Park Villa: Hospice Care Plan Failures - KS
The resident, identified as R5 in inspection documents, had severe cognitive impairment with a Brief Interview of Mental Status score of two. She required substantial or maximal assistance with nearly all daily activities, including oral hygiene, toileting, bed mobility, transfers, and dressing. Staff had to help her put on and take off her shoes.
R5 was admitted to hospice services on March 10, 2026. Her care plan, last revised in July 2025, directed staff to monitor her closely for signs of pain, administer pain medications as ordered, and notify both the physician and hospice immediately if breakthrough pain occurred.
But the plan failed to include basic coordination information required for hospice care.
Administrative Nurse F confirmed on April 14 at 4:03 PM that R5's care plan lacked information about hospice visits, phone numbers, and medical supplies that hospice services would provide. The nurse acknowledged this information should have been included in the resident's care plan.
The facility's own hospice services policy, revised January 22, 2026, required an interdisciplinary care plan that integrated care and services provided by both the facility and the hospice provider. The policy specifically mandated coordination details that were missing from R5's plan.
According to facility policy, hospice care plans must address resident, staff, and physician comfort with dealing with death. They must account for family expectations and ensure resident and family knowledge of disease progression and eventual outcomes.
The policy also required documentation of staff time needed to provide necessary care and services, cultural and ethnic considerations, and communication between all participants and agencies providing palliative care aspects.
None of these coordination elements appeared in R5's care plan.
R5 had multiple serious medical conditions including diabetes, hypertension, and atherosclerotic heart disease. The atherosclerotic condition involved buildup of fats, cholesterol, and other substances in her artery walls, narrowing pathways and restricting blood flow.
Her March 10 Minimum Data Set assessment documented her complete dependence on staff for footwear assistance and need for substantial or maximal help with oral hygiene, toileting hygiene, bed mobility, transfers, and both upper and lower body dressing. She required partial to moderate assistance with personal hygiene.
The care plan directed staff to adjust their provision of daily living activities to compensate for R5's changing abilities. It encouraged staff to let R5 participate to whatever extent she wished.
Staff were instructed to assess R5 for coping strategies, respect her wishes, and consult with both the physician and hospice services to continue her hospice care within the facility.
But without contact information for hospice staff, notification requirements became meaningless. If R5 experienced breakthrough pain requiring immediate hospice notification, staff had no way to reach hospice providers quickly.
The missing supply and equipment information created additional coordination gaps. Staff couldn't know what medical supplies hospice would provide versus what the facility needed to maintain on hand.
Without schedules for when hospice staff would be in the building, facility staff couldn't coordinate care transitions or ensure someone was available to communicate with hospice providers about R5's condition changes.
The care plan also lacked details about what specific care hospice staff would provide during their visits. This left facility staff uncertain about their responsibilities versus hospice responsibilities for R5's daily care needs.
During the April 15 inspection, R5 rested in bed with her eyes closed, showing no signs or symptoms of pain at 8:10 AM. But her condition could change rapidly given her severe cognitive impairment and multiple medical conditions.
The facility's hospice policy emphasized the importance of communication and coordination between all agencies providing palliative care. Yet R5's care plan contained none of the contact information or coordination details the policy required.
Federal inspectors classified this as a deficiency with minimal harm or potential for actual harm, affecting few residents. But for R5 and her family, the missing coordination information represented a gap in end-of-life care planning.
Hospice care requires seamless coordination between facility staff and hospice providers to ensure dying residents receive appropriate comfort measures and pain management. When care plans lack basic contact information and service details, that coordination breaks down.
R5's severe cognitive impairment meant she couldn't advocate for herself or communicate her needs clearly. She depended entirely on facility staff to coordinate her care with hospice providers and ensure her comfort during her final days.
The inspection found R5's care plan directing staff to encourage her participation in activities to whatever extent she wished, but without proper hospice coordination, even basic comfort measures could be compromised.
Staff were told to respect R5's wishes and assess her coping strategies, but the missing hospice contact information meant they couldn't quickly reach hospice providers when R5's condition changed or when breakthrough pain occurred.
The facility maintained a detailed hospice services policy outlining all the coordination requirements missing from R5's care plan. Administrative Nurse F acknowledged the deficiency, confirming the missing information should have been included.
But R5 continued receiving hospice care with an incomplete coordination plan, leaving gaps in communication between the facility and hospice providers responsible for her end-of-life comfort and dignity.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Park Villa from 2026-04-15 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
PARK VILLA in CLYDE, KS was cited for violations during a health inspection on April 15, 2026.
The resident, identified as R5 in inspection documents, had severe cognitive impairment with a Brief Interview of Mental Status score of two.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.