OXFORD GRAND AT SHOAL CREEK.

PRINTED: 03/19/2026 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 B.WING 03/10/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8280 N TULLIS AVE KANSAS CITY, MO 64158 (X4) ID | SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION PREFIX | {EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE TAG | REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) OXFORD GRAND AT SHOAL CREEK A3224) 19 CSR 30-86.032(23) Rooms Neat, Orderly, Cleaned Daily Rooms shall be neat, orderiy and cleaned daily. HAH This regulation is not met as evidenced by: Class Ill Based on observation and interview, the facility failed to ensure resident rooms were neat, clean, : and orderly on the memory care unit. The facility | census was 72. The facility staff did not provide a policy for cleaning resident rooms or making beds. 1. Observation on 03/10/26 between 11:35 - 11:52 A.M. of the memory care unit showed: ~The bed in memory care room 310 showed the bed was not made and the fitted sheet had a large, yellow wet spot in the middle of the sheet and the room smelled of urine; -The far bed against the wall in room 307 was | made, the bed spread was dry but the sheet under the bed spread had a large round wet spot | in the middie of the sheet with the dry bed spread | pulled up over it. Observation on 03/10/26 at 12:50 P.M. of the memory care unit showed: -The sheets on the bed in room 310 were still wet and the bed was unmade; -The sheets on the bed against the wall in room 307 with a large light yellow colored ring where the previously noted wet spot had dried. During an interview on 03/10/26 at 3:52 P.M. the Administrator said: | «He/She expected beds to be made daily and : sheets changed if needed. Missouri Department of Health and Senior Services LABORATORY DIREGFOR': ER REPRESENTATIVE'S SIGNATURE TITLE ExGcutive 4/326 G6X011 H continuation sHeet 1 of 13 STATE FORM 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 OXFORD GRAND AT SHOAL CREEK (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) PRINTED: 03/19/2026 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED Cc 03/10/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 8280 N TULLIS AVE KANSAS CITY, MO 64158 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A3224 19 CSR 30-86.032(23) Rooms Neat, Orderly, Cleaned Daily Rooms shall be neat, orderly and cleaned daily. I/II This regulation is not met as evidenced by: Class Ill Based on observation and interview, the facility failed to ensure resident rooms were neat, clean, and orderly on the memory care unit. The facility census was 72. The facility staff did not provide a policy for cleaning resident rooms or making beds. 1. Observation on 03/10/26 between 11:35 - 11:52 A.M. of the memory care unit showed: -The bed in memory care room 310 showed the bed was not made and the fitted sheet had a large, yellow wet spot in the middle of the sheet and the room smelled of urine; -The far bed against the wall in room 307 was made, the bed spread was dry but the sheet under the bed spread had a large round wet spot in the middle of the sheet with the dry bed spread pulled up over it. Observation on 03/10/26 at 12:50 P.M. of the memory care unit showed: -The sheets on the bed in room 310 were still wet and the bed was unmade; -The sheets on the bed against the wall in room 307 with a large light yellow colored ring where the previously noted wet spot had dried. During an interview on 03/10/26 at 3:52 P.M. the Administrator said: -He/She expected beds to be made daily and sheets changed if needed. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 G6X011 If continuation sheet 1 of 13 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 8280 N TULLIS AVE OXFORD GRAND AT SHOAL CREEK KANSAS CITY, MO 64158 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG A6005 19 CSR 30-87.020(5) Toxic Material Storage Poisonous or toxic materials consist of the following categories: insecticides and rodenticides; disinfectants, sanitizer and related cleaning or drying agents; and caustics, acids, polishes and other chemicals. Each of these three (3) categories set forth shall be stored and physically located separate from each other. All poisonous or toxic materials shall be stored in locked cabinets or in a similar physically separate place used for no other purpose which is not accessible to residents. II This regulation is not met as evidenced by: Class II Based on observation and interview the facility failed to ensure all poisonous or toxic materials were stored in locked cabinets or in a similar physically separate place used for no other purpose and not accessible to residents. The facility census was 72. The facility did not provide a policy regarding storage of poisonous or toxic materials. 1. Observation in the drink preparation area of the kitchen on 03/10/26 at 10:58 A.M. showed: -The door to the drink preparation area was open and accessible to residents in the dining room; -Three spray bottles of Rapid Multi Surface Cleaner on the bottom shelf; -An aerosol can of Lysol cleaner; -One spray bottle of GreaseLift; -Next to the cleaners on the bottom shelf was a bucket of tongs and drink pitchers. 2. Observation in the dry food storage area of the kitchen on 03/10/26 at 11:10 A.M. showed bottles Missouri Department of Health and Senior Services STATE FORM 6899 G6x011 (X2) MULTIPLE CONSTRUCTION PRINTED: 03/19/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 03/10/2026 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 2 of 13 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 OXFORD GRAND AT SHOAL CREEK (X2) MULTIPLE CONSTRUCTION A. BUILDING: KANSAS CITY, MO 64158 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 of Rapid Multi Surface Cleaner, and bottles of GreaseLift on the bottom shelf of a wire shelving unit. During an interview on 03/10/26 at 11:15 A.M. the Dining Services Director said: -He/She would expect all toxic materials to be kept stored in a locked cabinet or closet; -He/She would not expect to see toxic materials sitting next to food, utensils, or pitchers. During an interview on 03/10/26 at 3:52 P.M. the Administrator said he/she expected all toxic materials to be kept separate and locked away for safety. 19 CSR 30-87.020(11) No Deodorizers/Sprays to Eliminate Odors Deodorizers or sprays shall not be used to cover up odors. Odors shall be eliminated to the source by prompt cleaning of bedpans and commodes, floors, furniture and equipment and by proper ventilation. II/III This regulation is not met as evidenced by: Class III Based on observation and interview, the facility failed to ensure the facility was free from offensive odors when a persistent odor of urine permeated from three resident rooms (307, 310, and 311). The facility census was 72. The facility did not provide a policy for cleaning the removal of odors. 1. Observation on 03/10/26 at 11:37 A.M. showed a strong urine odor coming from room Missouri Department of Health and Senior Services STATE FORM 6899 G6x011 PRINTED: 03/19/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 03/10/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 8280 N TULLIS AVE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 3 of 13 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 OXFORD GRAND AT SHOAL CREEK (X2) MULTIPLE CONSTRUCTION A. BUILDING: KANSAS CITY, MO 64158 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 311, room 310, and room 307. During an interview on 03/10/26 at 3:52 P.M. the Administrator said he/she expected all rooms to be promptly and appropriately cleaned to prevent offensive odors from lingering. 19 CSR 30-87.020(12) Floor Surfaces All floors in the facility shall be clean and shall be maintained in good repair. Floors and floor coverings of all food-preparation, food-storage and utensil-washing areas, and the floors of all walk-in refrigerating units, dressing rooms, locker rooms, toilet rooms and vestibules shall be constructed of smooth durable material such as sealed concrete, terrazzo, ceramic tile, durable grades of linoleum or plastic, or tight wood impregnated with plastic. Nothing in this section shall prohibit the use of antislip floor covering in areas where necessary for safety reasons. Ill This regulation is not met as evidenced by: Class Ill Based on observation and interview the facility failed to ensure all floors in food preparation areas, dishwashing areas, and walk-in refrigerating units were kept in a clean manner. The facility census was 72. The facility did not provide a policy regarding floor cleanliness. 1. Observation in the kitchen on 03/10/26 at 11:05 A.M. showed: -A visible layer of grease on the floor under and around the fryer; -Debris on the floor of the walk in refrigerator; Missouri Department of Health and Senior Services STATE FORM 6899 G6x011 PRINTED: 03/19/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 03/10/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 8280 N TULLIS AVE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 4 of 13 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 OXFORD GRAND AT SHOAL CREEK (X2) MULTIPLE CONSTRUCTION A. BUILDING: KANSAS CITY, MO 64158 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 -Debris under shelving in the drink prep area; -Debris under shelving in the dry food storage area; -Debris under and around shelving, grill, and stove area. During an interview on 03/10/26 at 11:15 A.M. the Dining Services Director said: -He/She had a daily, weekly, monthly, and quarterly clean schedule but his/her staff often did not sign off that they completed the tasks; -He/She expected all floors to be cleaned at least daily in the evening after dinner service was completed, but spot swept and mopped as needed throughout the day between meals. During an interview on 03/10/26 at 3:52 P.M. the Administrator said: -He/She expected floors to be kept clean; -He/She expected all kitchen staff to assist in keeping the kitchen floors clean. 19 CSR 30-87.020(13) Carpeting Carpeting, if used as a floor covering, shall be of closely woven construction, properly installed, easily cleanable and maintained in good repair. Carpeting is prohibited in food-preparation, equipment-washing and utensil-washing areas where it would be exposed to large amounts of grease and water, in food-storage areas and toilet room areas where urinals or toilet fixtures are located. III This regulation is not met as evidenced by: Class Ill Based on observation and interview the facility failed to ensure all carpeting used as a floor Missouri Department of Health and Senior Services STATE FORM 6899 G6x011 PRINTED: 03/19/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 03/10/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 8280 N TULLIS AVE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 5 of 13 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 OXFORD GRAND AT SHOAL CREEK (X2) MULTIPLE CONSTRUCTION A. BUILDING: KANSAS CITY, MO 64158 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 5 covering was easily cleanable and maintained in good repair when the carpet in the dining room had dark brown stains and was sticky. The facility census was 72. The facility did not provide a policy regarding carpet cleaning. 1. Observation of the facility's dining room carpet on 03/10/26 at 11:12 A.M. showed: -A dark brown stain covering all highly foot trafficked areas around the dining room including the entrance and exit to the kitchen, around tables, and around the salad bar; -The dark stained area beginning outside the kitchen exit was sticky to the touch; -Food crumbs, debris, and smaller food stains under most tables. During an interview on 03/10/26 at 11:26 A.M. the Maintenance Coordinator said: -He/She was aware of the heavy staining of the dining room carpet; -He/She ran the carpet shampooer over the dining room carpet at least monthly and as needed, but the heavy staining on the floor have been there for so long, shampooing was no longer working to get the staining or stickiness out. During an interview on 03/10/26 at 11:15 A.M. the Dining Services Director said: -He/She expected his/her staff to keep the dining room floor clean, but it did not matter how much they cleaned the floor the stains would not come out; -He/She had mentioned to corporate about needing new flooring in the dining room, but had not heard on a plan moving forward. Missouri Department of Health and Senior Services STATE FORM 6899 G6x011 PRINTED: 03/19/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 03/10/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 8280 N TULLIS AVE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 6 of 13 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 OXFORD GRAND AT SHOAL CREEK (X2) MULTIPLE CONSTRUCTION A. BUILDING: KANSAS CITY, MO 64158 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 6 During an interview on 03/10/26 at 3:52 P.M. the Administrator said: -He/She expected all carpet flooring to be easily cleanable and maintained in good repair; -He/She was aware of the heavily stained carpet in the dining room and had passed the concern on to corporate for replacement but had not heard back on if they planned to replace the floor or not. 19 CSR 30-87.020(31) Kitchen Waste Containers Covered Waste containers used in food-preparation and utensil-washing areas shall be kept covered when not in actual use. III This regulation is not met as evidenced by: Class III Based on observation and interview the facility failed to ensure waste containers in the food preparation and utensil washing areas were kept covered when not in use. The facility census was 72. The facility did not provide a policy regard waste containers. 1. Observation of the kitchen on 03/10/26 at 10:58 A.M. showed: -One uncovered trash can next to the ice machine in the drink preparation area, and no staff in the area using the trash can; -One uncovered trash can in the dishwashing area, and no staff actively in the area using the trash can; -One uncovered trash can next to the preparation table in the dry food storage area, and no staff in Missouri Department of Health and Senior Services STATE FORM 6899 G6x011 PRINTED: 03/19/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 03/10/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 8280 N TULLIS AVE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 7 of 13 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 OXFORD GRAND AT SHOAL CREEK (X2) MULTIPLE CONSTRUCTION A. BUILDING: KANSAS CITY, MO 64158 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 7 the area using the trash can. During an interview on 03/10/26 at 11:15 A.M. the Dining Services Director said he/she expected all trash cans to be kept covered when not in use. During an interview on 03/10/26 at 3:52 P.M. the Administrator said he/she expected all trash cans in the kitchen to be kept covered when not in use. 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 container is not exposed to floor moisture; and containers may be stored on dollies, racks or pallets, provided the equipment is easily movable. ll 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 several boxes of frozen food were stored on the floor of the walk-in freezer. The facility census was 45. 1. Observation on 3/10/2026 at 11:25 A.M. of the walk-in freezer showed eleven boxes of food being stored on the floor, including: -One box of ground beef; Missouri Department of Health and Senior Services STATE FORM 6899 G6x011 PRINTED: 03/19/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 03/10/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 8280 N TULLIS AVE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 8 of 13 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 OXFORD GRAND AT SHOAL CREEK (X2) MULTIPLE CONSTRUCTION A. BUILDING: KANSAS CITY, MO 64158 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 8 -One box of tater tots; -One box of croissants; -One box of hash browns; -One box of pork sausage. During an interview on 03/10/26 at 3:52 P.M. the Administrator said: -Food was supposed to be stored on shelves and not on the floor. 19 CSR 30-87.030(55) Ventilation Hoods, Clean, Filters Removable Ventilation hoods and devices shall be designed to prevent grease or condensation from collecting on walls and ceilings and from dripping into food or onto food-contact surfaces. Filters or other grease-extracting equipment shall be readily removable for cleaning and replacement if not designed to be cleaned in place. III This regulation is not met as evidenced by: Class III Based on observation and interview, the facility failed to ensure the ventilation hood filters were kept clean and free of grease build up. The facility census was 72. The facility did not provide a policy regarding vent hood cleaning. 1. Observation of the kitchen on 03/10/26 at 10:58 A.M. showed: -Three sections of the vent hood filters above the grill, black with buildup of grease, nearly dripping off the filters. During an interview on 03/10/26 at 11:15 A.M. the Missouri Department of Health and Senior Services STATE FORM 6899 G6x011 PRINTED: 03/19/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 03/10/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 8280 N TULLIS AVE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 9 of 13 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 OXFORD GRAND AT SHOAL CREEK (X2) MULTIPLE CONSTRUCTION A. BUILDING: KANSAS CITY, MO 64158 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 9 Dining Services Director said: -An outside company came out to clean the hood vent filters every three months; -The evening cook cleaned the filters weekly, but that cook had been on leave for two weeks and he/she was still working to train the other cook; -He/She was unsure of the last time the hood vent filters were cleaned. During an interview on 03/10/26 at 3:52 P.M. the Administrator said: -He/She expected vent hoods to be cleaned weekly; -It was the responsibility of all kitchen staff to ensure these were kept clean. 19 CSR 30-87.030(65) Nonfood Contact Surfaces,Cleaned as Needed Nonfood-contact surfaces of equipment shall be cleaned as often as is necessary to keep the equipment free of accumulation of dust, dirt, food particles and other debris. III This regulation is not met as evidenced by: Class III Based on observation, and interview the facility failed to ensure all nonfood-contact surfaces of equipment were kept clean and free from accumulation of dust, dirt, food particles, and other debris. This had the potential to affect all residents. The facility census was 72. The facility did not provide a policy regarding kitchen cleaning. 1. Observation of the kitchen on 03/10/26 at 10:58 A.M. showed: Missouri Department of Health and Senior Services STATE FORM 6899 G6x011 PRINTED: 03/19/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 03/10/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 8280 N TULLIS AVE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 10 of 13 PRINTED: 03/19/2026 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 03/10/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8280 N TULLIS AVE KANSAS CITY, MO 64158 (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) OXFORD GRAND AT SHOAL CREEK Continued From page 10 -The bottom shelf below the counter next to the soda machine with a sticky substance and debris; -The top of the ice cream freezer with puddles of melted ice cream; -Red splatter on the inside of the microwave; -Grime build up and debris on the shelf holding the microwave; -The back splash behind the grill and griddle with splatter; - The small preparation refrigerator next to the grill had water mixed with dirt and food debris pooled in the bottom of it; -The bottom shelf of the preparation table in the back of the kitchen was corroded with a sticky substance, dirt, and debris. 2. Observation of the dining room on 3/10/26 at 11:39 A.M. showed: -All of the dining room tables were sticky. During an interview on 03/10/26 at 11:45 A.M. the Dining Services Director said: -He/She was aware the dining room tables were sticky to touch; -The tables were not sticky because they were dirty, but the varnish/finish had begun to break down over time caused by cleaning chemicals; -He/She felt the tables needed to be replaced. During an interview on 03/10/26 at 3:52 P.M. the Administrator said: -He/She was aware the dining room tables were sticky to touch; -The facility had not addressed the issue yet but was working to figure out how to correct the problem. 19 CSR 30-87.030(87) Glasses/Cups/Utensils Storage Missouri Department of Health and Senior Services STATE FORM 6899 G6xX011 If continuation sheet 11 of 13 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 OXFORD GRAND AT SHOAL CREEK (X2) MULTIPLE CONSTRUCTION A. BUILDING: KANSAS CITY, MO 64158 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 11 Glasses and cups shall be stored inverted. Other stored utensils shall 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 utensil to the consumer. III This regulation is not met as evidenced by: Class III Based on observation an interview the facility failed to ensure glasses, bowls, plates and utensils were stored in an inverted position to prevent contamination from splash and debris. The facility census was 72. The facility did not provide a policy regarding storage of dishes. 1. Observation in the kitchen on 03/10/26 at 10:58 A.M. showed: -Bowls, plates, and ramekins stored upright on a shelf in the drink preparation area; -Plastic plates and bowls stored upright on a shelf next to an open window; -The top bowls with dust and debris inside the bowls. During an interview on 03/10/26 at 11:15 A.M. the Dining Services Director said he/she expected all plates, bowls, utensils, and cookware to be stored inverted to prevent contamination from splash, splatter, dust, and debris. During an interview on 03/10/26 at 3:52 P.M. the Missouri Department of Health and Senior Services STATE FORM 6899 G6x011 PRINTED: 03/19/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 03/10/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 8280 N TULLIS AVE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 12 of 13 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 8280 N TULLIS AVE OXFORD GRAND AT SHOAL CREEK KANSAS CITY, MO 64158 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION PRINTED: 03/19/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 03/10/2026 (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 A7089 | Continued From page 12 Administrator said he/she expected all kitchen to assist in ensuring dishware, utensils, and cookware were stored in an inverted manner. Missouri Department of Health and Senior Services STATE FORM oeee G6xX011 If continuation sheet 13 of 13 PLAN OF CORRECTION Provider/Supplier Oxford Grand at Shoal Creek Name: Street Address, ne pe 8280 N Tullis Ave, Kansas City, MO 64158 City, Zip: Date of Survey: 03/10/2026 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 This Plan of Correction is submitted in response to the Statement of Deficiencies and does not constitute an admission or agreement with the findings or conclusions set forth therein. The facility submits this Plan of Correction to demonstrate its commitment to compliance with all applicable regulations and to outline the steps taken to correct the identified concerns. 19 CSR 30-86.032(23) Rooms Neat, Orderly, Cleaned Daily 1. Immediate Correction: All identified deficiencies related to resident beds and - linens were immediately corrected upon identification. This included thorough cleaning, removal of any contaminated materials, and restoration of compliance with regulatory expectations. Staff were verbally in-serviced immediately. 2. Potential to Affect Other Residents: All residents had the potential to be affected by this deficient practice. 4/3/2026 3. Systemic Changes / Long-Term Correction: The Resident Care Director/Designee provided education to all applicable staff regarding regulatory requirements and facility expectations on 3/24/2026. The Executive Director/Designee will round frequently and will ensure issues are corrected if identified. Ongoing education will be provided as needed to ensure sustained compliance. Documentation of education maintained. This will be reviewed with new staff members during orientation. 4. Monitoring / Auditing: The Resident Care Director or designee will conduct LG&E | Execupre Dirreh 4 /3/2¢ routine audits to ensure continued compliance. Audits will be conducted 5 times per week for | week, 3 times per week for 1 week, and weekly thereafter. Any identified concerms will be corrected immediately and addressed through additional staff education. Audit logs maintained. 19 CSR 30-87.020(5) Toxic Material Storage 1. Immediate Correction: All identified toxic material storage practices related to this deficiency were immediately corrected upon identification. This included removal of all the mentioned toxic materials, and restoration of compliance with regulatory expectations. Staff were verbally in-serviced immediately. 2. Potential to Affect Other Residents: All residents had the potential to be affected by this deficient practice. 3. Systemic Changes / Long-Term Correction: The Executive Director/Designee provided education to all applicable staff regarding regulatory requirements and facility expectations on 3/24/2026. The Executive Director/Designee will round frequently and will ensure issues are corrected if identified. Ongoing education will be provided as needed to ensure sustained compliance. Documentation of education maintained. This will be reviewed with new staff members during orientation. 4/3/2026 4. Monitoring / Auditing: The Executive Director or designee will conduct routine audits to ensure continued compliance. Audits will be conducted 5 times per week for | week, 3 times per week for | week, and weekly thereafter. Any identified concerns will be corrected immediately and addressed through additional staff education. Audit logs maintained. 19 CSR 30-87.020(1 1) No Deodorizers/Sprays to Eliminate Odors 1. Immediate Correction: All identified odor control and sanitation practices related to this deficiency were immediately corrected upon identification. Rooms 307, 310 and 311 were thoroughly cleaned to remove the odor. Staff were verbally in-serviced immediately. Staff was educated to offer more frequent toileting to those who need it. 4/3/2026 2. Potential to Affect Other Residents: All residents had the potential to be affected by this deficient practice. 3. Systemic Changes / Long-Term Correction: The Executive Director/Designee provided education to all applicable staff regarding regulatory requirements and facility expectations on 3/24/2026. The carpets in rooms 307, 310 and 311 will cleaned weekly. The Executive Director/Designee will round frequently and will ensure issues are corrected if identified. Ongoing education will be provided as needed to ensure sustained compliance. Documentation of education maintained. This will be reviewed with new staff members during orientation. 4, Monitoring / Auditing: The Executive Director or designee will conduct routine audits to ensure continued compliance. Audits will be conducted 5 times per week for 1 week, 3 times per week for 1 week, and weekly thereafter. Any identified concerns will be corrected immediately and addressed through additional staff education. Audit logs maintained. Pp 4/3/2026 19 CSR 30-87.020(12) Floor Surfaces 1. Immediate Correction: All identified floor cleanliness in kitchen and food service areas related to this deficiency were immediately corrected upon identification. This included thorough cleaning, removal of any contaminated materials, and restoration of compliance with regulatory expectations. Staff were verbally in-serviced immediately on their cleaning duties. 2. Potential to Affect Other Residents: All residents had the potential to be affected by this deficient practice. 3. Systemic Changes / Long-Term Correction: The Executive Director/Designee provided education to all applicable staff regarding regulatory requirements and facility expectations on 3/24/2026. The Executive Director/Designee will round frequently and will ensure issues are corrected if identified. Ongoing education will be provided as needed to ensure sustained compliance. Documentation of education maintained. Cleaning logs will be reviewed by the Dining Director or designee. This will be reviewed with new staff members during orientation. 4, Monitoring / Auditing: The Executive Director or designee will conduct routine audits to ensure continued compliance. Audits will be conducted 5 times per week for 1 week, 3 times per week for 1 week, and weekly thereafter. Any identified concerns will be corrected immediately and addressed through additional staff education. Audit logs maintained. 19 CSR 30-87.020(13) Carpeting 1. Immediate Correction: All identified carpet and dining area deficiencies have been corrected. The dining room has been vacuumed and all crumbs and particles have been removed. Carpet was professionally cleaned on 03/27/2026. Staff were verbally in-serviced immediately. 2. Potential to Affect Other Residents: All residents had the potential to be affected by this deficient practice. 3. Systemic Changes / Long-Term Correction: The Executive Director/Designee provided education to all applicable staff regarding regulatory requirements and facility expectations on 3/24/2026. Staff will vacuum the dining room daily and spot clean as needed. The 4/10/2026 maintenance director or designee will clean the dining room carpet weekly. The Executive Director/Designee will round frequently and will ensure issues are corrected if identified. Ongoing education will be provided as needed to ensure sustained compliance. Documentation of education maintained. This will be reviewed with new staff members during orientation. 4, Monitoring / Auditing: The Executive Director or designee will conduct routine audits to ensure continued compliance. Audits will be conducted 5 times per week for 1 week, 3 times per week for 1 week, and weekly thereafter. Any identified concerns will be corrected immediately and addressed through additional staff education. Audit logs maintained. 19 CSR 30-87.020(31) Kitchen Waste Containers Covered 1. Immediate Correction: All identified waste container practices have been corrected. Trash cans have been covered. Staff were verbally in-serviced immediately. 2. Potential to Affect Other Residents: All residents had the potential to be affected by this deficient practice. 3. Systemic Changes / Long-Term Correction: The Executive Director/Designee provided education to all applicable staff regarding regulatory requirements and facility expectations on 3/24/2026. The Executive Director/Designee will round frequently and will ensure issues are corrected if identified. Ongoing education will be provided as needed to ensure sustained compliance. Documentation of education maintained. This will be reviewed with new staff members during orientation. 4. Monitoring / Auditing: The Executive Director or designee will conduct routine audits to ensure continued compliance. Audits will be conducted 5 times per week for 1 week, 3 times per week for 1 week, and weekly thereafter. Any identified concerns will be corrected immediately and addressed through additional staff education. Audit logs maintained. 4/3/2026 P| 4/3/2026 19 CSR 30-87.030(15) Food-Stored Above the Floor, Protected 1. Immediate Correction: All identified deficient food storage practices have been corrected; all identified boxes of food were removed off the floor immediately. Staff were verbally in-serviced immediately. 2. Potential to Affect Other Residents: All residents had the potential to be affected by this deficient practice. 3. Systemic Changes / Long-Term Correction: The Executive Director/Designee provided education to all applicable staff regarding regulatory requirements and facility expectations on 3/24/2026. The Executive Director/Designee will round frequently and will ensure issues are corrected if identified. Ongoing education will be provided as needed to ensure sustained compliance. Documentation of education maintained. This will be reviewed with new staff members during orientation. 4. Monitoring / Auditing: The Executive Director or designee will conduct routine audits to ensure continued compliance. Audits will be conducted 5 times per week for 1 week, 3 times per week for 1 week, and weekly thereafter. Any identified concerns will be corrected immediately and addressed through additional staff education. Audit logs maintained. ee 19 CSR 30-87.030(55) Ventilation Hoods, Clean, Filters Removable 1. Immediate Correction: All identified ventilation hood and filter cleanliness related to this deficiency were immediately corrected upon identification. Staff were verbally in-serviced immediately. 2. Potential to Affect Other Residents: All residents had the potential to be affected by this deficient practice. 3. Systemic Changes / Long-Term Correction: The Executive Director/Designee provided education to all applicable staff regarding regulatory requirements and facility expectations on 3/24/2026. Vents will be cleaned 4/3/2026 weekly. The Executive Director or Designee will round weekly to ensure cleanliness. Ongoing education will be provided as needed to ensure sustained compliance. Documentation of education maintained. This will be reviewed with new staff members during orientation. 4. Monitoring / Auditing: The Executive Director or designee will conduct routine audits to ensure continued compliance. Audits will be conducted once a week x three weeks and weekly thereafter. Any identified concerns will be corrected immediately and addressed through additional staff education. Audit logs maintained. fT 19 CSR 30-87.030(65) Nonfood Contact Surfaces,Cleaned as Needed 4/10/2026 1. Immediate Correction: All identified nonfood-contact surface cleanliness related to this deficiency were immediately corrected upon identification. Tablecloth covering process related to this deficiency was implemented. Staff were verbally in- serviced immediately. 2. Potential to Affect Other Residents: All residents had the potential to be affected by this deficient practice. 3. Systemic Changes / Long-Term Correction: The Executive Director/Designee provided education to all applicable staff regarding regulatory requirements and facility expectations on 3/24/2026. Tables will be covered with non-porous covering and table cloths will be used for each meal. The Executive Director/Designee will round frequently and will ensure issues are corrected if identified. Ongoing education will be provided as needed to ensure sustained compliance. Documentation of education maintained. This will be reviewed with new staff members during orientation. 4. Monitoring / Auditing: The Executive Director or designee will conduct routine audits to ensure continued compliance. Audits will be conducted 5 times per week for 1 week, 3 times per week for 1 week, and weekly thereafter. Any identified concerns will be corrected immediately and addressed through additional staff education. Dining Director or Designee will review cleaning logs to ensure compliance. Audit logs maintained. 19 CSR 30-87.030(87) Glasses/Cups/Utensils Storage 1. Immediate Correction: All identified improperly stored dishware and utensil related to this deficiency were immediately corrected upon identification. Staff were verbally in-serviced immediately. 2. Potential to Affect Other Residents: All residents had the potential to be affected by this deficient practice.. 3. Systemic Changes / Long-Term Correction: The Executive Director provided education to all 4/3/2026 applicable staff regarding regulatory requirements and facility expectations on 3/24/2026. The Dining Director/ Designee will round daily and correct any issues immediately. Ongoing education will be provided as needed to ensure sustained compliance. Documentation of education maintained. This will be reviewed with new staff members during orientation. 4. Monitoring / Auditing: The Executive Director or designee will conduct routine audits to ensure continued compliance. Audits will be conducted 5 times per week for 1 week, 3 times per week for 1 week, and weekly thereafter. Any identified concerns will be corrected immediately and addressed through additional staff education. Audit logs maintained. The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approval of the plan of correction being submitted on this form.

PRINTED: 07/01/2025 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: COMPLETEO Cc B.WING 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8280 N TULLIS AVE KANSAS CITY, MO 64158 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x8) PREFIX (EACH DEFICIENCY MUST 8E PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) : CROSS-REFERENCED TO THE APPROPRIATE DATE i DEFICIENCY) OXFORD GRAND AT SHOAL CREEK 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 I* Based on interview and record review, facility staff failed to provide proper and timely care for three of four sampled residents (Resident #1, #2, ; and #3) when they failed to answer residents call lights in a timely manner. The facility census was 75. The facility did not have a policy regarding call lights. | 1. Review of Resident #1's medical record | showed: -Diagnoses included anxiety, depression, obsessive compulsive disorder (OCD - a mental health condition characterized by persistent, intrusive thoughts (obsessions) and repetitive i behaviors (compulsions) that can cause : Significant distress and interfere with daily life), ' and difficulty walking. Review of the facility's June 2025 call light report : showed the following: | -Resident #1 had a call light on for 1 hour and 2 | minutes on 06/03/25 at 6:09 P.M.; Missouri Department of Health and Senior Services P, YA a # f LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE - TITLE g ley Slope (X6) DATE STATE FORM 6890 4SPV11 If continuation sheet 1 of 5 PRINTED: 07/01/2025 FORM APPROVED partment of Health and Senior Services {X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: Missouri De STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X2} MULTIPLE CONSTRUCTION A, BUILDING: (X3) DATE SURVEY COMPLETED Cc 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADORESS, CITY, STATE, ZIP CODE 8280 N TULLIS AVE KANSAS CITY, MO 64158 OXFORD GRAND AT SHOAL CREEK (X4) iD SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION} TAG CROSS-REFERENCED TO THE APPROPRIATE DATE ! DEFICIENCY) A8030 | Continued From page 1 | -Resident #1 had a call light on for 16 minutes on : 06/03/25 at 8:36 P.M... -Resident #1 had a cail light on for 23 minutes on | 06/06/25 at 8:52 P.M.; -Resident #1 had a call light on for 19 minutes on 06/07/25 at 11:25 A.M.; | -Resident #1 had a call light on for 26 minutes on 06/08/25 at 12:47 A.M.; | -Resident #1 had a call light on for 46 minutes on 06/08/25 at 8:50 A.M.; -Resident #1 had a call light on for 1 hour and 19 minutes on 06/08/25 at 5:46 P.M.; : -Resident #1 had a call light on for 2 hours and 7 minutes on 06/09/25 at 5:59 P.M.; -Resident #1 had a call light on for 35 minutes on 06/10/25 at 4:22 P.M.; i: -Resident #1 had a call light on for 17 minutes on - 06/11/25 at 5:55 P.M.; -Resident #1 had a call light on for 1 hour and 2 . minutes on 06/13/25 at 5:39 P.M.; | -Resident #1 had a call light on for 1 hour and 19 | minutes on 06/17/25 at 6:07 P.M.; -Resident #1 had a call light on for 19 minutes on 06/19/25 at 10:09 P.M.; . -Resident #1 had a call light on for 29 minutes on | 06/20/25 at 3:24 A.M.; -Resident #1 had a call light on for 25 minutes on ' 06/20/25 at 4:12 A.M. | During and interview on 06/20/25 at 1:37 P.M. | Resident #1 said: i -He/She had to wait long periods for staff to arrive | | after pressing his/her call light; | ' -He/She used his/her call light for help to the | bathroom; -He/She felt dirty when he/she had to wait a long time for staff to answer his/her call light. . 2, Review of Resident #2's record showed: ; -Diagnoses included high blood pressure, Missouri Department of Health and Senior Services STATE FORM Se89 1SPV11 If continuation sheet 2 of 5 PRINTED: 07/01/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X41) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc B.WING 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8280 N TULLIS AVE KANSAS CITY, MO 64158 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) OXFORD GRAND AT SHOAL CREEK A8030 | Continued From page 2 | dementia (a general term for a group of brain disorders that cause a progressive decline in cognitive functions, such as memory, thinking, ' reasoning, and problem-solving), and _ incontinence (lack of voluntary control over _ urination or defecation). ' Review of the facility's June 2025 call light report showed the following: -Resident #2 had a call light on for 20 minutes on 06/01/25 at 1:29 P.M.; | «Resident #2 had a call light on for 16 minutes on | 06/02/25 at 4:54 A.M.; | -Resident #2 had a call light on for 54 minutes on | 06/04/25 at 2:32 P.M.; -Resident #2 had a call light on for 23 minutes on 06/08/25 at 1:42 P.M.; -Resident #2 had a call light on for 30 minutes on 06/09/25 at 3:32 P.M.; -Resident #2 had a call light on for 22 minutes on 06/12/25 at 7:23 A.M.; -Resident #2 had a call light on for 34 minutes on 06/13/25 at 6:23 A.M.; -Resident #2 had a call light on for 18 minutes on 06/14/25 at 4:12 A.M.; -Resident #2 had a call light on for 50 minutes on 06/16/25 at 6:25 A.M.; -Resident #2 had a call light on for 19 minutes on 06/20/25 at 9:06 A.M. During an interview on 06/20/25 at 1:18 P.M. Resident #2 said: -He/She had occasionally waited for 15 or more minutes for staff to answer his/her call light; ~Having to wait a long time for staff to answer his/her call light made him/her feel inadequate; ~He/She felt call lights should be answered within 15 minutes. 3. Review of Resident #3's record showed: Missouri Depariment of Health and Senior Services STATE FORM 6899 4SPV11 i continuation sheet 3 of § PRINTED: 07/01/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X71} PROVIDER/SUPPLIER/CLIA (X2}) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: Cc B.WING 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8280 N TULLIS AVE KANSAS CITY, MO 64158 (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 j DEFICIENCY) OXFORD GRAND AT SHOAL CREEK | Continued From page 3 ; -Diagnoses included Parkinson's disease (a ' progressive neurodegenerative disorder that primarily affects the brain, causing problems with ; movement and other functions). Review of the facility's June 2025 call light report showed the following: -Resident #3 had a call light on for 46 minutes on 06/01/25 at 8:54 P.M.; | -Resident #3 had a call light on for 23 minutes on 06/04/25 at 7:16 P.M.; | -Resident #3 had a call light on for 27 minutes on 06/04/25 at 8:57 P.M.; | “Resident #3 had a call light on for 22 minutes on - 06/05/25 at 8:03 P.M.; -Resident #3 had a call light on for 18 minutes on : 06/07/25 at 9:06 A.M.; -Resident #3 had a call light on for 33 minutes on , 06/07/25 at 10:01 P.M.; | -Resident #3 had a call light on for 19 minutes on 06/08/25 at 8:53 A.M.; -Resident #3 had a call light on for 31 minutes on 06/09/25 at 5:42 P.M.; : “Resident #3 had a call light on for 36 minutes on , 06/18/25 at 2:20 P.M.; -Resident #3 had a cail light on for 18 minutes on 06/18/25 at 8:09 P.M.; | “Resident #3 had a cail light on for 17 minutes on . 06/19/25 at 8:54 P.M. : During an interview on 06/20/25 at 2:04 P.M, | Resident #3 said: | -He/She did occasionally have to wait a while for staff to answer his/her call light; : ~-He/She felt the facility occasionally did not have enough staff on duty, which caused the long wait times. During an interview on 06/25/25 at 2:08 P.M., Medication Partner A said: Missouri Department of Health and Senior Services STATE FORM 6899 4SPV14 If continuation sheet 4 of 5 PRINTED: 07/01/2025 Missouri Department of Health and Senior Services FORM APPROVED STATEMENT OF DEFICIENCIES {X1) PROVIDER/SUPPLIER/CLIA {X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8280 N TULLIS AVE KANSAS CITY, MO 64158 (x4) 1D | SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD 8E TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) OXFORD GRAND AT SHOAL CREEK Continued From page 4 -He/She was expected to answer call lights within 5-10 minutes of alerting; During an interview on 06/25/25 at 2:29 P.M. Caregiver A said: -He/She was expected to answer call lights | before they turn red on the pager; _ -Call lights turn red with in nine minutes of the | initial call. | During an interview on 06/20/25 at 11:30 A.M. the Executive Director said: -Was not aware that call lights were not being | answered timely; | -He/She expected call lights to be answered | within 10 minutes. : *The higher classification merited due to the _ Violation's effect on the resident(s). MO254976 Missouri Department of Health and Senior Services STATE FORM 6808 4SPV11 COMPLETED c 06/20/2025 (x5) COMPLETE DATE If continuation sheet § of 5 PLAN OF CORRECTION Oxford Grand Shoal Creek Name: Facility ID #30758 Street Address, City, Zip: 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 Education was completed on 6/20/25 on call light answering expectation. Facility ordered more pagers to assist with the answering of the call lights. Leadership will have access to pagers and waikies to assist with he answering of call lights. A8030 Residents #1, #2, and #3 were all affected by the call lights not being answered in a timely manner. RCD or designee will complete call light audit 2-3x weekly for 4 8280 N Tullis Ave. Kansas City, MO 64158 7/14/25 weeks, 1x weekly for 4 weeks and 1x monthly there after. 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. MLE fer SAA 11.45/95

PRINTED: 08/22/2024 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: COMPLETEO B.WING 08/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 8280 N TULLIS AVE KANSAS CITY, MO 64158 (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 i ATE DEFICIENCY) OXFORD GRAND AT SHOAL CREEK 19 CSR 30-86.022(4)(B)(1)(2) Range Hood-After | 7/11/80 & Before 10/1/00 Range Hood Extinguishing Systems. (B) in licensed facilities with a total of twenty-one (21) or more licensed beds and whose application was filed after July 11, 1980, and prior to October 1, 2000: | 1. The kitchen shall be provided with a range , hood and an approved automatic range hood | extinguishing system unless the facility has an approved sprinkler system. Facilities with range hood systems shall continue to maintain and test these systems; and 2. The extinguishing system shall be installed, | tested, and maintained in accordance with NFPA : 96, 1998 edition. H/HI This regulation is not met as evidenced by: Class Ill Based on observation and interview on 8/20/24 this facility failed to have the range hood extinguishing system maintained in accordance with NFPA 96, 1998 edition which in part requires ' the hood extinguishing system to be certified at , least annually by a qualified person. The facility census was 83. This Potentially affected 83 of 83 residents. | Observation on 8/20/24 at 2:15 P.M. showed an inspection tag on the hood extinguishing system in the demonstration kitchen dated May 23, 2023 making it expired by about three months past its annual inspection due date. - During an interview on 8/20/24 at 2:15 P.M. the | Maintenance Director said the kitchen was not used any more, but he she would get the annual inspection done on it. Missouri Deparment of Health and Senior Services } 2 Py Keke (X6) DAT! LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVES SIGNATURE _, ila STATE FORM 6695 BBGM1i If continuation sheet 1 of 2 PRINTED: 08/22/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X1) PROVIDER/SUPPLIERICLIA {X2) MULTIPLE CONSTRUCTION {X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER; A. BUILDING: : COMPLETED 30758 B.WING 08/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8280 N TULLIS AVE KANSAS CITY, MO 64158 (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) i i CROSS-REFERENCED TO THE APPROPRIATE i DATE : ; DEFICIENCY) ; OXFORD GRAND AT SHOAL CREEK Continued From page 1 19 CSR 30-86.022(10)(i) Smoke Section Partitions > than 20 beds | Protection from Hazards. (I} In facilities whose plans were approved or which were initially licensed after December 31, : 1987, for more than twenty (20) beds and all | facilities licensed after August 28, 2007, each smoke section shall be separated by one- (1-) hour fire-rated smoke partitions. The smoke | partitions shall be continuous from outside ' wall-to-outside wall and from floor-to-floor or floor-to-roof deck. All doors in this wall shall be at least twenty- (20-) minute fire-rated or its equivalent, self-closing, and may be held open : only if the door closes automatically upon _ activation of the complete fire alarm system. I This regulation is not met as evidenced by: , Class tl | Based on observation and interview on 8/20/24 | this facility failed to ensure the smoke stop partition doors would properly close during a fire alarm. The facility census was 83. This Potentially | affected 83 of 83 residents. Observation on 8/20/24 at 1:45 P.M. showed the smoke separation door hitting the frame at the top and not allowing the doors to close properly. During an interview on 8/20/24 at 1:45 P.M. the Maintenance Director said he/she would get the doors adjusted or shaved down so they will | properly close. Missouri Department of Health and Senior Services STATE FORM S598 BBGM11 H continuation sheet 2 of 2 PLAN OF CORRECTION Provider/Supplier Oxford Grand at Shoal Creek Name: Street Address, gt 8280 N Tullis Ave, Kansas City Mo, 64158 City, Zip: Date of Survey: August 20", 2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 26D2137216 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: {EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE Immediate actions taken for the resident found to have been affected include: Scheduled inspections for all hood extinguishing systems. Identification of other residents having the potential to be affected was accomplished by: Ensuring that all inspections were scheduled or up to date. Actions taken/systems put into place to reduce risk of future occurrence include: Maintenance Director rounded the building to ensure all tags were up to date. The Maintenance Director and Administrator follow inspection log to ensure that all inspections are completed in a timely manner. Inspections are scheduled for 9/3/24 9/6/24 How the corrective action will be monitored to ensure the practice will not occur: Maintenance Director will review the inspection log weekly x4 weeks then monthly there after Immediate actions taken for the resident found to have been affected include: Inspect the building to check all fire doors. identification of other residents having the potential to be affected was accomplished by: 9/6/24 Rounding was completed throughout the building to ensure safety of each resident. Actions taken/systems put into place to reduce risk of future occurrence include: Adjustment to each fire door has been made to ensure that the door properly closes. How the corrective action will be monitored to ensure the practice will not occur: Maintenance Director will inspect each safety door weekly X 4 weeks then Biweekly X 4 Weeks then monthly there 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.