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Inspection visit

Inspection

Parkwood VillageCMS #6755654 citations on this visit
4 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to provide a private meeting space for residents' monthly council meetings for 8 of 8 residents (Residents #13, #14, #15, #17, #21, #23, #38, and #39) reviewed for resident council. Residents Affected - Some The facility failed to provide a private space for resident council meetings for Residents #13, #14, #15, #17, #21, #23, #38, and #39. This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns due to a lack of privacy. Findings included: Observation and interview during a confidential resident group interview on 10/05/2022 at 10:10 AM with Residents #13, #14, #15, #17, #21, #23, #38, and #39 in attendance revealed the meeting was held in an open dining room, near the entrance to the facility's secured unit. There were no doors that could be closed to ensure the residents' privacy during the meeting. Staff and visitors were observed walking through the area while the meeting was in progress. During the confidential group meeting, all eight residents revealed they always met in an open dining room area. They stated they have never been offered an opportunity to meet in a private area. Residents #21 and #23 stated residents had not always vocalized what they felt at meetings because staff could overhear them. Interview on 10/06/2022 at 8:12 AM with the Administrator revealed he had worked at the facility for three years and during that time resident council had always met in the open dining room near the secured unit. He said the facility did not have a private area for the group to meet. He stated he knew the group should have access to a private meeting space to ensure they were able to voice any concerns without fear of staff hearing them. He said the residents had a right to privacy and to hold private meetings. He said he would provide the facility's policy related to the resident's rights to meet privately. Interview on 10/06/2022 at 3:00 PM with the Director of Community Life Services revealed the last three resident council meetings were held in the open dining room. She said she had worked at the facility for the past three years and during that time all resident council meetings were held in an open dining room area. She stated the facility did not have a closed area to facility private meetings. She said she knew that the residents had a right to hold private meetings. Record review of the resident council minutes for July 2022, August 2022, and September 2022 revealed no location of the resident council meeting. (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 7 Event ID: 675565 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 675565 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkwood Village 2600 Parkview Dr Bedford, TX 76022 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 0565 Level of Harm - Minimal harm or potential for actual harm Record review of the facility's current, undated Resident Council policy reflected: the names of residents making comments should not be part of the Resident Council minutes. A show of hands to determine a given comment or complaint is common should be noted. No other policy was provided. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675565 If continuation sheet Page 2 of 7 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 675565 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkwood Village 2600 Parkview Dr Bedford, TX 76022 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 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a quarterly Minimum Data Set assessment was completed no less than once every three months as required for one of 18 residents (Resident #4) reviewed for comprehensive assessments. Residents Affected - Few The facility failed to ensure a quarterly assessment was completed for Resident #4. This failure could place residents at risk of not having their care and treatment needs assessed to ensure necessary care and services were provided. Findings included: Record review of Resident #4's Face Sheet dated 10/06/2022 revealed the resident was a [AGE] year-old female admitted on [DATE] with diagnoses including major depressive disorder, sepsis, unspecified organism (a life-threatening complication of infection), muscle wasting, essential (primary) hypertension (high blood pressure) and gastroesophageal reflux disease (a digestive disease in which stomach acid or bile irritates the food pipe lining). Review of Resident #4's Electronic MDS tab revealed a Quarterly MDS assessment completed 05/15/2022 and a quarterly MDS assessment dated [DATE] was still in process. Observation on 10/05/2022 at 12:40 PM revealed Resident 4 was in her room in her wheelchair. The resident was alert and oriented to person and place. Interview on 10/05/2022 at 2:13 PM with MDS Nurse C revealed she was responsible for completing the annual and quarterly MDS assessments accurately, efficiently, timely, and expedited. She stated the MDS assessments should be completed annually and quarterly or if there was a change in condition. She stated Resident #4 did not have a quarterly assessment completed in a timely manner on 08/15/2022 although the assessment was started. She stated a quarterly assessment should have been completed in August 2022 within 14 days since it was showing in process, but she could have missed it. Interview on 10/05/2022 at 3:46 PM with the DON revealed her expectation was for all MDS assessments to be completed accurately, efficiently, and timely. She stated the MDS Coordinator was responsible for completing the MDS accurately and timely. She stated she was not responsible for signing the MDS after assessment, the facility had a Corporate RN responsible for signing the MDS after the assessment was completed. Interview on 10/05/2022 at 4:22 PM with the Administrator revealed his expectation was for all MDS assessments to be completed accurately, efficiently, and timely as per the guidelines. He stated the MDS Coordinator was responsible for assisting and guiding MDS Nurse C and not having the MDS competed it was an opportunity that was missed. Interview on 10/06/2022 at 3:33 PM with the MDS RN D revealed she was responsible for signing the MDS after the MDS nurse had completed assessment. She stated once the assessment was completed it would reflect on her screen as open. She stated she checked every day for the completed assessment so that she can sign for process completion. The MDS coordinator was called, and she did not respond or call back. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675565 If continuation sheet Page 3 of 7 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 675565 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkwood Village 2600 Parkview Dr Bedford, TX 76022 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 0638 Level of Harm - Minimal harm or potential for actual harm Review of the facility's current MDS Completion and Submission Timeframe policy, revised July 2017, reflected: Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. Residents Affected - Few 1. The assessment coordinator or designee is responsible for ensuring that resident assessment are submitted to CMS' OIES Assessment submission and processing (ASAP) system in accordance with current federal and state guidelines. 2. Timeframes for completion and submission of assessment is based on the current requirements published in the resident Assessment Instrument manual. 3. Submission of MDS records to the QIES ASAP is electronic. A hard copy of each record submitted is maintained in the resident's clinical record for a period of (15) months from the date submitted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675565 If continuation sheet Page 4 of 7 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 675565 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkwood Village 2600 Parkview Dr Bedford, TX 76022 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 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. Residents Affected - Many 1. The facility failed to ensure food items and clean dishes were kept away from airborne contaminants. 2. The Facility failed to ensure food items were properly labeled, dated, and thawed in accordance with professional standards. These failures could place residents who receive food from the kitchen, at risk for food contamination and food-borne illness. Findings included: Observation on 10/04/2022 at 9:15 AM revealed, a large fan on the floor inside the entrance to the kitchen. The fan was blowing toward a food preparation area of the kitchen. The grill on the front of the fan and fan blades were covered with clumps of fuzz and dust. The clumps were fluttering from the propulsion of the fan. In the same area, a film of tacky substance covered with dust and food crumbs was observed on the shelves of the racks which contained clean insulated meal delivery plate covers and bases. A juice dispensing machine, in the same preparation area, was observed with dust adhered to the machine's top and sides with a tacky substance. Interview on 10/04/2022 at 9:20 AM with the Director of Culinary Services revealed the tacky substance on the juice dispenser and place cover rack was likely grease. She said the dust and crumbs stuck to the equipment could become dislodged and contaminate food or clean dishes. She stated the fan had been in the kitchen for about two weeks to help with keeping the kitchen food prep area cooler. She said dust and fuzz on the fan cover and blades could blow off and get into food at the steam table. She said this placed resident at risk of food borne illnesses. Observation and interview on 10/04/2022 at 9:30 AM revealed an unlabeled or dated package of frozen red meat wrapped in plastic wrap on the prep table. [NAME] A said she did not know who took the meat out of the freezer and was not sure what it was. She said the meat was not labeled or dated. The Director of Culinary Services said she was not sure what the meat was or how old it was because it was not labeled or dated. She stated food items should always be dated and labeled to ensure freshness and thawing should occur in the refrigerator or under cold running water to ensure the meat maintains a food safe temperature. She was observed throwing it into the trash. Observation and interview on 10/04/2022 at 9:35 AM revealed two ceiling vents, adjacent to the dishwashing area, covered with dust and fuzz. A rack that contained clean pots and stainless-steel inserts was under the vents. [NAME] B stated the dust and fuzz hanging from the vents could become dislodged and contaminate the clean dishes on the rack below. He said this could cause a risk of food borne illness to residents in the facility. Observation and interview on 10/04/2022 at 9:50 AM revealed food crumbs and dirt on the floors under the racks in the dry food storage area. The floor in the corners of the room were thick with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675565 If continuation sheet Page 5 of 7 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 675565 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkwood Village 2600 Parkview Dr Bedford, TX 76022 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 Level of Harm - Minimal harm or potential for actual harm buildup of black dirt and food particles. The Director of Culinary Services stated staff clean the floors after they have received a food order. She said the dirty floors could attract pests. She said she was responsible for ensuring the kitchen was kept clean. She said there was an issue with pests in the room, but pest control was coming weekly to address the issue. She said she had a daily cleaning schedule and was working on a deep cleaning schedule. Residents Affected - Many Interview with the Administrator on 10/05/2022 at 3:45 PM revealed there should not be any dust or grease on any of the kitchen equipment. He said the Director of Culinary Services was responsible for ensuring the kitchen was clean. He stated dust could be dislodge from the racks, vents, or fan and contaminate dishes and food which would pose a risk of food-borne illness to residents who ate food from the kitchen. Record review of the facility's Weekly Cleaning Schedule dated 10/02/2022 - 10/08/2022 revealed staff signed off on all the cleaning tasks noted. No tasks were listed for vents, shelves, or the juice machine. Record review of the facility's current Cleaning and Sanitation of Dining and Food Service Areas policy, dated 2019, reflected: The food and nutrition services staff will maintain the cleanliness and sanitation of the ding and food service areas through compliance with a written, comprehensive cleaning schedule. The director of food and nutrition services will determine all cleaning and sanitation tasks needed for the department. The facility's policy titled Food Storage dated 2019 revealed Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored, at approximate temperatures and by methods designed to prevent contamination or cross contamination. Frozen Foods - all foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. Safe Thawing - thawing frozen meat, poultry, and fish in a refrigerator. Record review of Food and Drug Administration Food Code dated 2017 Section 4-601.11 reflected: .Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 3-305.11 Food Storage. (A) Except as specified in (B) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) FOOD in packages and working containers may be stored less than 15 cm (6 inches) above the floor on case lot handling EQUIPMENT as specified under § 4-204.122. 3-305.14 Food Preparation. During preparation, UNPACKAGED FOOD shall (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675565 If continuation sheet Page 6 of 7 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 675565 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkwood Village 2600 Parkview Dr Bedford, TX 76022 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete be protected from environmental sources of contamination. 3-307.11 Miscellaneous Sources of Contamination. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306. 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. 92 3-501.13 revealed Thawing: TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be thawed: (A) Under refrigeration that maintains the FOOD temperature at 5 [degrees] C[elsius] (41 [degrees] F) or less; or (B) Completely submerged under running water: (1) At a water temperature of 21 [degrees] C (70 [degrees F) or below, (2) With sufficient water velocity to agitate and float off loose particles in an overflow. Event ID: Facility ID: 675565 If continuation sheet Page 7 of 7

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Citations

4 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0565GeneralS&S Epotential for harm

    F565 - The resident has a right to organize and participate in resident groups in the

    Honor the resident's right to organize and participate in resident/family groups in the facility.

  • 0638GeneralS&S Dpotential for harm

    F638 - Quarterly Review Assessment

    Assure that each resident’s assessment is updated at least once every 3 months.

  • 0812GeneralS&S Fpotential for harm

    F812 - Food safety requirements

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0006GeneralS&S Fpotential for harm

    Conduct risk assessment and an All-Hazards approach.

FAQ · About this visit

Common questions about this visit

What happened during the October 6, 2022 survey of Parkwood Village?

This was a inspection survey of Parkwood Village on October 6, 2022. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at Parkwood Village on October 6, 2022?

Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to organize and participate in resident/family groups in the facility."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.