observation and interview the facility failed to ensure all employees used effective hair restraints when three employees (Cook A , Server A, and the Director of Dining Services) did not wear hair restraints while performing duties in the kitchen. This could have affected all residents. The facility census was 89. The facility did not provide a hair restraint policy. 1. Observations on 03/03/26 at 11:10 A.M., showed: -Cook A prepared food near the grill and did not have his/her hair in a restraint; -Dietary Aide A prepared individual bow!s of cake without his/her hair in a restraint; -The Director of Dining Services stood in the food preparation area and talked with kitchen staff without his/her hair in a restraint. During an interview on 03/03/26 at 11:35 A.M., the Director of Dining Services said all staff should wear a hair restraint at all times while in the kitchen. During an interview on 03/03/26 at 2:59 P.M., the Administrator said he/she expected all staff to wear a hair restraint at all times while in the kitchen. 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 Missouri Department of Health and Senior Services STATE FORM 6899 HB1M11 PRINTED: 03/10/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED 03/03/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 1201 NW TULLISON RD PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 2 of 8 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 MCCRITE PLAZA AT BRIARCLIFF ASSISTED LIVING (X2) MULTIPLE CONSTRUCTION A. BUILDING: KANSAS CITY, MO 64116 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 from the facility, food shall be protected from potential contamination, including dust, insects, 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 class merited due to extent of violation. Based on observation and interview facility staff failed to prepare food in a manner to prevent potential contamination and/or spoilage This had the potential to affect all residents. The facilty census was 89. The facility did not provide a policy regarding food preparation. 1. Observation on 03/03/26 at 11:00 A.M. of the kitchen showed: -Two large pans with two large, prepared, loaves Missouri Department of Health and Senior Services STATE FORM 6899 HB1M11 PRINTED: 03/10/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED 03/03/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 1201 NW TULLISON RD PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 3 of 8 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 MCCRITE PLAZA AT BRIARCLIFF ASSISTED LIVING (X2) MULTIPLE CONSTRUCTION A. BUILDING: KANSAS CITY, MO 64116 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 of raw meat in each pan sitting on a rolling cart in the food preparation area; -Neither pan was covered; -There was also a second rolling cart with a zippered food storage bag containing approximately three pounds of ground beef, a plastic container of shredded cabbage, a plastic container of celery, a bag of baby carrots, anda plastic container of diced onions; -There was not a staff member anywhere near the rolling carts of food. Observation on 3/3/2026 at 11:25 A.M. of the kitchen showed: -Both rolling carts and the food items on them were still sitting in the same place and did not appear to have been touched; -The temperature of the prepared, raw, meatloaf was 57.6° Fahrenheit (F); -The temperature of the zippered food storage bag of raw ground beef was 51° F; -The temperature of the shredded cabbage was 63° F; -The temperature of the celery was 67.6° F. During an interview on 03/03/26 at 11:30 A.M., Cook B said: -He/She pulled the cabbage, celery, carrots, and onions out of the refrigerator to prepare a salad for the next day; -He/She pulled the vegetables from the refrigerator about an hour ago; -He/She left the vegetables on the cart unattended in room temperature; -He/She knew cold food had to be kept below 45° F to be kept from spoiling. During an interview on 03/03/26 at 11:40 A.M., Chef A said: -He/She had been preparing meatloaf for the next Missouri Department of Health and Senior Services STATE FORM 6899 HB1M11 PRINTED: 03/10/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED 03/03/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 1201 NW TULLISON RD PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 4 of 8 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 MCCRITE PLAZA AT BRIARCLIFF ASSISTED LIVING (X2) MULTIPLE CONSTRUCTION A. BUILDING: KANSAS CITY, MO 64116 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 day; -He/She left the kitchen to go on a break; -He/She did not think he/she needed to put the food away prior to going on a break; -He/she knew cold food should be kept below 45° F. During an interview on 03/03/26 at 11:44 A.M., the Director of Dining Services said: -He/She knew cold food should be kept below 45° F to prevent spoilage. -He/She expected staff to cover and put food in the refrigerator if they intend to take a break while preparing food. During an interview on 03/03/26 at 2:59 P.M. the Administrator said: -He/She expected all food intended to be cold, to be kept below 45° F during preparation and storage to prevent spoilage; -He/She expected all food not currently being prepared or served to be covered to prevent contamination; -He/She would have expected Cook B and Chef A to cover and place the food they were preparing in the refrigerator prior to leaving the kitchen to ensure they were free from spoiling temperatures and contamination. 19 CSR 30-87.030(15) Food-Stored Above the Floor, Protected Containers of food shall be stored above the floor in a manner that protects the food from splash and other contamination and that permits easy cleaning of the storage area, except that metal pressurized beverage containers, and cased food packaged in cans, glass or other waterproof containers need not be elevated when the food Missouri Department of Health and Senior Services STATE FORM 6899 HB1M11 PRINTED: 03/10/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED 03/03/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 1201 NW TULLISON RD PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 5 of 8 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER 1201 NW TULLISON RD KANSAS CITY, MO 64116 MCCRITE PLAZA AT BRIARCLIFF ASSISTED LIVING SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 5 container is not exposed to floor moisture; and containers may be stored on dollies, racks or pallets, provided the equipment is easily movable. HT This regulation is not met as evidenced by: Class III Based on observation and interview, the facility failed to ensure food was stored above the floor in a manner that protects the food from splash and other contamination when food was stored on the floor of the walk-in freezer and two large bags of rice were on the floor in the dry food storage area. The facility census was 89. The facility did not provide a food storage policy. 1. Observation on 3/3/2026 at 11:17 A.M. of the walk-in freezer showed five boxes of food being stored on the floor, including: -Two large buckets of ice cream; -One box of peas and carrots; -Two boxes of pork shoulder roasts. During an interview on 03/03/26 at 11:40 A.M., the Director of Dining Services said food should not be stored on the floor of the walk-in freezer. During an interview on 03/03/26 at 2:59 P.M. the Administrator said he/she expected food to be stored off the floor to prevent contamination. 19 CSR 30-87.030(87) Glasses/Cups/Utensils Storage Glasses and cups shall be stored inverted. Other stored utensils shall be covered or inverted, wherever practical. Facilities for the storage of Missouri Department of Health and Senior Services STATE FORM 6899 HB1M11 (X2) MULTIPLE CONSTRUCTION PRINTED: 03/10/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED 03/03/2026 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 6 of 8 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 MCCRITE PLAZA AT BRIARCLIFF ASSISTED LIVING (X2) MULTIPLE CONSTRUCTION A. BUILDING: KANSAS CITY, MO 64116 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 6 knives, forks and spoons shall be designed and used to present the handle to the employee or consumer. Unless tableware is prewrapped, holders for knives, forks and spoons at self-service locations shall protect these articles from contamination and present the handle of the utensil to the consumer. III This regulation is not met as evidenced by: Class III Based on observation and interview, the facility failed to ensure all glasses, dishware, cups, and utensils were stored inverted and in a manner that protected them from contamination. This had the potential to affect all residents. The facility census was 89. The facility did not provide a policy regarding storage of glasses and dishware in the kitchen. 1. Observation of the main kitchen on 03/03/26 at 11:00 A.M. showed: -All stacks of plates on the wire shelving near the sinks were placed upright; -Stacks of plates and bowls on the shelf under the preparation table were placed upright. 2. Observation of the 3rd floor kitchen on 03/03/26 at 11:15 A.M. showed a tray of glassware placed upright. During an interview on 03/03/26 at 11:40 A.M., the Director of Dining Services said all all glassware and dining ware should be stored inverted to prevent splash and splatter contaminating it. During an interview on 03/03/26 at 2:59 P.M. the Administrator said he/she expected all dining Missouri Department of Health and Senior Services STATE FORM 6899 HB1M11 PRINTED: 03/10/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED 03/03/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 1201 NW TULLISON RD PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 7 of 8 PRINTED: 03/10/2026 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 03/03/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1201 NW TULLISON RD KANSAS CITY, MO 64116 (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) MCCRITE PLAZA AT BRIARCLIFF ASSISTED LIVING A7089 | Continued From page 7 ware and glassware to be stored inverted. Missouri Department of Health and Senior Services STATE FORM 6899 HB1M11 If continuation sheet 8 of 8 Plan of Correction Dietary Services Department McCrite Plaza at Briarcliff State Survey — March 2026 Tag A2257 19 CSR 30-86.022 (10) (B) Combustible Materials, Unnecessary Storage Of Protection from Hazards. (B) The storage of unnecessary combustible materials in any part of the building in which a licensed facility is located is prohibited. I/I This regulation is not met as evidenced by: Class Ill Based on observation and interview, the facility failed to keep unnecessary combustibles properly secured while stored in the facility. This violation had the potential to affect all assisted living residents. The census was 89. Observation on 03/03/26 at 11:20 a.m. of the basement level food storage area showed there were four bottles of charcoal lighter fluid. Three closed bottles stored on a metal shelf and one opened bottle on top of the ice machine. During an interview on 03/03/26 at 11:24 a.m. the Director of Dining Services said the bottles of charcoal lighter fluid should be stored in the fire box. During an interview on 03/03/26 at 2:59 p.m., the Administrator said he/she agreed with the Director of Dining Services that the bottles of fluid should be stored in the fire box. Plan of Correction: 1. How Deficient Practice Was Corrected The charcoal lighter fluid identified during the survey was immediately removed from the food storage area and placed in the designated fire safety storage box. 2. How Other Areas Were Protected All dietary staff were re-educated by the Director of Dining Service or the Assistant Manager regarding proper storage of chemicals and non-food items. 3. Systemic Changes Implemented Staff were instructed by Director of Dining Service or the Assistant Manager that chemicals and non-food items must be stored in designated areas away from food, food preparation areas, and food-contact items. 4. Monitoring Plan The Director of Dining Services or designee will conduct routine inspections weekly of storage areas to ensure compliance. All residents could have been affected Date of Compliance: 04/10/2026Tag A7003 Continued From page 1 This regulation is not met as evidenced by: Class lil Based on observation and interview, the facility failed to ensure all employees used effective hair restraints when three employees (Cook A, Server A, and the Director of Dining Services) did not wear hair restraints while performing duties in the kitchen. This could have affected all residents. The facility census was 89. The facility did not provide a hair restraint policy. 1. Observations on 03/03/26 at 11:10 a.m., showed: a. Cook A prepared food near the grill and did not have his/her hair in a restraint. b. Dietary Aide A prepared individual bowls of cake without his/her hair in a restraint. c. The Director of Dining Services stood in the food preparation area and talked with kitchen staff without his/her hair in a restraint. 2. During an interview on 03/03/26 at 11:35 a.m. the Director of Dining Services said all staff should always wear a hair restraint while in the kitchen. 3. During an interview 03/03/26 at 2:59 p.m., the Administrator said he/she expected all staff to always wear a hair restraint while in the kitchen. Plan of Correction: 1. How Deficient Practice Was Corrected Staff observed without appropriate hair restraints were immediately instructed by management to place proper hair coverings prior to continuing work 2. How Other Areas Were Protected All dietary staff received re-education by Director of Dining Service or the Assistant Manager regarding hair restraint requirements in food service areas. 3. Systemic Changes Implemented The facility implemented the following measures: « A written Hair Restraint Policy has been developed and implemented for the Dietary Department. A copy of the policy is attached. e Hair nets, hats, or approved hair restraints are now required for all dietary staff working in food preparation or service areas e Staff were notified verbally and in writing of this requirement by the Director of Dining Service or the Assistant Manager « Approved hats may be worn in line with company standard. 4. Monitoring Plan The Director of Dining Services, or designee will conduct daily uniform and appearance checks to verify compliance. Noncompliance will result in immediate correction and progressive disciplinary action as necessary. All residents could have been affected. Date of Compliance: 04/10/26 Tag A7015 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, rodents, unclean equipment and utensils, unnecessary handling, coughs and sneezed, flooding, drainage and overhead drippage from condensation. The temperature of potentially hazardous food shall always be forty-five degrees Fahrenheit 45 degrees or below one hundred forty degrees (140 degrees) or above, except as otherwise provided in this section. In the event of a fire, flood, power outage or similar events 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 & 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/Ill This regulation is not met as evidenced by: Class Il *Higher class merited due to extent of violation. Based on observation and interview facility staff failed to prepare food in a manner to prevent potential contamination and/or spoilage. This had the potential to affect all residents. The facility census was 89. The facility did not provide a policy regarding food preparation. 1. Observation on 03/03/26 at 11:00 a.m. of the kitchen showed: a. Two large pans with two large, prepared loaves of raw meat in each pan sitting on a rolling cart in the food preparation area. i. Neither pan was covered. ii. There was also a second rolling cart with a zippered food storage bag containing approximately three pounds of ground beef, a plastic container of shredded cabbage, a plastic container of celery, a bag of baby carrots, and plastic container of diced onions. iii. There was not a staff member anywhere near the rolling carts of food. 2. Observation on 3/3/2026 at 11:25 a.m. of the kitchen showed: a. Both rolling carts and food items on them were still sitting in the same place and did not appear to have been touched. i. The temperature of the prepared, raw, meatloaf was 57.6 degrees Fahrenheit (F) ii. The temperature of the zippered food storage bag of the raw ground beef was 51 degrees Fahrenheit (F); iii. The temperature of the shredded cabbage was 63 degrees F; iv. The temperature of the celery was 67.6 degrees F. 3. During an interview on 03/03/26 at 11:30 a.m. Cook B said: a. He/She pulled the cabbage, celery, carrots and onions out of the refrigerator to prepare a salad for the next day. b. He/She pulled the vegetables from the refrigerator about an hour ago. c. He/She left the vegetables on the cart unattended in room temperature. d. He/She knew cold food had to be kept below 45-degree F to be kept from spoiling. 4. During an interview on 03/03/26 at 11:40 a.m., Chef A said: a. He/She had been preparing meatloaf for the next day. b. He/She left the kitchen to go on a break. c. He/She did not think he/she needed to put the food away prior to going on a break. d. He/She knew cold food should be kept below 45 degrees F to prevent spoilage. 5. During an interview on 03/03/26 at 11:44 a.m. the Director of Dining Services said: a. He/She knew cold food should be kept below 45 degrees F to prevent spoilage. b. He/She expected staff to cover and put food in the refrigerator if they intend to take a break while preparing food. 6. During an interview on 03/03/26 at 2:59 p.m. the Administrator said: a. He/She expected all food intended to be cold, to be kept below 45 degrees F during preparation and storage to prevent spoilage. b. He/She expected all food not currently being prepared or served to be covered to prevent contamination. c. He/She would have expected Cook B and Chef A to cover and place the food they were preparing in the refrigerator prior to leaving the kitchen to ensure they were free from spoiling temperatures and contamination. Plan of Correction: 1. How Deficient Practice Was Corrected The food items identified during the survey that were outside of safe temperature control were immediately discarded. Staff involved were immediately re-educated by management on safe food handling procedures, including monitoring of Time/Temperature Control for Safety (TCS) foods during preparation, holding, and service to ensure proper temperature control. 2. How Other Areas Were Protected All dietary staff received re-education by the Director of Dining Service or the Assistant Manager regarding proper temperature control procedures for TCS foods. Staff were instructed by the Director of Dining Service or the Assistant Manager that food items may not remain at room temperature outside approved time limits and must be monitored during preparation and service. 3. Systemic Changes implemented The facility implemented the following corrective actions: e A Food Preparation and Temperature Control Policy has been developed and implemented. Staff were educated on the policy and a copy is attached. e Reinforcement of temperature monitoring procedures for all hot and cold holding equipment « Implementation and review of temperature logs for equipment and food holding e Reinforcement of staff responsibilities for monitoring food temperatures during meal preparation and service e Increased supervisory oversight during meal preparation periods 4. Monitoring Plan The Director of Dining Services or designee will review temperature monitoring logs daily. Random spot checks of food temperatures will be conducted during meal service and preparation periods to ensure compliance. All residents could have been affected. Date of Compliance 04/10/2026 Tag A7017 19CSR 30-87.030(15) Food-Stored Above the Floor, Protected Containers of food shall be stored above the floor in a manner that protects the food from splash and other contamination and that permits easy cleaning of the storage area, except that metal pressurized beverage containers, and cased food packaged in cans, glass or other waterproof containers need not be elevated when the food container is not exposed to floor moisture; and containers may be stored on dollies, racks or pallets, provided the equipment is easily movable. III This regulation is not met as evidenced by: Class Ill Based on observation and interview, the facility failed to ensure food was stored above the floor in a manner that protects the food from splash and other contamination when food was stored on the floor of the walk-in freezer, and two large bags of rice were on the floor in the dry food storage area. The facility census was 89. The facility did not provide a food storage policy. 1. Observation on 3/3/2026 at 11:17 a.m. of the walk-in freezer showed five boxes of food being stored in the floor, including: a. Two large buckets of ice cream. b. One box of peas and carrots. c. Two boxes of pork shoulder roasts. 2. During an interview on 3/3/26 at 11:40 a.m., the Director of Dining Services said food should not be stored on the floor of the walk-in freezer. 3. During an interview on 3/3/26 at 2:59 p.m. the Administrator said he/she expected food to be stored off the floor to prevent contamination. Plan of Correction: 1. How Deficient Practice Was Corrected Items observed stored on the floor were immediately relocated to appropriate shelving. 2. How Other Areas Were Protected All dietary staff were re-educated by the Director of Dining Service or the Assistant Manager, that food, supplies, and single-service items must be stored at a minimum of six inches off the floor. 3. Systemic Changes Implemented The facility reinforced food storage requirements in all areas including: « Dry storage areas « Refrigeration units « Freezers « Food preparation areas e Staff were instructed that items may not be staged on the floor at any time. e A Food Storage Policy has been developed and implemented to ensure food is stored properly and protected from contamination. A copy of the policy is attached. 4. Monitoring Plan The Director of Dining Services or designee will perform routine kitchen inspections to verify compliance with storage requirements. Date of Compliance 04/10/2026 Tag A7089 19 CSR 30-87.030(87) Glasses/Cups/Utensils Storage Glasses and cups shall be stored inverted. Other stored utensils should be covered or inverted, wherever practical. Facilities for the storage of knives, forks and spoons shall be designed and used to present the handle to the employee or consumer. Unless tableware is prewrapped, holders for knives, forks and spoons at self- service locations shall protect these articles from contamination and present the handle of the utensils to the consumer. [Il This regulation is not met as evidenced by: Class Ill Based on observations and interviews, the facility failed to ensure all glasses, dishware, cups and utensils were stored inverted and in a manner that protected them from contamination. This had the potential to affect all residents. The facility census was 89. 1. Observation of the main kitchen on 03/03/26 at 11:00 a.m. showed: a. All stacks of plates on the wire shelving near the sinks were placed upright. b. Stacks of plates and bowls on the shelf under the preparation table were placed upright. 2. Observation of the 3" floor kitchen on 03/03/26 at 11:15 a.m. shored a tray of glassware placed upright. 3. During an interview on 03/03/26 at 11:40 a.m., the Director of Dining Services said all glassware and dining ware should be stored inverted to prevent splash and splatter contaminating it. 4, During an interview on 03/03/26 at 2:59 p.m., the Administrator said he/she expected all dining ware and glassware to be stored inverted. Plan of Correction: 1. How Deficient Practice Was Corrected Dishware and glassware observed stored upright during the survey were immediately inverted and properly stored. 2. How Other Areas Were Protected All dietary staff were re-educated Director of Dining Service or the Assistant Manager by the on proper storage procedures for clean dishes and food-contact items. 3. Systemic Changes Implemented Staff were instructed that: « Plates must be stored upside down « Utensils must be stored in protected containers e Single-service items must be protected from contamination 4. Monitoring Plan The Director of Dining Services or designee will conduct daily spot checks of dish storage areas to ensure proper storage procedures are followed. All residents could have been affected. Date of Compliance 04/10/26 Quality Assurance and Performance Improvement (QAP!) Oversight To ensure ongoing compliance, the Dietary Department will incorporate the monitoring of food safety, sanitation, and regulatory compliance into the facility’s Quality Assurance and Performance Improvement {QAPI) program. The Director of Dining Services will conduct routine audits of: e Food temperature logs e Eguipment temperature logs e Food storage practices e Personal hygiene and hair restraint compliance e Chemical storage practices These audits will be conducted weekly for four weeks, then quarterly thereafter to ensure continued compliance. Any identified concerns will be addressed immediately through: e Staff re-education « Corrective coaching « Progressive disciplinary action if necessary. Results of these audits will be reviewed with facility leadership to ensure sustained compliance with food safety regulations.

PRINTED: 10/27/2025 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 B.WING 10/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1201 NW TULLISON RD KANSAS CITY, MO 64116 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES } ID i PROVIDER'S PLAN OF CORRECTION | (X5) PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL ' pREFIK (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) i TAG i CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) MCCRITE PLAZA AT BRIARCLIFF ASSISTED LIVING 19 CSR 30-86.047(5) Administrator - Licensed The operator shall designate an individuat for administrator who is currently licensed as an administrator by the Missouri Board of Nursing Home Administrators, in accordance with Chapter 344, RSMo. Ii This regulation is not met as evidenced by: Class Il Based on interview and record review, the facility failed to ensure the administrator maintained a current administrator's license as required by the Missouri Board of Nursing Home Administrators (MBNHA). The census was 66. The facility did not provide a policy regarding employing a licensed Administrator. 1. Review documentation from the MBNHA dated 10/14/25 at 3:10 P.M., showed: -Their records indicated the administrator had been acting as an administrator on an expired license since 6/30/25; -They sent the administrator a reminder notice via email on 2/3/25; -They sent another reminder notice via email on 4/1/25; -They received the administrator's renewal application and fee on 7/28/25; -They sent a notice on 8/1/25 stating the renewal application was late and had not been received. During an interview on 10/27/25 at 12:15 P.M. P.M. the Administrator said: -She originally obtained her nursing home administrator license in October 2023; -She did not receive either of the reminder notices the BNHA sent on 2/3/25 and 4/1/25; -She did receive the the notice they sent on Missouri Department of Health and LABORATORY DIRECTOR'S OR PB IDER/SUPPLIER REPRESENTATIVE'S SIGNATURE (X6) DATE leleyps STATE FORM ROGI1 PRINTED: 10/27/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X83) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc B.WING 10/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1201 NW TULLISON RD KANSAS CITY, MO 64116 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION %6) 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) MCCRITE PLAZA AT BRIARCLIFF ASSISTED LIVING Continued From page 1 | 8/1/25 stating the renewal application was late but by that time she had submitted the renewal : application and fee. -This was the first instance of her needing to renew her license and she was unsure of the process; -She knew when she sent her application and renewal fee on 7/28/25 that it was late, but thought that it would be fine since she included the late fee with her application as well. MO258802 Missouri Department of Health and Senior Services STATE FORM 6699 R9GI11 lf continuation sheet 2 of 2 PLAN OF CORRECTION Provider/Supplier McCrite Plaza at Briarcliff ALF Name: Street Address, . . 1201-1301 NW Tullison Road, KCMO 64116 City, Zip: Date of Survey: 10/14/2025 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 18 CSR 30-86.047(5) A4703 To ensure McCrite Plaza at Briarcliff has a licensed assisted living administrator, license expiration dates will be kept track of by the administrator as well as the business office. Internal 11/7/2025 reminders and check will be in place to ensure ones license doesn’t expire. 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: 05/22/2025 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: BAWING 05/13/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 1201 NW TULLISON RD KANSAS CITY, MO 64116 NAME OF PROVIDER OR SUPPLIER MCCRITE PLAZA AT BRIARCLIFF ASSISTED LIVING (X4) ID SUMMARY STATEMENT OF DEFICIENCIES 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) A2286, 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 May 13, 2025 the facility failed to ensure that only metal or UL- or FM- fire-resistant rated wastebaskets shall | be used for trash. The facility census was 51. This deficiency affects 51 of 51 residents. Observation at 1:42 P.M. in resident room 304 showed three (3) non-fire-resistant rated wastebaskets in use. | Observation at 1:48 P.M. in resident room 306 | showed three (3) non-fire-resistant rated wastebaskets in use. Observation at 2:07 P.M. in resident room 315 showed three (3) non-fire-resistant rated wastebaskets in use. | Observation at 2:15 P.M. in resident room 317 showed one (1) non-fire-resistant rated wastebasket in use. Observation at 2:23 P.M. in resident room 319 showed two (2) non-fire-resistant rated | wastebaskets in use. Observation at 2:29 P.M. in resident room 323 showed two (2) non-fire-resistant rated wastebaskets in use. | Observation at 2:37 P.M. in resident room 325 Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIV, Gh f G } STATE FORM (X6) DATE 6899 CCWN11 If continuation sheet 1 of 6 PLAN OF CORRECTION Provider/Supplier 29084 Name: Street Address, 1201 nw Tullison rd City, Zip: Kansas city, Mo 64116 Date of Survey: 05/13/2025 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER COMPLETION DATE 05/14/2025 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) All non-compliant wastebaskets have been removed from units In addition to all noted rooms on SOD, all other rooms have been reinspected to ensure noncompliant wastebaskets have been removed Monthly room checks will now include the inspection of wastebaskets, also housekeeping will be instructed to add to their cleaning check list, to look at the wastebaslets to ensure they are the proper ones. The maintenance supervisor will inspect quarterly the monthly room inspection reports and do random inspections of rooms to ensure inspections are conducted properly by staff. Staff also have been trained in what the proper wastebasket should be. A2286 05/14/2025 A2286 05/15/2025 A2286 05/16/2025 Sheetrock repair has been completed in noted area 5/19/2025 Monthly common area, storage room, offices inspection sheets have been created to ensure damage or repairs will not go unnoticed. Also, any work by third party contractors will be 6/20/2025 inspected before the contractor leaves, a contractor inspection sheet has been created for these situations Maintenance supervisor will review inspection sheets quarterly men to ensure reports are being done correctly All mutli plug adapters have been removed from noted rooms All non ul listed extension cords have been removed from noted rooms A3219 All non-circuit protected and ul listed power strips have been 5/16/2025 removed from noted rooms. All outlets have been inspected to ensure that only two items are lugged into the outlets. All non-noted rooms on the SOD have also been inspected 6/16/2025 Staff have been trained as to what is allowed and what is not allowed to be plugged in the outlets. Monthly room checks will include the inspection of all outlets in rooms to ensure non- compliant items are not plugged in. The maintenance supervisor will review the monthly room inspection reports quarterly, to ensure proper inspections are taking place. Random inspections will also occur 5/19/2025 A3219 PRINTED: 05/22/2025 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 05/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1201 NW TULLISON RD KANSAS CITY, MO 64116 (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) MCCRITE PLAZA AT BRIARCLIFF ASSISTED LIVING 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. Il This regulation is not met as evidenced by: Class II Based on observation and interview on May 13, 2025 the facility failed to ensure that only metal or UL- or FM- fire-resistant rated wastebaskets shall be used for trash. The facility census was 51. This deficiency affects 51 of 51 residents. Observation at 1:42 P.M. in resident room 304 showed three (3) non-fire-resistant rated wastebaskets in use. Observation at 1:48 P.M. in resident room 306 showed three (3) non-fire-resistant rated wastebaskets in use. Observation at 2:07 P.M. in resident room 315 showed three (3) non-fire-resistant rated wastebaskets in use. Observation at 2:15 P.M. in resident room 317 showed one (1) non-fire-resistant rated wastebasket in use. Observation at 2:23 P.M. in resident room 319 showed two (2) non-fire-resistant rated wastebaskets in use. Observation at 2:29 P.M. in resident room 323 showed two (2) non-fire-resistant rated wastebaskets in use. Observation at 2:37 P.M. in resident room 325 Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 CCWN11 If continuation sheet 1 of 6 PRINTED: 05/22/2025 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 05/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1201 NW TULLISON RD KANSAS CITY, MO 64116 (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) MCCRITE PLAZA AT BRIARCLIFF ASSISTED LIVING Continued From page 1 showed two (2) non-fire-resistant rated wastebaskets in use. Observation at 2:39 P.M. in resident room 326 showed one (1) non-fire-resistant rated wastebasket in use. Observation at 2:47 P.M. in resident room 328 showed one (1) non-fire-resistant rated wastebasket in use. Observation at 2:50 P.M. in resident room 330 showed one (1) non-fire-resistant rated wastebasket in use. Observation at 2:55 P.M. in resident room 332 showed one (1) non-fire-resistant rated wastebasket in use. Observation at 2:59 P.M. in resident room 333 showed one (1) non-fire-resistant rated wastebasket in use. Observation at 3:10 P.M. in resident room 336 showed one (1) non-fire-resistant rated wastebasket in use. Observation at 3:13 P.M. in resident room 337 showed two (2) non-fire-resistant rated wastebasket in use. Observation at 3:29 P.M. in resident room 345 showed two (2) non-fire-resistant rated wastebasket in use. Observation at 3:31 P.M. in resident room 347 showed one (1) non-fire-resistant rated wastebasket in use. Observation at 3:36 P.M. in resident room 348 Missouri Department of Health and Senior Services STATE FORM 6899 CCWN11 If continuation sheet 2 of 6 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 MCCRITE PLAZA AT BRIARCLIFF ASSISTED LIVING (X2) MULTIPLE CONSTRUCTION A. BUILDING: KANSAS CITY, MO 64116 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 showed three (3) non-fire-resistant rated wastebasket in use. Observation at 3:38 P.M. in resident room 338 showed one (1) non-fire-resistant rated wastebasket in use. Observation at 3:44 P.M. in resident room 340 showed two (2) non-fire-resistant rated wastebasket in use. During an interview with the Facility Maintenance Supervisor at 3:50 P.M., he/she said the wastebaskets would be replaced as soon as practical. 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 III Based on observation and interview on May 13, 2025 the facility failed to ensure the building was substantially constructed and kept 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 51. This deficiency affects 51 of 51 residents. Observation at 2:32 P.M. showed missing sheet rock needing repair/replaced in the mechanical room. Missouri Department of Health and Senior Services STATE FORM 6899 CCWN11 PRINTED: 05/22/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/13/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 1201 NW TULLISON RD PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 3 of 6 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 MCCRITE PLAZA AT BRIARCLIFF ASSISTED LIVING (X2) MULTIPLE CONSTRUCTION A. BUILDING: KANSAS CITY, MO 64116 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 During an interview with the maintenance supervisor at 2:34 P.M., he/she said he would get it repaired as soon as practical. 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 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/IIl This regulation is not met as evidenced by: Class III Based on observation and interview on May 13, 2025 the facility failed to ensure that no more than two (2) appliances were served by one duplex outlet and approved circuit protected power strips and/or approved extension cords were used. The facility census was 51. This deficiency affects 51 of 51 residents. Observation at 1:35 P.M. in resident room 300 a multi-plug adapter in use that allowed for more than two (2) appliances to be plugged into a duplex outlet. Appliances should be plugged directly into the duplex outlet not a multi plug. Observation at 1:51 P.M. in resident room 309 a extension cord and a multi-plug adapter in use that allowed for more had two (2) appliances to Missouri Department of Health and Senior Services STATE FORM 6899 CCWN11 PRINTED: 05/22/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/13/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 1201 NW TULLISON RD PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 4 of 6 PRINTED: 05/22/2025 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 05/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1201 NW TULLISON RD KANSAS CITY, MO 64116 (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) MCCRITE PLAZA AT BRIARCLIFF ASSISTED LIVING Continued From page 4 be plugged into a duplex outlet. Appliances should be plugged directly into the duplex outlet not a multi plug. Observation at 1:55 P.M. in resident room 310 a multi-plug adapter in use that allowed for more than two (2) appliances to be plugged into a duplex outlet. Appliances should be plugged directly into the duplex outlet not a multi plug. Observation at 2:02 P.M. in resident room 313 two (2) multi-plug adapters in use that allowed for more than two (2) appliances to be plugged into a duplex outlet. Appliances should be plugged directly into the duplex outlet not a multi plug. Observation at 2:18 P.M. in resident room 318 a multi-plug adapter in use that allowed for more than two (2) appliances to be plugged into a duplex outlet. Appliances should be plugged directly into the duplex outlet not a multi plug. Observation at 2:39 P.M. in resident room 326 a multi-plug extension cord in use and not an approved circuit protected power strip. Appliances should be plugged directly into the duplex outlet not a multi-plug. Observation at 2:42 P.M. in resident room 327 a multi-plug adapter in use that allowed for more than two (2) appliances to be plugged into a duplex outlet. Appliances should be plugged directly into the duplex outlet not a multi-plug. Observation at 2:50 P.M. in resident room 330 two (2) multi-plug adapters in use that allowed for more than two (2) appliances to be plugged into a duplex outlet. Appliances should be plugged directly into the duplex outlet not a multi-plug. Missouri Department of Health and Senior Services STATE FORM 6899 CCWN11 If continuation sheet 5 of 6 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 MCCRITE PLAZA AT BRIARCLIFF ASSISTED LIVING (X2) MULTIPLE CONSTRUCTION A. BUILDING: KANSAS CITY, MO 64116 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 5 Observation at 2:55 P.M. in resident room 332 two (2) multi-plug adapters in use that allowed for more than two (2) appliances to be plugged into a duplex outlet. Appliances should be plugged directly into the duplex outlet not a multi-plug. Observation at 3:04 P.M. in resident room 334 two (2) multi-plug adapters in use that allowed for more than two (2) appliances to be plugged into a duplex outlet. Appliances should be plugged directly into the duplex outlet not a multi-plug. Observation at 3:08 P.M. in resident room 335 a multi-plug adapter in use that allowed for more than two (2) appliances to be plugged into a duplex outlet. Appliances should be plugged directly into the duplex outlet not a multi-plug. Observation at 3:31 P.M. in resident room 347 a multi-plug adapter in use that allowed for more than two (2) appliances to be plugged into a duplex outlet. Appliances should be plugged directly into the duplex outlet not a multi-plug. Observation at 3:44 P.M. in resident room 340 a multi-plug extension cord in use. Appliances should be plugged directly into the duplex outlet not a multi-plug. During an interview with the maintenance supervisor at 4:00 P.M., he/she said they would replace the unapproved electrical devices as soon as practical. Missouri Department of Health and Senior Services STATE FORM 6899 CCWN11 PRINTED: 05/22/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/13/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 1201 NW TULLISON RD PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 6 of 6

PRINTED: 01/17/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (Xt) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc B.WING 01/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1201 NW TULLISON RD KANSAS CITY, MO 64116 (X4 ID SUMMARY STATEMENT OF DEFICIENCIES : PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST 8E PRECEDED BY FULL i (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE : DEFICIENCY) MCCRITE PLAZA AT BRIARCLIFF ASSISTED LIVING AA75S 19 CSR 30-86.047(28)(H) Individual Service Plan ' - Review Requirements | The facility may admit or retain an individual for i residency in an assisted living facility only if the individual does not require hospitalization or skilled nursing placement as defined in this rule, and only if the facility: (H) Reviews the ISP with the resident, or legal _ fepresentative of the resident, at least annually or | when there is a significant change in the resident :'$ condition which may require a change in ' services; HI _ ' This regulation is not met as evidenced by: : Class Il Based on record review, and interview the facility : failed to review the individualized service pian | (ISP) with the resident, or legal representative of | the resident, when there was a significant change | in the resident's condition which may require a | change in services. This affected four of five ; sampled residents (Resident #1, #2, #3, and #4). The facility census was 42. No policy was provided regarding updating ISP's. | 1. Review of Resident #1's record showed: -He/She was admitted to the facility on 10/18/24; -Diagnoses included depression, psychosis (a term used to describe a group of symptoms that indicate a loss of contact with reality), altered ; mental status, cognitive communication deficit, ‘ right foot drop (a condition that makes it difficult to lift the front part of the foot and toes), difficulty walking, history of falls, and dementia (a general ; term for a group of brain conditions that cause a - decline in mental abilities). Review of Resident #1's progress notes showed: Z Missouri Department of Hea id Senior Services LABORATORY DIRECTOR'# OK PROVIDER/SUPPLIER REPRESENJAJIVE'S SIGNATURE TITI (X6) DATE Si f MG FT W ‘ (2. STATE FORM Ce 6899 URQJ11 If continuation sheet 1 of 7 PRINTED: 01/17/2025 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 01/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1201 NW TULLISON RD KANSAS CITY, MO 64116 (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) MCCRITE PLAZA AT BRIARCLIFF ASSISTED LIVING Continued From page 1 -On 11/10/24 the resident was found sitting on the floor next to his/her bed, he/she advised staff he/she slipped off the bed, but had no injuries or pain; -On 11/15/24 at 4:37 A.M. the resident was found on the floor near his/her bed, he/she advised he/she was standing and fell, landing on his/her buttocks, no complaints of injury or pain; -On 11/15/24 at 7:55 A.M., the resident was found on the floor between his/her bed and the bathroom doorway, the resident could not give a reason to how he/she got on the floor, small amount of blood to 4th toe on right foot, and increased confusion noted including exit seeking; -Multiple notes on 11/15/24 indicated further episodes of exit seeking, pulling pants down in commons area, and incontinence episode refusing to be changed, the resident was sent to the local hospital by the physician for possible urosepsis (a life-threatening medical emergency that occurs when a urinary tract infection (UTI) spreads throughout the body and causes sepsis); -On 11/25/24 the resident was found sitting on the floor in his/her room, skin tear to left elbow but no complaint of pain or explanation as to how he/she got on the floor; -On 11/26/24 the resident was noted to be wandering the halls, very confused, disagreeable, and hard to redirect; -On 11/26/24 the resident was found on the floor of another resident's room, exit seeking; -On 12/07/24 the resident had an injury fall with a skin tear to the right elbow after falling in his/her bathroom and scooting to his/her bedroom, this was noted to be his/her third fall in 24 hours; -On 12/9/24 the resident was found leaning over the bed but not in it, confused and looking for a moving company to move him/her to Kansas; -On 12/21/24 the resident had a non-injury fall that morning and was found on his/her floor near Missouri Department of Health and Senior Services STATE FORM 6899 UR9QJ11 If continuation sheet 2 of 7 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 MCCRITE PLAZA AT BRIARCLIFF ASSISTED LIVING (X2) MULTIPLE CONSTRUCTION A. BUILDING: KANSAS CITY, MO 64116 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 the bed;. Review on 01/13/25 of the resident's ISP dated 10/18/24 showed: -Resident #1 was a stand by assist for all ambulation and mobility, transfers, and grooming; -Resident #1 required assistance x 1 with bathing, dressing, and toileting; -Resident's goal for safety/falls was to have no fall related injury; -Original interventions dated 10/18/24 included appropriate lighting, family participation, and complete fall risk assessment; -The ISP safety/fall section was revised on 11/15/24 with new interventions, but not again until 01/13/25; -The facility did not provide updates to the resident's fall interventions despite many falls after the last update on 11/15/24. -Resident was a risk for elopement evidenced by cognitive impairment; -Interventions for his/her elopement risk included monitoring for agitation, anxiety, wandering or exit seeking and reporting them to the nurse immediately, providing the resident with activities and keeping the unit controlled by the fob system; -The facility did not provide updates to the residents elopement interventions despite episodes of confusion and exit seeking. During an interview on 01/13/25 at 3:03 P.M. Resident #1 said: He/She had no concerns for his/her care, it was a combined effort between himself/herself and the staff; He/She had some falls but could not recall specifics that led to the falls other than imbalance. 2. Review of Resident #2's record showed: Missouri Department of Health and Senior Services STATE FORM 6899 URQJ11 PRINTED: 01/17/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 01/13/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 1201 NW TULLISON RD PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 3 of 7 PRINTED: 01/17/2025 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 01/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1201 NW TULLISON RD KANSAS CITY, MO 64116 (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) MCCRITE PLAZA AT BRIARCLIFF ASSISTED LIVING Continued From page 3 -He/She was admitted to the facility on 03/12/24: -Diagnoses included right hip fracture, neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet), spinal stenosis (the spaces inside the bones of the spine get too small cause pain, tingling or weaknes in extremeties), difficulty in walking, cognitive communication deficit, and dementia. Review of Resident #2's progress notes showed: -On 11/10/24 at 10:51 A.M. the resident was found on the floor in his/her room near the bed, he/she denied pain; -On 01/06/25 the resident was found on the floor with his/her head towards the door and feet towards the recliner, and a pool of blood underneath him/her, and a 2.5 inch laceration on top right side of his/her scalp, Emergency Medical Service (EMS) was called and transported the resident to the hospital where the resident received stitches and staples. Review on 01/13/25 of the resident's ISP dated 03/12/24 showed: -The resident had altered mobility and interventions include arranging his/her room to accommodate, monitor for use of assistive devices, and assisting with transfers; -Interventions for the residents risk of falls included adequate lighting, complete fall risk assessment, family participation, using call light for assistance, and education to resident and family; -The last intervention to the ISP was updated on 06/25/24; -The facility did not provide updates to the resident's fall interventions after the 11/10/24 or 01/06/25 falls. During an interview on 01/13/25 at 3:06 P.M. Missouri Department of Health and Senior Services STATE FORM 6899 UR9QJ11 If continuation sheet 4 of 7 PRINTED: 01/17/2025 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 01/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1201 NW TULLISON RD KANSAS CITY, MO 64116 (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) MCCRITE PLAZA AT BRIARCLIFF ASSISTED LIVING Continued From page 4 Resident #2 said: -His/Her daughter was his/her power of attorney and likely did the care planning with the facility staff; -He/She had no concerns for his/her care, he/she just needed to stay compliant with calling for help before getting up. 3. Review of Resident #3's record showed: -He/She was admitted to the facility on 06/13/24; -Diagnoses included dementia, cognitive communication deficit, unsteady on feet, and age-related physical debility (state of being weak in health or body). Review of Resident #3's progress notes showed: -On 09/19/24 the resident was found on the floor in the sunroom, he/she advised he/she was attempting to transfer from the wheelchair to love seat when the love seat slid backwards, he/she denied pain; -On 10/28/24 the resident was found on his/her bathroom floor, denied pain, and advised he/she went to transfer and the wheelchair was not there; -On 11/06/24 the resident was found on the floor in front of his/her closet holding onto the transfer bar, he/she advised he/she missed the chair when he/she went to sit back down after grabbing something from the closet; -On 12/05/24 the resident was found on the floor in front of his/her wheelchair, he/she advised he/she had just slid out and had no injuries. Review on 01/13/25 of the resident's ISP dated 06/14/24 showed: -The resident was identified as a fall risk due to impaired mobility; -Interventions included lighting, fall risk assessment, and family participation; Missouri Department of Health and Senior Services STATE FORM 6899 UR9QJ11 If continuation sheet 5 of 7 PRINTED: 01/17/2025 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 01/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1201 NW TULLISON RD KANSAS CITY, MO 64116 (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) MCCRITE PLAZA AT BRIARCLIFF ASSISTED LIVING Continued From page 5 -The fall interventions were updated on 06/25/24, 09/09/24, 10/03/24, and then not again until 01/13/24; -The facility did not provide updates to the resident's fall interventions after any of his/her recent falls. 4. Review of Resident #4's record showed: -He/She was admitted to the facility on 10/31/24; -Diagnoses included unsteadiness on feet, dementia, falls, epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizure), generalize muscle weakness, degenerative disease of nervous system, and age-related physical debility. Review of Resident #4's progress notes showed: -On 11/17/24 the resident was found laying on his/her floor next to the bed, no complaints of pain; -On 11/18/24 the resident was found laying on the floor between the wall and bed, small red mark on left side of back, but otherwise no signs of pain; -On 12/22/24 the resident was found laying on the floor with complaints of head pain and a hematoma the size of a golf ball on the back of his/her head, resident was transported to local hospital; -On 12/26/24 a new order for physical therapy was placed for the resident at the request of the resident's daughter; -On 01/04/25 the resident was found on the floor after sliding out of his/her bed while trying to stand up to use the restroom, no complaints of pain; -On 01/10/25 therapy staff found the resident lying on the bathroom floor with feet towards the toilet and shoulders and head on the shower floor, resident complained of right hip pain with touch or movement, the resident was taken to Missouri Department of Health and Senior Services STATE FORM 6899 UR9QJ11 If continuation sheet 6 of 7 PRINTED: 01/17/2025 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 01/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1201 NW TULLISON RD KANSAS CITY, MO 64116 (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) MCCRITE PLAZA AT BRIARCLIFF ASSISTED LIVING Continued From page 6 the local hospital where no injuries were found. Review on 01/13/25 of the resident's ISP dated 10/31/24 showed: -The resident was identified as a fall risk due to weakness; -Interventions included lighting, fall risk assessment, and family participation; -The fall interventions had not been updated until 01/13/25; -An intervention for therapy was not updated until 01/13/25; -The facility did not provide updates to the resident's fall interventions after falls on 11/17/24, 11/18/24, 12/22/24, 12/26/24, or 01/04/25. During an interview on 01/13/25 at 3:30 P.M. the Director of Nursing said: -He/She was in charge of updating ISP's at change of condition; -He/She did not know why he/she had not updated the ISP's; -He/She knew ISP's should be updated at change of condition; -He/She did update ISP's for Residents #1, #3, and #4 after being asked for a list of residents with falls in the last 60 days, to make sure things were put together. During an interview on 01/13/25 at 3:35 P.M. the Owner said he/she expected ISP's to be updated at change of condition for each resident per the regulation. MO247486 Missouri Department of Health and Senior Services STATE FORM 6899 UR9QJ11 If continuation sheet 7 of 7 PLAN OF CORRECTION Provider/Supplier McCrite Plaza at Briarcliff Name: Street Address, City, Zip: 1301 NW Tullison Road, KCMO 64116 1/13/25 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER a ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE Preparation, submission, and implementation of the POC does not constitute admission or agreement by McCrite Plaza to the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The POC is prepared, submitted, and implemented in accordance with the provisions of the state of law. McCrite Plaza maintains that the alleged deficiencies do not © Date of Survey: jeopardize the health and safety of residents, nor is it of such character as to limit McCrite Plazas to render reasonable and adequate care. Immediate Correction: DON/designee to update service plans for falls for Assisted Living Plus and Memory Care in the last 90 days by 1/27/25. Individualized Service plans will be updated by DON/designee for any falls going forward on the next business day. Resident/ family will be notified of falls and intervention added to 1/27/2025 individualized service plan added by next business day. Falls will be discussed in clinical morning meeting, weekly meeting or as needed ongoing to ensure notifications made to resident/family and that intervention was added to Individualized Service Plan. Monitoring: Individualized Service Plans will be updated by DON/designee for any falls going forward on the next. business day. Falls will be discussed in clinical morning meeting, weekly meeting or as needed by DON/Administrator ongoing to ensure notifications made to resident/family and that intervention was added to Individualized Service Plan. 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.

Nov.18.2024 01:46 PM McCrite Flaza & Briarcliff 816 437 9365 #1163 FP 2 PRINTED: 11/01/2024 FORM APPROVED a = NCES (A2) MULTIPLE CONSTRUCTION (X38) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED c 29084 B. WING 10/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ACQDRESS, CITY, STATE, ZIP CODE 1201 NW TULLISON RD KANSAS CITY, MO 64116 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD 5E REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) MCCRITE PLAZA AT BRIARCLIFF ASSISTED LIVING 48025) 19 CSR 30-88.010(25) Report A/N to DHSS/DMH When Neadad If the administrater or other employee cf a long-term care facility has reasonable cause to bellave that a resident of the facility has bean abused or neglected, the administrator or employee shail immediately report or cause a report to be made to the department. Any administrator or other employee of & long-term care facility having reasonable cause to suspect that a vulnerable person has been subjected to abuse or naglact or observes such 3 person being subjected to conditions or clrcumstances that would reasonably result in abuse or neglect shall immediately report or cause a report to be made to the department and to the Department of Mental Health. I/II This regulation is not met as evidenced by: Class II Based on Interview and record review, the facility falled to follow facility policy to Immediately raport an allegation of staff to resident abuse of Resident #1 by Nurse A, to the state survey agency, the Department of Health and Senior Services (DHSS). The facility census was 49, Review of the facility's undated Abuse and Neglect Policy showed: -All ernployees of the facility were required to report immediately to the Administrator any alleged violations involving mistreatment, neglect, or abuse, including injurias of an unknown origin; -Following @ questionable or substantiated incident of neglect or abuse the Administrator was ta Immediately report the Information to the appropriate licansing of certifying agency (DHSS); -The facility was to report immediately after the initial fact finding, ail allagad violations ta the Missouri Department of Health and LABORATORY DIRECTOR'S © (X48) DATE Ifcontinuatian sheat TofS State of Missouri 8166321810 11/18/2024 01:52PM Pg 02/10 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 MCCRITE PLAZA AT BRIARCLIFF ASSISTED LIVING (X2) MULTIPLE CONSTRUCTION A. BUILDING: KANSAS CITY, MO 64116 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 proper state agencies and all substantiated incidents as required. 1. Review of Resident #1's medical record showed: -He/She was admitted to the facility on 02/16/23; -He/She passed away on 09/07/24; -Diagnoses included dementia (a chronic condition that causes a person to lose cognitive functioning, such as the ability to think, remember, and reason, to the point that it interferes with daily life), type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), Bell's Palsy (Sudden weakness in the muscles on one half of the face), depression, anxiety, hypertension (high blood pressure), stage 3 kidney disease, a, chronic obstructive pulmonary disease (COPD-a common lung disease that makes it difficult to breathe and worsens over time). Review of an email correspondence dated 09/08/24 showed: -The previous Assistant Director of Nursing (ADON) notified the Director of Nursing (DON) and the Administrator that Level One Medication Aide (LIMA) A notified the him/her via text about concerns regarding statements Nurse A made to LIMAA, moments after Resident #1 passed away; -The concerns alleged Nurse A abused Resident #1. Review of the facility's undated investigation showed: -LIMAA's statement dated 09/08/24 included claims of possible physical abuse based on Nurse A's statements to LIMAA which included "I may have been a little rough when | went in to Missouri Department of Health and Senior Services STATE FORM 6899 2EIV11 PRINTED: 11/01/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 10/24/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 1201 NW TULLISON RD PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 2 of 5 PRINTED: 11/01/2024 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 Cc 10/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1201 NW TULLISON RD KANSAS CITY, MO 64116 (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) MCCRITE PLAZA AT BRIARCLIFF ASSISTED LIVING Continued From page 2 turn him/her earlier", | kind of dropped him/her back a little bit, you know how you drop a baby on its head", "a little trick of the trade a little nursing trick, get him/her out of here faster and | think that's probably what did it"; -Nurse A's statement dated 09/10/24 included details about how he/she went into Resident #1's room where family were at bedside, and turned the resident with the assistance of a family member. 15 minutes after turning the resident, family came out of the room to advise the resident had passed away. Conversation in the office with LIMA A included speaking about wives tales, and the belief that some people will pass away after being repositioned. Nurse A denied making any statements about dropping or being rough with the resident, and that family was at bedside the entire time he/she interacted with the resident that day; -Review of the Administrator's summary showed upon receiving the allegations made towards Nurse A, he/she notified Nurse A of his/her suspension pending investigation, at which time Nurse A left the facility. At the conclusion of the investigation, Nurse A was allowed back to work on 09/11/24, due to the Administrator being unable to substantiate the allegations. During and interview on 10/24/24 at 12:28 P.M. LIMAA said: -On 09/07/24 moments after Resident #1 passed away, he/she and Nurse A were in the nurse's office area when Nurse A began making comments that made him/her feel uncomfortable about; -Statements he/she recalled Nurse A making, included "I might have been a little rough with him/her earlier”, “it's a little trick of the trade, you know, like how you drop a baby on it's head"; -Nurse A was then demonstrating how he/she Missouri Department of Health and Senior Services STATE FORM 6899 2EIV11 If continuation sheet 3 of 5 PRINTED: 11/01/2024 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 Cc 10/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1201 NW TULLISON RD KANSAS CITY, MO 64116 (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) MCCRITE PLAZA AT BRIARCLIFF ASSISTED LIVING Continued From page 3 turned the resident, LIMAA interpreted as rough and not being gentle; -He/She reported these statements to the previous ADON the evening of 09/07/24; -He/She knew to follow the chain of command to report any allegations or suspicion of abuse, and felt that was what he/she did. During an interview on 10/24/24 at 1:55 P.M. Nurse A said: -He/She went into Resident #1's room earlier in the day and helped the resident's grandchild reposition the resident; -After the resident had passed away, he/she was in the office with LIMAA, where Nurse A was mentioning old wives tales, as well as how repositioning a resident that is passing away, could cause a resident to pass away; -He/She was not rough with the resident in any way and did not suggest to LIMAA that he/she was, or that he/she dropped the resident; -He/She was suspended on 09/08/24 due to the abuse allegation, and returned to work on 09/11/24 at the completion of the Administrator's investigation. During an interview on 10/24/24 at 2:13 P.M. the DON said: -He/She knew all allegations were to be reported to the Administrator for investigation and making a self-report to the state survey agency. -He/She knew about the allegations of abuse, but the Administrator handled the investigation. During an interview on 10/24/24 at 11:05 A.M. the Administrator said: -He/She was notified on 09/08/24 by the previous ADON about the abuse allegations against Nurse A; -He/She immediately notified Nurse A of their Missouri Department of Health and Senior Services STATE FORM 6899 2EIV11 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 1201 NW TULLISON RD MCCRITE PLAZA AT BRIARCLIFF ASSISTED LIVING KANSAS CITY, MO 64116 PRINTED: 11/01/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 10/24/2024 (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 suspension effective immediately on 09/08/24, pending his/her investigation; -Although he/she suspended Nurse A due to abuse allegations, he/she did not feel the allegations needed to be reported to the state survey agency after he/she concluded his/her investigation, therefore he/she did not notify the state survey agency of the allegations. MO244013 Missouri Department of Health and Senior Services STATE FORM 6899 2EIV11 DEFICIENCY) If continuation sheet 5 of 5 Nov.18.2024 01:48 PM McCrite Flaza & Briarcliff 816 437 9365 #1163 F 9 PLAN OF CORRECTION Provider/Suppliar Name: Cassidy MeCrte Street Addrass, City, 12012 NW Tullisen Road, KCMO 64116 | a] Date af Survey! 40/24/2024 PROVIDER/SUPPUIER/CUA IDENTIFICATION NUMBER po 1D PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS. COMPLETION DATE | oma REFERENCED TO THE APPROPRIATE DEFICIENCY) cOMPLTON DATE Corrective action accomplished for the resident found to be affected by the deficient practice was to revisit reporting criteria to ensure that any internal reports of ANE are communicated to the appropriate parties, in this case DHSS. All residents in the 1201 assisted living licensed area could bea affected by not reporting ANE appropriately. Administrator reviewed company policy on reporting A8025 criteria for ANE and educated himself on when to report based off the education received during the survey process. Clarification was also made to the policy to ensure there’s enough detail to follow for future reference. This correction was made on 10/24/2024. Expectation for when to report ANE will be followed by the Administrator going forward. The facility management will continue compliance by continuing quarterly staff education on how to recognize, report and communicate abuse, neglect and expioitation. State of Missouri 8166321810 11/18/2024 01:52PM Pg 09/10 Nov.18.2024 01:48 PM McCrite Flaza & Briarcliff 816 437 9365 #1163 F 10 The Administrator signing and dating the first page of the CMS5-2567/State Form is indicating their approval of the plan of correction being submitted on this form. State of Missouri 8166321810 11/18/2024 01:52PM Pg 10/10

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 (X2) MULTIPLE CONSTRUCTION A. BUILDING: 1201 NW TULLISON RD KANSAS CITY, MO 64116 MCCRITE PLAZA AT BRIARCLIFF ASSISTED LIVING (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) 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. I/II This regulation is not met as evidenced by: Class II Based on observation, interview, and record review on 4/25/24 this facility failed to inspect part of the sprinkler system monthly to ensure the pressure gage readings and valve positions on a portion of the sprinkler system was done as required in accordance with NFPA 13, 1999 edition. The facility census was 48. This potentially affected 48 of 48 residents. Observation on 4/25/24 at 12:31 P.M. showed no monthly sprinkler valve and pressure gage check sheet for the sub-riser in the 3rd floor East mechanical room. It was observed all the other areas with sub-risers had current monthly check sheets within them. Record review on 4/25/24 at 1:54 P.M. showed the 2023 check sheets for all the riser areas except the 3rd floor East mechanical room. During an interview on 4/25/24 at 1:54 P.M. with the director of maintenance he/she said he/she did not know how this riser had been skipped but would immediately include it with the other monthly checks already being done on the others. Missouri Department of Health and Senior Services LABORATORY DJAECTPR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE ASS | STATE FOwwMd 6899 NC rit € ya 42D411 PRINTED: 06/21/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/25/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) TITLE (X6) PATE 24/2 If continuatfjn sheet 1 off