Parkview Healthcare

F-F565) Residents Affected - Some 26006

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 61 265463 Department of Health & Human Services Printed: 09/08/2025 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 265463 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Parkview Healthcare 128 North Hardesty Kansas City, MO 64123

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)

F 0806 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 12273

Residents Affected - Few 26006

Based on observation, interview and record review, the facility failed to ensure that one of one resident (R)50) in the sample of 27 revealed the resident's preference for a sandwich to be add to the lunch and dinner meals was not being honored. The failure to ensure that a resident's food preferences were honored could result in the resident loosing weight.

Findings include:

1. Review of Resident R50's Medical Diagnosis tab of the EMR revealed he/she was admitted on [DATE REDACTED] with diagnoses including peripheral vascular disease, heart disease, and amputation of toes.

Review of Resident R50's quarterly MDS with an ARD of 02/05/25 and located under the MDS tab of the EMR, revealed the BIMS score of 15 out of 15 which indicated intact cognition.

During an interview on 02/17/25 at 10:08 AM, Resident R50 stated he/she was supposed to receive a sandwich with his/her meals, but he/she never received one. He/She explained his/her meal tickets documented he/she was to receive a sandwich with every meal because he/she did not feel like he/she got enough to eat with

the regular meal.

During an observation on 02/17/25 at 1:18 PM, Resident R50 received the regular meal of pork, mashed potatoes, and vegetables. There was no sandwich with the meal. The tray ticket documented, sandwich with meal. Resident R50 stated he/she did not receive a sandwich but would have liked one.

During an observation on 02/19/25 2:06 PM, Resident R50 was served his/her meal of a hot dog and chips. He/She did not receive a sandwich with the meal. Resident R50 stated he/she did not receive a sandwich but would have liked one, as his/her meal was not enough. The tray ticket documented, Sandwich with meal.

During an interview on 02/21/25 at 7:02 PM, the Dietary Manager (DM) stated he/she had noticed Resident R50 was not receiving sandwiches with lunch and dinner per his/her tray ticket. He/She stated the resident was to receive a sandwich.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 61 265463 Department of Health & Human Services Printed: 09/08/2025 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 265463 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Parkview Healthcare 128 North Hardesty Kansas City, MO 64123

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)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 12273

Residents Affected - Many Based on observation, interview, Food and Drug Administration (FDA) Food Code and policy review, the facility failed to ensure foods were stored, prepared, and distributed under sanitary conditions. This had the potential to 112 of 112 residents who ate food from the kitchen and placed these residents at risk for a food borne illness.

Findings include:

Review of the 2022 Food Code, published by the Food and Drug Administration (FDA) Food Code and accessible at https://www.fda.gov, revealed, . Handwashing sink shall be equipped to provide water at a temperature of at least . (85 degrees F [Fahrenheit]) through a mixing valve or combination faucet .

Review of the facility's policy titled, Food Preparation and Service, revised 04/2019, revealed, . Food and nutrition services [sic] employees prepare and serve food in a manner that complies with safe food handling practices . Appropriate measures are used to prevent cross contamination. These include . cleaning and sanitizing work surfaces . and food-contact equipment between uses, following food code guidelines . Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness .

The 'danger zone' for food temperatures is between 41 [degrees Fahrenheit (F)] and 135 [degrees F]. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness . Proper hot and cold temperatures are maintained during food service . Employees also wash their hands

after collecting soiled plates and food waste prior to handling food trays .

1. During the initial tour of the kitchen on 02/17/25 at 9:20 AM, the water at the handwashing sink was noted to be cold after the water ran for 10 minutes. The [NAME] stepped to the sink and washed their hands. When asked if the water got hot, he/she stated yes, and then commented he/she did not have enough time to wait for it to warm up.

A food processor, located on a counter in the kitchen, was noted to have water inside the bowl. The blade was removed, and food residue was inside the blender bowl. The base of the food processor was soiled with dried food splatter. The Dietary Manager (DM) stated the equipment should be washed and clean if on the base.

The can opener was noted to have black colored food residue adhered to the blade, and the base was observed with dried food spills and splash.

The head of the dispenser gun for the juice dispenser was heavily soiled with visible juice pulp and smelled of sour juice. The handle of the device was soiled and sticky to the touch. The DM stated Dietary Aide (DA) 13 was responsible for cleaning the machine. DA13 stated he/she did not remove the cap or soak the head of the dispenser to clean it.

The handle on the microwave was observed with dried food and was sticky. The interior had food spills inside. The DM commented it must have been used last night.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 61 265463 Department of Health & Human Services Printed: 09/08/2025 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 265463 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Parkview Healthcare 128 North Hardesty Kansas City, MO 64123

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)

F 0812 The walk-in refrigerator had one opened and undated box of health shakes. The DM stated the shakes could be served for up to 14 days after being placed in the refrigerator and should have been dated when placed in Level of Harm - Minimal harm or the refrigerator. potential for actual harm

An undated and unlabeled pan with two cooked pork loins was noted in the walk-in refrigerator. The DM Residents Affected - Many stated the pork was cooked the previous day, then refrigerated, and would be served for the noon meal that day.

The temperature of the handwashing sink was checked, after running the water for 10 minutes, a check of

the temperature found it only reached 72 degrees F. The temperature did not reach the FDA recommendation for handwashing sinks in food service areas of 85 degrees F.

On 02/19/25, at 9:30 AM, during an interview with the DM, DA12 was observed rinsing soiled dishes and loading them into rack while wearing gloves. After preparing several racks of soiled dishes, DA12 stepped to

the clean side of the dish machine and picked up clean water pitchers with the same gloves. The DM was asked about DA12's actions. The DM directed DA12 to wash their hand in the handwashing sink. DA12 doffed his/her gloves, went to the sink, and rinsed his/her hand under the waterspout. DA12 did not use soap or friction to wash his/her hands. The DM observed this and reapproached DA12 and directed him/her to use soap, friction, and water when washing hands.

On 2/19/25 at 11:50 AM, the Assistant Dietary Manager (ADM) was observed testing and documenting temperatures of foods served for the noon meal on a log. After preparing to serve the meal, two additional food items, cheese quesadillas and soup were observed on the steamtable; however, the temperature log did not record temperatures for either item. When asked, ADM tested the temperatures and found the soup was 128 degrees F and the quesadillas were 117 degrees F. ADM stated the items were not hot enough and reheated them.

On 02/20/25 at 11:00 AM, burritos and toasted cheese sandwiches were noted on the tray line. The [NAME] measured their holding temperatures, and it was noted the temperature of both items was 128 degrees F. [NAME] then moved the items to the oven to reheat them.

2. During delivery of room meal trays in the [NAME] Hall on 02/17/25 beginning at 1:09 PM, the meal trays were observed on a metal cart. Each tray had a plate covered with an insulated cover and a small dish containing the apple cobbler dessert, which was not covered. The staff brought the meal trays from the cart at one end of the hall to residents' rooms up and down the length of the hall with the dessert uncovered.

In an interview on 02/17/25 at 1:15 PM, certified nurse aide (CNA) 8 stated the desserts on the trays were not covered because it did not fit under the cover over the main plate. CNA8 stated the dessert was typically served uncovered in a separate dish.

During delivery of room meal trays in the [NAME] Hall on 02/19/25 beginning at 1:36 PM, the meal trays were observed on a metal cart covered with plastic. Each tray had a plate covered with an insulated cover and a small dish containing the muffin dessert, which was not covered. The staff brought the meal trays from

the cart at one end of the hall to residents' rooms up and down the length of the hall with the dessert uncovered. The Director of Nursing (DON) served a tray to a resident containing an uncovered dessert.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 61 265463 Department of Health & Human Services Printed: 09/08/2025 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 265463 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Parkview Healthcare 128 North Hardesty Kansas City, MO 64123

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)

F 0812 In an interview on 02/19/25 at 2:06 PM, the DON confirmed the dessert was uncovered while on the uncovered cart and while in transit down the hall. Level of Harm - Minimal harm or potential for actual harm In an interview on 02/21/25 at 2:31 PM, the DM stated he/she noticed the desserts were not covered again today when going down the hall in the uncovered cart. Residents Affected - Many

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 61 265463 Department of Health & Human Services Printed: 09/08/2025 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 265463 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Parkview Healthcare 128 North Hardesty Kansas City, MO 64123

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)

F 0814 Dispose of garbage and refuse properly.

Level of Harm - Minimal harm or 12273 potential for actual harm Based on observation and interview, the facility failed to ensure refuse and garbage was disposed of Residents Affected - Many properly when the lid to the dumpster was not kept closed. This had the potential to increase the risk of rodents and other pests which could affect all 112 residents who resided at the facility.

Findings include:

During observations of the dumpsters located behind the kitchen on 02/17/25 at 10:00 AM, 02/18/25 at 10:45 AM, 02/20/25 at 11:45 AM and 2/21/25 at 9:30 AM, the dumpster lid was observed open.

During an interview on 02/17/25 at 10:00AM, the Dietary Manager (DM) reported that all the departments in

the facility discarded garbage in the area and should close the lid when they finished adding trash to the dumpster.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 61 265463 Department of Health & Human Services Printed: 09/08/2025 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 265463 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Parkview Healthcare 128 North Hardesty Kansas City, MO 64123

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)

F 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Level of Harm - Minimal harm or 26006 potential for actual harm Based on interview, record review, and policy review, the facility failed to inform the 29 residents, Resident R315, Resident R77, Residents Affected - Some Resident R97, Resident R104, Resident R316, Resident R72, Resident R105, Resident R61, Resident R107, Resident R68, Resident R63, Resident R24, Resident R13, Resident R108, Resident R7, Resident R106, Resident R314, Resident R67, Resident R62, Resident R110, Resident R22, Resident R73, Resident R109, Resident R115, Resident R119, Resident R116, and Resident R117, and/or their representatives who signed the binding arbitration agreement out of a census of 112 in writing they were not required to enter into a binding arbitration agreement as a condition of admission. This failure placed these 29 residents at risk of signing the agreement involuntarily.

Findings include:

Review of the facility's Arbitration Agreement Rider to the Admission Contract, provided by the Administrator revealed, The parties agree that any and all disputes arising out of or in any way related to the contract or

the Resident's stay at the facility . shall be decided by arbitration in accordance with this Rider. The arbitration proceeding and settlement shall remain confidential . The resident also understands that nothing

in this Rider prevents him/her from communicating with federal, state, or local officials . The parties agree that the Operator shall pay the fees of the arbitrators: [sic] and Operator shall pay up to $5,000 of the Resident's attorney fees and costs . ; the Resident shall have the right to choose the location of the arbitration; and the Federal Arbitration Act would govern the proceedings . This Rider may be revoked within 30 days of this signed Arbitration Agreement Rider.

The agreement did not include a statement that neither the resident or his/her representative is required to sign the biding arbitration agreement as a condition of admission to, or as a requirement to continue to receive care at the facility.

Review of an undated document titled, Signed & Uploaded Arbitration Agreements, provided by the Admissions Coordinator revealed 29 facility residents had entered into the binding arbitration agreement.

During an interview on 02/21/25 at 2:29 PM, the Admissions Coordinator stated the facility's arbitration agreement did not include the statement that neither the resident or his/her representative is required to sign

the binding arbitration agreement as a condition of admission to, or as a requirement to continue to, receive care at the facility. He/She stated residents were not required to sign the arbitration agreement on admission even though the form did not have a place to mark a declination.

Review of the undated facility policy titled, Binding Arbitration Agreements revealed This facility asks all residents to enter into an agreement for binding arbitration . The agreement must: . Explicitly state that neither the resident nor his or her representative is required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 61 265463 Department of Health & Human Services Printed: 09/08/2025 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 265463 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Parkview Healthcare 128 North Hardesty Kansas City, MO 64123

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)

F 0848 Provide a neutral and fair arbitration process and agree to arbitrator and venue.

Level of Harm - Minimal harm or 26006 potential for actual harm Based on interview, record review, and policy review, the facility failed to inform the 29 residents and/or their Residents Affected - Some representatives (Resident (R)315, Resident R77, Resident R97, Resident R104, Resident R316, Resident R72, Resident R105, Resident R61, Resident R107, Resident R68, Resident R63, Resident R24, Resident R13, Resident R108, Resident R7, Resident R106, Resident R314, Resident R67, Resident R62, Resident R110, Resident R22, Resident R73, Resident R109, Resident R115, Resident R119, Resident R116, and Resident R117) who signed the binding arbitration agreement out of a census of 112 in writing of the right to selection of neutral arbitrator agreed upon by both parties. This failure placed these 29 residents at risk of misunderstanding the process for selection of an arbitrator.

Findings include:

Review of a copy of the facility's Arbitration Agreement Rider to the Admission Contract, provided to the survey team by the Administrator, revealed, The parties agree that any and all disputes arising out of or in any way related to the contract or the Resident's stay at the facility . shall be decided by arbitration in accordance with this Rider. The arbitration proceeding and settlement shall remain confidential . The resident also understands that nothing in this Rider prevents him/her from communicating with federal, state, or local officials . The parties agree that the Operator shall pay the fees of the arbitrators: [sic] and Operator shall pay up to $5,000 of the Resident's attorney fees and costs . ; the Resident shall have the right to choose the location of the arbitration; and the Federal Arbitration Act would govern the proceedings . This Rider may be revoked within 30 days of this signed Arbitration Agreement Rider.

The agreement did not provide for the selection of a neutral arbitrator agreed upon by both parties.

Review of an undated document titled, Signed & Uploaded Arbitration Agreements, provided by the Admissions Coordinator, revealed 29 facility residents had entered into the binding arbitration agreement.

During an interview on 02/21/25 at 2:29 PM, the Admissions Coordinator stated the facility's arbitration agreement did not provide for selection of a neutral arbitrator agreed upon by both parties.

Review of the undated facility policy titled, Binding Arbitration Agreements revealed The agreement must: . Provide for the selection of a neutral arbitrator agreed upon by both parties.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 61 265463 Department of Health & Human Services Printed: 09/08/2025 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 265463 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Parkview Healthcare 128 North Hardesty Kansas City, MO 64123

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)

F 0865 Have a plan that describes the process for conducting QAPI and QAA activities.

Level of Harm - Minimal harm or 18750 potential for actual harm Based on interview, and policy review, the facility failed to ensure a Quality Assurance and Performance Residents Affected - Many Improvement (QAPI) plan was developed containing the process the facility will follow to guide the care and services provided to residents and measure improvement. This deficient practice had the potential to not capture the efforts made in measuring the care and services for 112 residents.

Findings include:

Review of the facility policy titled Quality Assurance and Performance Improvement (QAPI) Program- Governance and Leadership revised March 2020 revealed, Policy Statement The quality assurance and performance improvement program are overseen and implemented by the QAPI committee, which reports its findings, actions and results to the administrator and governing body.

During an entrance conference with the facility's Director of Nursing (DON) on 02/17/25 at 9:31 AM and at 4:45PM, a request was made to get the QAPI plan for review.

On 02/18/25 at 2:48 PM and 02/20/25 at 11:00AM, a request was made to the Administrator for the QAPI plan.

On 02/20/25 at 09:44 AM, the Administrator stated. We do not know what a QAPI plan is and have never heard of that before. We do not have a QAPI plan.

During an interview 02/21/25 at 6:33 PM, the DON stated the Administrator was new as of January 2025. There has been only one meeting with staff and that was the passing out of the clinical pathways, that each department head would take what pertains to their department. The group will come together for the next meeting and present their findings. The DON was asked what improvements programs are being worked on.

The DON stated he/she could not find the previous meetings with the previous Administrator.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 61 265463 Department of Health & Human Services Printed: 09/08/2025 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 265463 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Parkview Healthcare 128 North Hardesty Kansas City, MO 64123

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)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 12273 potential for actual harm 52126 Residents Affected - Few Based on observation, interviews, and facility policy, the facility failed to implement infection prevention strategies to prevent cross-contamination during the medication pass for three of five residents (Resident (R) 94, Resident R316, and Resident R18) observed during the medication pass out of a total sample of 27. This failure had the potential to spread infectious diseases to all residents. The facility census was 112 residents.

Findings include:

Observation on 2/19/25 at 9:13 AM. CMT6 did not sanitize the blood pressure cuff prior to taking Resident R94's blood pressure.

Observation on 02/19/25 at 9:30 AM, CMT6 did not sanitize the blood pressure cuff prior to taking Resident R316's blood pressure.

Observation on 02/19/25 at 9:41 AM, CMT6 did not sanitize the blood pressure cuff prior to taking Resident R18's blood pressure.

During an observation on 02/19/25 at 9:13 AM to 10:05 AM, during medication administration, CMT6 failed to perform handwashing or hand hygiene prior to preparing medications for administration to Resident R18.

During an interview on 02/19/25 at 2:27 PM, Registered Nurse (RN) 1 stated blood pressure cuffs are to be cleaned after each use, after each patient.

During an interview on 02/19/25 at 2:47 PM, CMT6 stated the blood pressure cuff is to be cleaned/sanitized

after every 4-5 residents. CMT6 then stated he/she made an error and the blood pressure cuff should be

after every resident.

During an interview on 02/20/25 1:26 PM, the Director of Nursing (DON) stated that vital signs equipment should be cleaned between every resident use, including blood pressure cuffs and glucometers and that hands should be sanitized between each resident contact or washed if soiled.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 61 265463 Department of Health & Human Services Printed: 09/08/2025 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 265463 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Parkview Healthcare 128 North Hardesty Kansas City, MO 64123

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)

F 0881 Implement a program that monitors antibiotic use.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 26006 potential for actual harm Based on record review, interview, and policy review, the facility failed to ensure one (Resident (R) 32) of Residents Affected - Few one resident review for antibiotic use in the sample of 27 had a duration of antibiotic therapy specified and antibiotic use did not continue without medical necessity. This failure placed Resident R32 at risk of antibiotic resistance or unnecessary adverse effects of the medication.

Findings include:

Review of Resident R32's Medical Diagnosis tab of the EMR revealed he was admitted to the facility on [DATE REDACTED] with a diagnosis of chronic obstructive pulmonary disease.

Review of Resident R32's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 01/10/25 and located in the MDS tab of the EMR revealed he received antibiotics.

Review of Resident R32's EMR under the Orders tab revealed a physician's order dated 01/10/24 to give one drop of Ofloxacin Ophthalmic Solution 0.3 % (antibiotic eye drops) in the left eye four times a day for cataract surgery. The order did not include a stop date.

Review of Resident R32's Medication Administration Record (MAR) dated February 2025 and found under the Orders tab of the EMR, revealed the antibiotic eye drops had been administered four times daily from 02/01/25 to 02/18/25.

During an interview with Licensed Practical Nurse (LPN) 4 on 02/21/25 11:24 AM, he/she stated Resident R32 received antibiotic eye drops four times a day since 01/10/24 and the order did not have a stop date.

Interview on 02/21/25 at 2:35 PM, the Director of Nursing (DON) stated Resident R32 had cataract surgery and came back from the ophthalmologist with the order for antibiotic eye drops. The DON stated he/she needed to contact the resident's physician to make sure the eye drops should be continued.

During a telephone interview on 02/21/25 at 5:11 PM, the Medical Director (who was also Resident R32's physician) stated the antibiotic eye drops order should have included a stop date, as typically the eye drops were used only for several weeks post cataract surgery.

During an interview on 02/21/25 at 5:28 PM, the Infection Preventionist (IP) stated he/she was not aware Resident R32 had been receiving antibiotic eye drops since 01/10/24 and stated the order should have included a stop date. The IP stated if an antibiotic order did not include a stop date, the physician should be contacted for clarification. The IP stated all antibiotics should be included on the antibiotic tracking list and include stop dates. The IP stated he/she did not see Resident R32's use of antibiotic eye drops beginning 01/10/24 on the facility's surveillance or antibiotic tracking list.

Review of the facility's policy titled, Antibiotic Stewardship, dated December 2016, revealed, The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents . If an antibiotic is indicated, prescriber will provide complete antibiotic order including the following

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 61 265463 Department of Health & Human Services Printed: 09/08/2025 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 265463 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Parkview Healthcare 128 North Hardesty Kansas City, MO 64123

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)

F 0881 elements:

Level of Harm - Minimal harm or g. Duration of treatment: potential for actual harm (1) Start and stop date; or Residents Affected - Few (2) Number of days of therapy . and

i. Indications for use.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 61 265463 Department of Health & Human Services Printed: 09/08/2025 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 265463 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Parkview Healthcare 128 North Hardesty Kansas City, MO 64123

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)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 26006 potential for actual harm Based on record review, interview, and policy review, the facility failed to ensure five of five residents Residents Affected - Some (Resident (R) 85, Resident R70, Resident R107, Resident R34, and Resident R95) residents reviewed for immunizations out of a total sample of 27 were assessed for eligibility, educated on the risks and benefits, and offered pneumococcal vaccination.

This failure placed all eligible residents who wished to receive the vaccine at risk for contracting pneumonia unnecessarily.

Findings include:

In an interview on 02/21/25 at 5:21 PM, the Infection Preventionist (IP) stated he/she had just taken over the position about a month ago, and the former Assistant Director of Nursing who no longer worked at the facility had been in charge of the infection prevention and immunization program prior. He/She stated immunizations were documented either on paper in binders he/she kept or in the electronic medical record (EMR). The IP stated he/she was working on getting immunizations caught up, and stated he/she was able to administer influenza and COVID-19 immunizations but had not yet gotten to the pneumococcal vaccines. He/She stated he/she planned to address this next by assessing all residents to determine who needed the vaccine.

1. Review of Resident R85's Medical Diagnosis tab of the electronic medical record (EMR) revealed he/she was admitted to the facility on [DATE REDACTED] with diagnoses of paraplegia and vascular disorder of the intestine.

Review of Resident R85's EMR under the Immunizations tab revealed no documentation regarding offering or administering the pneumococcal vaccine.

During the interview with the IP on 02/21/25 at 5:21 PM and concurrent review of the EMR and vaccination binders, he/she stated he/she did not have paper records of offering, refusal, or administration of the pneumococcal vaccine, and there was no historical documentation of the vaccine in Resident R85's records.

2. Review of Resident R70's Medical Diagnosis tab of the EMR revealed he/he was admitted to the facility on [DATE REDACTED] with diagnoses of peripheral vascular disease and heart disease.

Review of Resident R70's EMR under the Immunizations tab revealed no documentation regarding offering or administering the pneumococcal vaccine.

During the interview with the IP on 02/21/25 at 5:21 PM and concurrent review of the EMR and vaccination binders, he/she stated he/she did not have paper records of offering, refusal, or administration of the pneumococcal vaccine, and there was no historical documentation of the vaccine in Resident R70's records.

3. Review of Resident R107's Medical Diagnosis tab of the EMR revealed he/she was admitted to the facility on [DATE REDACTED] with a diagnosis of acute respiratory failure.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 61 265463 Department of Health & Human Services Printed: 09/08/2025 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 265463 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Parkview Healthcare 128 North Hardesty Kansas City, MO 64123

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)

F 0883 Review of Resident R107's EMR under the Immunizations tab revealed no documentation regarding offering, refusal, or administering the pneumococcal vaccine. Level of Harm - Minimal harm or potential for actual harm During the interview with the IP on 02/21/25 at 5:21 PM and concurrent review of the EMR and vaccination binders, he/she stated he/she did not have paper records of offering, refusal, or administration of the Residents Affected - Some pneumococcal vaccine, and there was no historical documentation of the vaccine in Resident R107's records.

4. Review of Resident R34's Medical Diagnosis tab of the EMR revealed he/she was admitted to the facility on [DATE REDACTED] with a diagnosis of congestive heart failure.

Review of Resident R34's EMR under the Immunizations tab revealed no documentation regarding offering, refusal, or administering the pneumococcal vaccine.

During the interview with the IP on 02/21/25 at 5:21 PM and concurrent review of the EMR and vaccination binders, he/she stated he/she did not have paper records of offering, refusal, or administration of the pneumococcal vaccine, and there was no historical documentation of the vaccine in Resident R34's records.

5. Review of Resident R95's Medical Diagnosis tab of the EMR revealed he/she was admitted to the facility on [DATE REDACTED] with a diagnosis of peripheral vascular disease.

Review of Resident R95's EMR under the Immunizations tab revealed no documentation regarding offering, refusal, or administering the pneumococcal vaccine.

During the interview with the IP on 02/21/25 at 5:21 PM and concurrent review of the EMR and vaccination binders, he/she stated he/she did not have paper records of offering, refusal, or administration of the pneumococcal vaccine, and there was no historical documentation of the vaccine in Resident R95's records.

Review of the facility's policy titled, Pneumococcal Vaccination, dated October 2019, revealed, All residents will be offered pneumococcal vaccine to aid in preventing pneumonia/pneumococcal infections . Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated . Assessments of pneumococcal vaccination status will be conducted within five (5) working days of the resident's admission if not conducted prior to admission . Before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine . Provision of such education shall be documented in the resident's medical record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 61 265463 Department of Health & Human Services Printed: 09/08/2025 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 265463 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Parkview Healthcare 128 North Hardesty Kansas City, MO 64123

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)

F 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 26006

Residents Affected - Some Based on observations, interviews, and policy review, the facility failed to maintain a safe and comfortable environment for six rooms (Resident (R) 70, Resident R56, Resident R94, and Resident R65, room [ROOM NUMBER], and room [ROOM NUMBER]) of 32 rooms observed in Initial Pool.

Findings include:

1. During an interview on 02/21/25 at 7:08 PM, the Regional Maintenance Consultant (RMC) stated he/she had just been hired to start implementing the necessary corrective measures to ensure a safe, clean, and comfortable environment. The RMC stated he/she did notice issues with walls in disrepair, broken heating vents or light fixtures, and other maintenance issues. The RMC stated the Maintenance Director had been at

the facility for about a year and a half and he/she did not know why the issues had not yet been addressed and stated the Maintenance Director needed training on time management and prioritization. The RMC stated the facility had just recently implemented a reporting program through their electronic medical records (EMR) system in January 2025 for staff to report items needing maintenance. He/She stated the staff have used this system a few times.

2. Review of Resident R70's Medical Diagnosis tab of the EMR revealed he/she was admitted to the facility on [DATE REDACTED] with diagnoses of peripheral vascular disease and heart disease.

Review of Resident R70's quarterly Minimum Data Set (MDS), with an assessment reference date of 11/16/24 and located in the MDS tab of the EMR, revealed he/she scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition.

During an interview and concurrent observation in Resident R70's room, the walls were covered with screws, nails, chipped paint, holes, and large patches of discolored areas. Resident R70 stated the walls had always looked like that and it bothered him/her.

During an environmental tour with the RMC on 02/21/25 beginning at 7:20 PM, the RMC confirmed the walls remained in disrepair and needed to be addressed.

3. Review of Resident R56's Medical Diagnosis tab of the EMR revealed he/she was admitted to the facility on [DATE REDACTED] with a diagnosis of metabolic encephalopathy.

Review of Resident R56's quarterly MDS, with an ARD of 11/25/24 and located in the MDS tab of the EMR, revealed he/she scored 15 out of 15 on the BIMS, indicating intact cognition.

During an interview and concurrent observation on 02/17/25 at 3:59 PM in Resident R56's room, the mirror above the sink was observed without glass, only the backing, which was non-reflective. Resident R56 stated there was no mirror

in the bathroom, so if he/she wanted to see himself/herself in the mirror, he/she had to walk down to the shower room, which bothered him/her. In addition, there were multiple small holes in the wall and several large unpainted patches on the wall. Resident R56 stated, The wall bugs me, it has been like this for a while . I don't know where holes and patches came from; they were here before I came.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 61 265463 Department of Health & Human Services Printed: 09/08/2025 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 265463 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Parkview Healthcare 128 North Hardesty Kansas City, MO 64123

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)

F 0921 During an environmental tour with the RMC on 02/21/25 beginning at 7:20 PM, the missing glass in the mirror and holes and patches on the wall were again observed. The RMC stated the walls had several holes Level of Harm - Minimal harm or and unpainted areas and stated he would replace the mirror over the sink. potential for actual harm 4. During observation of the door exiting to the smoking area on the [NAME] Hall on 02/19/25 at 2:03 PM, the Residents Affected - Some baseboard near the door was peeled off and crumbling concrete, dirt, and one cigarette butt was observed at

the base of the wall.

During an environmental tour with the RMC on 02/21/25 beginning at 7:20 PM, the RMC stated the baseboard was still peeling off the wall exposing crumbling concrete and possibly creating access for pests. He/She stated this issue needed to be addressed.

5. Review of Resident R65's Clinical Census, located under the Census tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE REDACTED], with diagnoses which included spondylosis, osteoarthritis, opioid dependence, major depressive disorder, post-traumatic stress disorder, antisocial personality disorder, anxiety disorder, and chronic pain syndrome.

Review of Resident R94's Clinical Census located under the Census tab of the EMR revealed the resident was admitted on [DATE REDACTED], with diagnoses which included gastric ulcer, anxiety disorder, and hesitancy of micturition.

During an observation and interview on 02/17/25 at 10:18 AM, Resident R65 was observed wearing a jacket. Resident R94 was observed wearing a sweatshirt and sweatpants. Resident R65 and Resident R94 stated there had been no heat in the room all winter. Resident R65 stated the facility wanted them to move to another room but they did not want to move. Resident R65 stated they did get heat from the hallway with door open to the room. Resident R94 stated they were told heater would be replaced but the facility wants us to move to another room. It was observed that the bathroom for Resident R65 and Resident R94 had a ceiling vent with the cover off, holes in ceiling tiles, and holes in walls.

During an environmental tour with the RMC on 02/21/25 beginning at 7:20 PM, the RMC confirmed the heat was not working in the residents' room and was something he/she would have expected to be addressed immediately, as it was a matter of comfort and health in the cold winter.

6. Observation on 02/17/25 at 10:38 AM, of room [ROOM NUMBER], showed the heater cover was sitting on

the floor in front of the heater exposing the inside of the heater, the mirror over the sink was broken, and the closet doors were off the hinges.

During an environmental tour with the RMC on 02/21/25 beginning at 7:20 PM, the RMC confirmed the heater vent cover was not assembled properly and was able to put the cover back in place. The RMC stated that it was an important thing to address, as it could contribute to safety concerns with the heating elements.

7. Observation on 02/17/25 at 11:26 AM, of room [ROOM NUMBER], showed the light cover was broken and hanging down over the resident's bed.

During an environmental tour with the RMC on 02/21/25 beginning at 7:20 PM, the RMC confirmed the light was missing cover and it should be replaced.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 61 265463 Department of Health & Human Services Printed: 09/08/2025 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 265463 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Parkview Healthcare 128 North Hardesty Kansas City, MO 64123

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)

F 0921 Review of the facility's undated policy titled, Safe and Homelike Environment revealed, Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable Level of Harm - Minimal harm or environment . Report any furniture in disrepair to Maintenance promptly . Report any unresolved potential for actual harm environmental concerns to the Administrator.

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 61 265463 Department of Health & Human Services Printed: 09/08/2025 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 265463 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Parkview Healthcare 128 North Hardesty Kansas City, MO 64123

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)

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 26006 potential for actual harm Based on observation, interview, record review, and policy review, the facility failed to implement pest control Residents Affected - Some measures to prevent mouse infestation in the facility, which affected four of 27 sampled residents (Resident (R) 76, Resident R2, Resident R22, and Resident R73) and the common areas of the facility. This failure had the potential to cause an increase in rodent activity, creating a potential for spread of infection and dissatisfaction with living arrangements among the residents.

Findings include:

Review of March 2024 to December 2024 weekly pest control Service Inspection Reports, provided by the facility, revealed ongoing treatment for mice. The reports repeatedly documented the same recommendations for preventing the mice from entering the building. These recommendations included:

-Fixing holes in the walls near several heat registers,

-Fixing holes by baseboards throughout the facility,

-Ensuring kitchen doors were rodent-proofed by eliminating gaps,

-Ensuring gap under the front door was eliminated, and

-Removing trash from around the facility.

Review of the 01/10/25 pest control Service Inspection Report revealed, Inspected interior rodent traps. Found evidence of rodent activity. Recorded capture. All traps accessible and in good condition. Under Open Conditions, the report listed:

1. Condition: kitchen exterior entryway has a gap under the door sweep. - exterior entryway has

concrete that is not level, leaving a 1/2 [inch] gap under the door sweep. [NAME]: use self-leveling concrete and fill the hole. The severity level was high, responsibility was the facility, and the created date for this condition was 08/02/24.

2. Condition: back door area - trash and debris creating harborage opportunity for rodents

Action: Throw trash in dumpsters. The severity level was high, responsibility was the facility, and the created date for this condition was 11/15/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 61 265463 Department of Health & Human Services Printed: 09/08/2025 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 265463 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Parkview Healthcare 128 North Hardesty Kansas City, MO 64123

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)

F 0925 Review of the most recent pest control Service Inspection Report, dated 01/16/25 and provided on paper, revealed, Inspected interior rodent traps. Found evidence of rodent activity. Recorded capture . Inspected Level of Harm - Minimal harm or copy room for mouse sighting. Discovered a hole by the heat register . Inspected the west housekeeping potential for actual harm room for mouse sighting. Found holes by the baseboards by the door entrance and outer wall, recommended

these get sealed up . Followed up on the conditions of the doors being rodent-proofed and the trash being Residents Affected - Some removed that was sitting against the building by the back entrance door. Removing this trash will prevent rodents from potentially harboring there. Kitchen doors needs to be rodent-proofed, this creates an opportunity for rodents to enter the kitchen. Front door has a gap that creates a potential entry for rodents. Under Open Conditions, the report listed:

1. Condition: kitchen exterior entryway has a gap under the door sweep. - exterior entryway has

concrete that is not level, leaving a 1/2 [inch] gap under the door sweep. [NAME]: use self-leveling concrete and fill the hole. The severity level was high, responsibility was the facility, and the created date for this condition was 08/02/24.

2. Condition: back door area - trash and debris creating harborage opportunity for rodents

Action: Throw trash in dumpsters. The severity level was high, responsibility was the facility, and the created date for this condition was 11/15/24.

3. Condition: kitchen door needs to be rodent proofed please

4. Condition: front door needs to be rodent proofed please.

1. Review of Resident R76's Medical Diagnosis tab of the electronic medical record (EMR) revealed he/she was admitted to the facility on [DATE REDACTED] with a diagnosis of chronic obstructive pulmonary disease.

Review of Resident R76's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 01/07/25 and located in the MDS tab of the EMR, revealed he scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition.

During an interview on 02/17/25 at 3:27 PM, Resident R76 stated, I saw a mouse last night in the hall. He/She added he/she saw mice all the time and had two mouse traps in his/her room. Resident R76 stated it bothered him/her to have mice in his/her room.

2. Review of Resident R2's Medical Diagnosis tab of the electronic medical record (EMR) revealed he/she was admitted to the facility on [DATE REDACTED] with diagnoses including left-side paralysis following a stroke.

Review of Resident R2's quarterly MDS, with an ARD of 12/21/24 and located under the MDS tab of the EMR, revealed he/she scored 14 out of 15 on the BIMS, indicating intact cognition.

During an interview on 02/17/25 at 4:11 PM in Resident R2's room, Resident R2 stated there were a lot of mouse droppings behind his/her nightstand in his/her room, and he/she saw mice every night in his/her room.

Observation of the floor behind Resident R2's nightstand revealed a large area of the floor covered in mouse droppings. Resident R2 stated the mice ran over his/her feet at night and it bothered him/her.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 61 265463 Department of Health & Human Services Printed: 09/08/2025 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 265463 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Parkview Healthcare 128 North Hardesty Kansas City, MO 64123

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)

F 0925 3. Review of Resident R22's Medical Diagnosis tab of the EMR revealed he/she was admitted to the facility on [DATE REDACTED] with a diagnosis of left-side paralysis following a stroke. Level of Harm - Minimal harm or potential for actual harm Review of Resident R22's admission MDS, with an ARD of 11/13/24 and located under the MDS tab of the EMR, revealed he/she scored 14 out of 15 on the BIMS, indicating intact cognition. Residents Affected - Some

During an interview on 02/18/25 at 9:37 AM, Resident R22 stated there were mice in his/her room that came out at night and bothered him/her during the night. He/She stated a dead mouse had been found in his/her room that morning.

4. Review of Resident R73's Medical Diagnosis tab of the EMR revealed he/she was admitted to the facility on [DATE REDACTED] with a diagnosis of chronic obstructive pulmonary disease.

Review of Resident R73's admission MDS, with an ARD of 11/19/24, revealed he/she scored 15 out of 15 on the BIMS, indicating intact cognition.

During an interview on 02/18/25 at 9:46 AM, Resident R73 stated there were mice in his/her room that got into a bag of bread he/she kept for making sandwiches. Resident R73 stated it bothered him/her the mice ate his/her food.

During an interview on 02/21/25 at 7:08 PM, the Regional Maintenance Consultant (RMC) stated he/she had just been hired to start implementing the necessary corrective measures to prevent mouse infestation, as the facility had not yet addressed any of the recommendations found in the pest control reports. The RMC stated he/she did not know why any of the recommendations had not yet been addressed and stated he/she would have expected the facility to act on those recommendations when they were first made. The RMC stated the Maintenance Director had been at the facility for about a year and a half and needed training on time management and prioritization.

Review of the facility's policy titled, Pest Control, dated May 2008, revealed, This facility maintains an on-going pest control program to ensure that the building is kept free of insects

and rodents . Garbage and trash are not permitted to accumulate and are removed from the facility daily . Maintenance services assist, when appropriate and necessary, in providing pest control services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 61 265463