Park Villa

criteria described in the skin assessment policy. A skin assessment would be performed on the day of Level of Harm - Minimal harm return from a stay in another health care facility and seven days after that return, and each time a or potential for actual harm change in the resident's condition is noted. Braden Scale would be performed weekly for four weeks following an admission. After conducting an inspection of the resident's skin, the nurse would review Residents Affected - Few the resident's assessment protocol for pressure ulcers to identify risk factors for the development of pressure ulcers. An immediate plan to reduce a resident's risk of pressure ulcers or to treat an existing pressure ulcer would be implemented. The Certified Nurse Aide would perform a skin assessment at the time of each bathing experience document and report findings to the licensed nurse. Residents with lower extremities with ulcers would be assessed by a physician to determine

the etiology of the ulcer. The physician's diagnosis would be recorded in the resident's clinical record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete 175492 Page 4 of 8 Department of Health & Human Services Printed: 06/12/2026 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.Building 175492 04/15/2026 B. Wing NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Villa 114 S High St Clyde, KS 66938 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

professional principles; and all drugs and biologicals must be stored in locked compartments, Level of Harm - Minimal harm separately locked, compartments for controlled drugs. or potential for actual harm Based on observation, interview, and record review, the facility failed to discard expired stock Residents Affected - Few medication from the North Hall medication cart. Findings included: - On 04/13/2026 at 08:10 AM,

observation of the North Hall medication cart revealed the following:Acetaminophen suppositories 650 milligrams (mg), four suppositories, expiration 3/2026. On 04/13/2026 at 08:15 AM, Certified Medication Aide (CMA) R verified the medication aides or nurses were to discard expired medications.

On 4/15/2026 at 02:30 PM, Administrative Nurse E verified the medication aides or nurses were to check the medication cart and discard expired medications. The facility's Medication Labeling and Storage policy, dated 01/22/2026, documented medications are labeled and stored in accordance with facility requirements and State and Federal laws. All drug containers would be labeled, and drug labels must be clear, consistent, legible, and in compliance with State and Federal requirements.

Floor stock medications are labeled floor stock or house supply and kept in the original manufacturer's container with the expiration date and lot number clearly evident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete 175492 Page 5 of 8 Department of Health & Human Services Printed: 06/12/2026 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.Building 175492 04/15/2026 B. Wing NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Villa 114 S High St Clyde, KS 66938 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

the food and nutrition service, including a qualified dietician.

Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, and interview, the facility failed to employ a full-time certified dietary manager for the 31 residents who resided in the facility and received meals from the facility Residents Affected - Many kitchen. Findings included: - 04/14/26, a review of the noon meal consisted of shrimp, cornbread, cooked sliced squash, rice, and yellow cake with chocolate frosting. On 04/14/26 at 11:15 AM,

observation revealed Dietary Staff (DS) BB in the kitchen overseeing the preparation of the noon meal. On 04/13/26 at 10:56 AM, DS BB verified she was not a Certified Dietary Manager (CDM). DS BB stated she had enrolled in the classes but had not completed them 04/15/26 at 11:45 AM, Administrative Nurse D verified DS BB had no dietary manager certification, but had enrolled and started the dietary certification classes. The facility's Nutritional Services Policy, revised 01/21/26, documented the certified dietary manager would oversee all kitchen procedures, including the following:1. Menu planning2. Diet and diet manual with nutritional evaluations3. Office procedures, including the process of nursing staff informing the Registered Dietitian, in writing, of the arrival of new elders.4, Food production5, Food service Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete 175492 Page 1 of 8 Department of Health & Human Services Printed: 06/12/2026 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.Building 175492 04/15/2026 B. Wing NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Villa 114 S High St Clyde, KS 66938 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

serve food in accordance with professional standards.

Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, record review, and interview, the facility failed to store, distribute, and serve food by Residents Affected - Many professional standards for food service safety in the facility's kitchen. The facility failed to label, seal, and date food stored in the refrigerator/freezer and dry storage area. The facility also failed to consistently log freezer/refrigerator temperatures. Findings included:- On 04/13/26 at 08:10 AM,

observation in the kitchen revealed the following:A white upright freezer had approximately one-quarter inch (in) of ice built up along the inside of the freezer and the shelves.The refrigerator located in the kitchen had a plastic bag with unlabeled, undated sliced yellow cheese.The March 2026 Freezer/Refrigerator Temperature Logs lacked documentation of the readings for the following freezers and refrigerators in the morning and evening:1. Chest freezer located in dry storage on 05,06,10,11,14,15,17,19,21, and 23-31.2. A white stand-up freezer on 7,8,14, 15,18, 21, and 25.3. A double door refrigerator on 7,8,15, 18, 21, 22.4. A single door refrigerator on 6, 7, 8, 21.The April freezer/refrigerator temperature logs lacked documentation of the readings for the following freezers and refrigerators in the morning and evening:A double door freezer on 4, 5,The ice machine located in

the area between the kitchen and storage room had a plastic lid and a metal object on the floor behind it, and a plastic green drinking cup sitting on top of the drain underneath it.Eight 15.5-pound (lb.) plastic jugs of used cooking grease with numerous different sizes of grayish-black substances on their top.The dry storage area had the following:An approximately one-quarter full 5 lb. package of undated pasta Labello egg noodles.An approximately one-quarter full 4.5 lb. package of unlabeled, undated, unsealed [NAME] noodles. Approximately three-quarters of a full package of undated strawberry gelatin.An approximately three-quarters full bag of unsealed buttermilk pancake.On 04/13/26 at 08:20 AM, Dietary Staff (DS) CC verified the above findings and stated she would ask the dietary manager what to do with the findings when she arrived at the facility for her shift.On 04/14/26 at 01:30 PM, the Dietary Manager (DM) BB stated staff should label and date all food placed

in dry storage, refrigerator, or freezer, when received, and if open, make sure they are sealed, labeled, and dated with the open date.The facility's Dietary Purchases, Receipt and Storage Policy, revised 01/21/26, documented all products would be labeled with the date received in the facility. Frozen foods stored in the freezer, and the temperature would be maintained at 0 to -10 degrees Fahrenheit (F). Produce is stored in the refrigerator, and the temperature would be maintained at 38-44 degrees F. Dairy products would be stored in the refrigerator, and the temperature would be maintained at 35 to 40 degrees F. The facility's Monitoring of Refrigerators and Freezers Policy, revised 01/21/26, documented all refrigerators/freezers would be cleaned on a weekly basis and as necessary for spills. Refrigerators that are accessible to elders and used by multiple elders and/ or families would contain only food that is sealed in an airtight container that had not been inside an elder's room. All food items would be labeled with the contents of the container and the date it was placed in the refrigerator. A temperature log would be completed. The Certified Dietary Manager/designee is responsible for monitoring temperatures and appropriate logging of temperatures, and appropriate discarding from refrigerators/freezers containing food items. All temperature logs will be maintained

in the environmental services office for two weeks.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete 175492 Page 2 of 8 Department of Health & Human Services Printed: 06/12/2026 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.Building 175492 04/15/2026 B. Wing NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Villa 114 S High St Clyde, KS 66938 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

diabetes (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot Level of Harm - Minimal harm respond to the insulin, hypertension (HTN-elevated blood pressure), atherosclerotic heart disease(a or potential for actual harm disease involving the buildup of fats, cholesterol, and other substances in artery walls, which narrows pathways and restricts blood flow).

Residents Affected - Few Resident R5's Significant Change Minimum Data Set (MDS), revised 03/10/26, documented Resident R5 had a Brief

Interview of Mental Status (BIMS) score of two, which indicated severe cognitive impairment. The MDS document Resident R5, dependent on staff with putting on and taking off footwear, required substantial, maximal staff assist with oral and toileting hygiene, bed mobility, transfers, upper and lower body dressing, and partial, moderate assist with personal hygiene. The MDS documented Resident R5 received hospice care services.

R's Care Plan, revised 07/09/25, documented Resident R5 required moderate to extensive assistance with activities of daily living (ADLs). Resident R5's Care Plan documented that the resident was admitted [hospice services] on 03/10/26. The plan directed the staff to adjust the provision of Resident R5's activities of daily living to compensate for Resident R5's changing abilities and encourage Resident R5 to participate to the extent she wishes to participate. The plan directed staff to assess Resident R5 for coping strategies, respect her wishes, and consult with the physician and services to have continuing hospice care for Resident R5 in the facility. The plan directed staff to monitor Resident R5 closely for signs of pain, administer pain medications as ordered, and notify the physician and hospice immediately if there is breakthrough pain. The care plan lacked a contact number for hospice, what supplies, equipment, and medications hospice would provide, when hospice staff would be in the building, and what care they would provide.

A review of Resident R5's clinical record revealed the resident was admitted to hospice care on 03/10/26.

On 04/15/26 at 08:10 AM, Resident R5 rested in bed with eyes closed with no signs or symptoms of pain. 04/14/26 at 04:03 PM, Administrative Nurse F verified Resident R5's Care Plan lacked information regarding hospice visits, phone numbers, and medical supplies that hospice services would provide.

Administrative Nurse F stated the information should be on the resident's care plan.

The facility's Hospice Services Policy, revised 01/22/26, documented an interdisciplinary care plan would be established, which integrates the care and services provided by the facility and the hospice provider, including :

1. 1. Resident, staff, and physician comfort with dealing with death
2. 2. Family expectations,
3. 3. Resident and family knowledge of disease progression and eventual outcome
4. 4. Staff time required to provide necessary care and services
5. 5. Cultural and ethnic diversity
6. 6. Communication and/or coordination of participants and agencies providing aspects of palliative

care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete 175492 Page 7 of 8 Department of Health & Human Services Printed: 06/12/2026 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.Building 175492 04/15/2026 B. Wing NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Villa 114 S High St Clyde, KS 66938 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Level of Harm - Minimal harm Based on observation, record review, and interview, the facility failed to implement acceptable or potential for actual harm infection control practices related to hand hygiene when staff failed to change gloves or wash hands between cares for Resident (R)6. Findings included: - On 04/15/26 at 10:21 AM, observation revealed Residents Affected - Few Resident R6 rested in bed with her eyes closed. Licensed Nurse (LN) H and Certified Nurse Aide (CNA) M donned gowns applied an N95 mask and gloves, then entered the resident's room and explained to Resident R6

they were going to look at the wound on her bottom and provide catheter care. CNA M and LN H uncovered Resident R6 to reveal the resident had no incontinent brief on. LN H assisted Resident R6 in turning on her left side. CNA M separated the middle of Resident R6's buttocks to reveal an open area approximately 0.3 centimeters (cm) long by 0.2 CM wide. CNA M provided catheter care on the tubing, starting from the insertion site down the tubing with a wet soapy washcloth, then used a dry one on the tubing. Further

observation revealed LN H positioned Resident R6 on her back, then separated Resident R6's labia, then, with the same soiled gloves, pulled down the resident's front blouse, and placed her hands on the cloth bed pad to assist CNA M in pulling Resident R6 up in bed. Further observation revealed that, with the same soiled gloves, LN H pulled the resident sheet and blanket over Resident R6, placed the bed control in her right hand, and used

the control to put Resident R6's head of bed up, then removed and discarded the gloves, gown, and mask in a trash can. LN H verified she had not changed gloves after assessing Resident R6's labia and stated she should have.On 04/15/26 at 12:08 PM, Administrative Nurse E stated she would expect staff to change gloves and wash hands when providing care, when going from dirty to clean.The facility's Infection Control Policy, revised 01/19/26, instructed staff to remove soiled gloves, wash hands, and change gloves after having contact with infectious material and before leaving the resident's environment, and wash hands immediately with antimicrobial soap.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete 175492 Page 8 of 8