Inspection·February 23, 2024

F 0695 Level of Harm - Minimal harm or potential for actual harm In an observation and interview on 02/23/24 at 8:19 AM with Resident #82 revealed resident sitting in her recliner partially leaned back, eating fruit. Resident #82's oxygen tubing was touching the floor and the nasal cannula was positioned on top of concentrator undated, labeled, or bagged. Resident said she did not know if the facility changed her oxygen tubing. She does not know if she uses oxygen. Residents Affected - Few Resident #83 Record review of Resident #83's face sheet dated 02/23/24 reflected an [AGE] year-old female admitted on [DATE]. Resident #83's diagnoses include: Acute respiratory failure (difficulty with lungs loading blood with oxygen) with hypoxia (Hypoxemia is an abnormally low level of oxygen in the blood. More specifically, it is oxygen deficiency in arterial blood), Pneumonia, (inflammatory disease affecting the lungs) unspecified organism, Cognitive communication deficit (difficulty expressing thoughts). Record review of Resident #83's MDS dated [DATE] reflected BIMS of 10 - indicating she was moderately impaired cognitively, depression and mood .required Setup or clean-up assistance - ADL partial/moderate assistance self-care- Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort hygiene and mobility, sit to stand Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. Record review of Resident #83's admission care plan dated 02/06/24 impaired mobility, impaired strength, and poor safety awareness. observe fall precautions at all times .medication administration: resident at risk for adverse reactions to medications r/t side effects assess for s/s of respiratory failure such as SOB, confusion, restlessness, irritability, inability to move secretions .infection: admitted to community with an active infection. -monitor vital signs every shift. document and report any presence of fever or s/s of atypical manifestations oxygen: administer oxygen as ordered to maintain oxygen saturation >92%, observe oxygen precautions. monitor oxygen saturation via pulse oximetry q shift and PRN. Record review of Resident #83's care plan dated 2/14/24 did not address the use of oxygen or treatment related to respiratory follow all MD orders, assess, and report changes Record review of Resident #83's MD orders dated 02/06/24 reflected respiratory: O2 at 2L/MIN AT start per NC - titrate (measure) up 1l/min to maintain 02 sats >92% special instructions: continuous o2 at 2l/min to maintain o2 sats >92% - titrate 1l/min progressively and check o2 sats until maintained at > 92% - contact physician if unable to maintain o2 sats >92% every shift - prn 1, prn 2 .respiratory: change tubing on oxygen special instructions: change tubing Q Wk. and note in nursing notes once a day on Fri 07:00 - 21:00 (respiratory nursing) respiratory: Clean Air Filters on Oxygen Concentrators Special Instructions: Change Air Filters Q WK and note in nursing notes Once A Day on Wed 07:00 - 21:00. Record review of Resident #83's e-MAR reflected that on 02/10/24 through 02/23/24 administration record was blank for tubing change. In an observation and interview with Resident #83 on 02/23/24 at 8:20 AM, revealed her nasal cannula tubing and water bottle was undated. She was wearing her nasal cannula and oxygen concentrator was (continued on next page) 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 02/23/2024 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 0695 working. She said staff had not changed her tubing since she admitted from the hospital. Level of Harm - Minimal harm or potential for actual harm In an interview with RN-R on 02/23/23 at 12:50 PM, revealed nurses wase expected to change oxygen tubing and date every Sunday during the overnight shift. All nurses should conduct rounds and assess oxygen and look for dates. If not dated check TAR, changing tubing, date tubing, and document changes. Failure to change oxygen tubing routinely could result in respiratory infections. He stated that he had conducted rounds and prior to DON notifying him of resident tubing and water bottle being undated, he had not observed. He said he had changed the tubing and water and dated them. He said water bottles for oxygen concentrators should be dated and changed when empty. Residents Affected - Few In an interview with the ADON on 02/23/23 at 1:30 PM, revealed water bottles should be changed when empty and as needed, then dated to confirm change. The ADON said nursing should be conducting rounds every 2 hours, assuring tubing that was not being used was bagged and dated. The ADON said nurses should change and date tubing and water bottles as soon as possible if found undated, then date and document. The ADON said the negative outcome of failing to date and bag tubing, can lead to the resident receiving respiratory infections. It is the responsibility of the nursing managers (ADON, DON) to monitor. In an interview on 02/23/24 at 1:40 PM, the DON revealed all documentation of tubing changes should be listed in the MAR. She said Resident #82 does not receive oxygen and will remove the concentrator. She expects nursing staff to change oxygen tubing and dating change weekly, document in EMAR. She initially said the tubing and water bottle does not need to be dated. She then stated the importance of dating tubing and water bottle allows nursing to see the tubing was changed immediately upon observation, however she expects review of e-MAR to confirm. The DON said not dating and labeling tubing could lead to infections. The DON said she expects the ADON to audit and monitor nursing task for compliance. An interview with the administrator was not conducted, due to being absent from the facility on the day of exit. Policy for oxygen was requested from ADM on 02/21/24 and DON on 02/22/24 and was not provided to surveyor at the time of exit on 02/22/24. 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 02/23/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for 2 of 4 (Medication Cart #1 and Medication Cart #2) medication carts reviewed for pharmacy services. Medication cart #1 was observed unlocked and unattended with 6 blister packs medication cards left on top unsupervised by MA P for 4 minutes. Medication cart #2 was observed outside resident room facing hallway where individuals passed, unlocked and unattended for 2 minutes by RN N. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion. Findings included: In an observation on 02/23/24 at 8:15 AM, Medication cart #1 was observed unlocked and unattended with 6 blister medication filled packs placed on top, in the small resident dining areas on the north side of nursing station. There were 2 residents observed sitting behind the near the medication cart at the tables appropriately 2.5 feet away. MA P returned to her medication cart 4 minutes later, and she immediately removed the blister medication cards and locked inside of the cart. In an interview with MA P on 02/23/24 at 8:20 AM, revealed she forget to lock the medication cart. She stated it was the overnight nurse who left the medication packs on top of the cart. She said overnight nurse was at the facility upon her arrival to work on 02/23/24 at 6:00 AM. She said it was the assigned medication person's responsibility to keep medications locked and inaccessible during her assignment. MA P said all medications should be inside the locked medication cart to prevent medication from being stolen, or residents accessing the medication. An observation on 02/23/24 at 8:25 AM, revealed medication cart #2 positioned in front of a resident room with drawers facing the hallway unlocked. In an interview on 02/23/24 at 8;30 AM with RN N, she stated that she forgot to lock the medication cart. She stated she did not know State was in the building. She said medication carts should be locked regardless to prevent resident access to medications. In an interview with the ADON on 02/23/24 at 1:30 PM, revealed all medication carts should be locked when unattended to maintain safety and prevent others from taking medication. The ADON said medications should never be left on top of a medication cart. The ADON said failing to lock medication carts and secure medications properly could lead to residents having access and other dangerous health response. In an interview on 02/23/24 at 1:40 PM, the DON revealed medication carts must remain locked when unattended to prevent residents, staff, and visitors from accessing. This could lead to missing medication, resident having a bad reaction causing a dangerous medical event. (continued on next page) 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 02/23/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An interview with the administrator was not conducted, due to being absent from the facility on the day of exit. Record review of facility policy titled Administering Medications version 1.2 (H5MAPL0630) undated reflected The facility shall accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medications and biologicals, and the services of a licensed consultant pharmacist.9. The consultant pharmacist, in collaboration with the dispensing pharmacy and the facility, oversees the development of procedures related to pharmacy services, including (but not limited to): a. acquisition and availability of medications: (1) receipt, labeling and storage of medications. (2) reconciliation of medications from the pharmacy. (3) control of medications from point of receipt to secured storage areas; and (4) facility staff roles and responsibilities during the receipt and storage of medication. b. medication packaging and dispensing systems. c. administration of medications. d. disposition of medications. e. authorization, training, and competency of personnel; and f. documentation of processes, as applicable. 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 02/23/2024 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 (Resident #82) of 3 residents reviewed for safe , clean, sanitary, and comfortable environment. The facility failed to ensure Resident #82's rooms were free of smeared oatmeal, hard colorful candies, blanket on the floor obstructing walk path for resident #83 with a history of falls. This failure could place residents at risk falls, injuries, and unsanitary care. Findings included: Record review of Resident 82's dated 02/23/24 face sheet reflected a [AGE] year old female admitted on [DATE] with diagnoses of: Alzheimer's disease (memory loss) Congestive Heart Failure (impaired blood pumping function in the heart) 9 Generalized anxiety disorder (fear and worry of unknown), Need for assistance with personal care, Other abnormalities of gait and mobility, Other lack of coordination Cognitive communication deficit, Hypoxemia (Hypoxemia is an abnormally low level of oxygen in the blood. More specifically, it is oxygen deficiency in arterial blood. Hypoxemia has many causes, and often causes hypoxia as the blood is not supplying enough oxygen to the tissues of the body.) Record review of Resident #82s quarterly MDS dated [DATE] reflected resident needed setup for meals, substantial assistance for toileting, hygiene, and showers, moderate assistance for dress, partial moderate assistance for sit to stand. BIMS score of 11 indicating moderate cognitive impairment. Record review of Resident #82's care plan dated 01/27/24 reflected monitor for s/s of COVID-19 Q shift. Notify MD of any fever or temp greater than 99.0; new onset of cough, sore throat, shortness of breath; vomiting/diarrhea; new loss of smell/taste; fatigue, headache and body-aches Every Shift Day 06:00 - 2:00 PM, Evening 14:00 - 8:00 PM resident will have no complications from cardiac disease over next review date. In an observation and interview on 02/23/24 at 8:19 AM, with Resident #82 revealed resident sitting in recliner with smeared oatmeal on the floor, hard chocolate candies red, yellow, blue, and brown on the floor, and a red blanket laying in the walkway to the left of the resident. Resident #82 said she spilled her breakfast plate on the floor, and staff were returning to clean. She did not know how long it had been since the staff left the room. Interview with agency CNA S on 02/23/24 at 8:14 AM, revealed when called to room by Resident #82, she picked up the dishes of the floor and used a napkin to clean the oatmeal. She did not observe the hard candy and blanket on the floor. She said resident floors should be free of objects, food, water, and blankest to prevent trips, falls, and injuries. CNA S said she was not familiar with this resident's ability to self-ambulate. In an interview with RN R on 02/24/23 at 12:50 PM, revealed the expectation for all resident rooms to be free of clutter and objects to prevent accidents and injuries from occurring. He stated all staff were responsible for removing hazards of the floor then contact housekeeping immediately to prevent injuries. (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 02/23/2024 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview with the ADON on 02/23/24 at 1:30 PM, revealed she expected the nursing staff to keep all residents' floors and rooms free of clutter, food, obstacles to prevent accidents and injuries from occurring. In an interview on 02/23/24 at 1:40 PM, with the DON revealed staff are responsible for maintaining a safe clean environment free of objects, food, and obstacles to prevent falls and injuries for all. She expects staff to remove immediately and notify nurse and housekeeping to address spills. Record review of Facility policy titled Homelike Environment undated version 1.3 (H5MAPL1202) reflected Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible .Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences .The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: clean, sanitary, and orderly environment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675565 If continuation sheet Page 7 of 7