Health inspection·May 28, 2025

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the right to file grievances anonymously for 1 (Resident #1) of 3 residents reviewed for grievances. 1. The facility failed to ensure Resident #1 had access to file a grievance anonymously. The facility's failure could place the residents at risk for concerns not being reported and addressed. Findings included: Record review of Resident #1's MDS admission assessment, dated 02/19/25, reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Her BIMS score was 12. Her cognitive status was moderately impaired. Her diagnoses included stroke and diabetes. Record review of the Facility Grievances for April 2025 and May 2025 reflected there were four grievances completed for Resident #1, but none of them were filed anonymously. An interview on 05/28/25 at 11:00 AM with Resident #1 revealed she had a personal notebook that she wrote her complaints in. She said she would have a nurse make a copy of the document and she would take it to the SW or the DON and she felt like they did not want to hear from her. Resident #1 said her concerns on the paper were not addressed and she did not know where the grievance forms were. Resident #1 said she did not know if a grievance was ever filed for her complaints. She said she wanted to file a grievance anonymously but did not know how. An interview on 05/28/25 at 12:30 PM with the SW revealed she thought Resident #1 had provided her a copy of her complaints one time, but she could not remember for sure. She said she thought she filled out a grievance for the issues for Resident #1. The SW said she thought the paper with the resident's complaints might have been put with the grievance form, but she could not remember. The SW said a resident could file a grievance by getting a form from the receptionist and the office. The SW said she did not know if residents had access to the forms if there was not a staff at the receptionist desk. The SW said after a grievance form was filled out then it was given to her. An observation on 05/28/25 at 12:40 PM revealed there were blank grievance forms at the receptionist desk, but you could only obtain a grievance form from the receptionist. An interview on 05/28/25 at 1:00 PM with LVN A revealed Resident #1 had a personal notebook and (continued on next page) 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 REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 455727 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Village Healthcare and Rehabilitation 207 E Parkerville Rd Desoto, TX 75115 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)