Inspection Report Summary
The most recent inspection on December 12, 2024, found multiple deficiencies related to care planning, supervision during mechanical lifts, medication management, and infection control. Earlier inspections also identified issues with medication storage and security, respiratory care, food safety, and timely completion of assessments. Inspectors cited recurring themes involving incomplete care plans, medication handling errors, and environmental safety concerns. No complaint investigations or enforcement actions were listed in the available reports. The pattern of findings suggests ongoing challenges in several areas without clear improvement over time.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
43% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 6
Date: Dec 12, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, safety, and infection control at Parkwood Healthcare Community.
Findings
The facility was found deficient in multiple areas including failure to develop and implement comprehensive care plans, inadequate supervision during mechanical lifts, lack of proper assessment and consent for bed rails/grab bars, expired and improperly stored medications, unlocked medication carts, and failure to perform hand hygiene between feeding residents.
Deficiencies (6)
Failure to develop and implement a complete care plan that meets all the resident's needs, including documentation of bed rails/grab bars use for Resident #30.
Failure to ensure adequate supervision during mechanical lift transfers for Resident #43, specifically not using two staff members as required.
Failure to assess risks and benefits of bed rails and obtain informed consent prior to installation for Residents #29 and #54.
Failure to provide pharmaceutical services to meet resident needs, including expired insulin found in Med Room A.
Failure to ensure all drugs and biologicals were labeled and stored properly, including undated TB vaccine and food stored in medication fridge, and unlocked medication cart accessible outside Resident #209's room.
Failure to maintain an infection prevention and control program, including failure of CMA F to perform hand hygiene between feeding Resident #2 and Resident #7.
Report Facts
Residents reviewed for clinical records: 4
Residents reviewed for accidents: 2
Medication rooms reviewed: 2
Medication carts reviewed: 7
Residents reviewed for infection control: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Observed performing mechanical lift transfer alone and interviewed about transfer practices | |
| CNA B | Interviewed regarding proper mechanical lift procedures and training | |
| LVN I | Licensed Vocational Nurse | Interviewed about assessment and documentation of bed rails/grab bars |
| ADM | Administrator | Interviewed about bed rails/grab bars policies and medication storage |
| DON | Director of Nursing | Interviewed about bed rails/grab bars assessments, mechanical lift policies, medication management, and infection control |
| RN E | Registered Nurse | Observed leaving medication cart unlocked and interviewed about medication cart security |
| CMA F | Certified Medication Aide | Observed feeding two residents without hand hygiene and interviewed about infection control practices |
| LVN D | Licensed Vocational Nurse | Interviewed about undated TB vaccine and medication storage |
| LVN H | Licensed Vocational Nurse | Interviewed about feeding practices and hand hygiene training |
Inspection Report
Routine
Deficiencies: 3
Date: Feb 23, 2024
Visit Reason
The inspection was conducted to assess compliance with professional standards of care, medication storage, and environmental safety in the nursing home.
Findings
The facility failed to provide safe and appropriate respiratory care for residents needing oxygen therapy, failed to secure medication carts properly, and did not maintain a safe, clean, and comfortable environment free of hazards for residents.
Deficiencies (3)
Failed to ensure residents needing respiratory care received appropriate care, including proper handling and timely changing of oxygen tubing.
Failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for 2 of 4 medication carts reviewed.
Failed to provide a safe, functional, sanitary, and comfortable environment; resident rooms had smeared oatmeal, hard candies, and blankets obstructing walk paths.
Report Facts
Residents reviewed for respiratory care: 3
Medication carts reviewed: 4
Minutes medication cart #1 left unattended unlocked: 4
Minutes medication cart #2 left unattended unlocked: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN-R | Registered Nurse | Interviewed regarding expectations for oxygen tubing changes and rounds |
| ADON | Assistant Director of Nursing | Interviewed regarding nursing responsibilities for oxygen tubing and medication cart security |
| DON | Director of Nursing | Interviewed regarding documentation and expectations for oxygen tubing changes and medication cart security |
| MA P | Medication Aide | Interviewed regarding medication cart being left unlocked and medication handling |
| RN N | Registered Nurse | Interviewed regarding medication cart being left unlocked |
| CNA S | Certified Nursing Assistant | Interviewed regarding cleaning of resident room hazards |
Inspection Report
Routine
Deficiencies: 3
Date: Nov 8, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to Minimum Data Set (MDS) transmission, comprehensive person-centered care planning, and food service safety at Parkwood Healthcare Community.
Findings
The facility failed to transmit Discharge MDS data for 3 residents, failed to develop comprehensive person-centered care plans for 6 residents addressing medication, diet, and secure Alzheimer's unit placement, and failed to maintain proper food storage temperatures and labeling in the kitchen, potentially placing residents at risk of harm.
Deficiencies (3)
Failed to transmit Discharge MDS data for Residents #64, 41, and 26 within required timeframe.
Failed to develop comprehensive person-centered care plans for 6 residents addressing medication needs, special diet, fluid restrictions, and secure Alzheimer's unit placement.
Failed to properly store, label, and maintain refrigerated foods at or below 41 degrees Fahrenheit in the kitchen, including a walk-in refrigerator malfunction.
Report Facts
Residents reviewed for MDS transmission: 5
Residents reviewed for comprehensive care plans: 15
Temperature of walk-in refrigerator: 50
Temperature of ham in refrigerator: 55.2
Temperature of turkey in refrigerator: 55
Temperature of tuna salad in refrigerator: 55
Refrigerator temperature log: 40
Refrigerator temperature log: 50
Refrigerator temperature log: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CRN | Interviewed regarding MDS transmission and oversight | |
| DON | Interviewed regarding MDS transmission and care plan oversight | |
| ADM | Interviewed regarding MDS transmission, care plans, and food service issues | |
| DM | Dietary Manager interviewed regarding food storage and refrigerator issues | |
| Cook | Interviewed regarding food safety and refrigerator temperatures |
Inspection Report
Routine
Deficiencies: 3
Date: Oct 6, 2022
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, assessment completion, and food safety standards at Parkwood Healthcare Community.
Findings
The facility failed to provide a private meeting space for resident council meetings, did not complete a required quarterly Minimum Data Set assessment timely for one resident, and failed to maintain food safety standards in the kitchen including contamination risks from dust, unlabeled food, and unclean surfaces.
Deficiencies (3)
Failed to provide a private meeting space for residents' monthly council meetings for 8 of 8 residents reviewed.
Failed to ensure a quarterly Minimum Data Set assessment was completed timely for one of 18 residents reviewed.
Failed to store, prepare, distribute, and serve food in accordance with professional standards, including contamination risks from dust, grease, unlabeled food, and unclean kitchen equipment.
Report Facts
Residents reviewed for resident council meeting privacy: 8
Residents reviewed for comprehensive assessments: 18
Date of last completed quarterly MDS assessment for Resident #4: May 15, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Nurse C | MDS Nurse | Responsible for completing annual and quarterly MDS assessments; noted quarterly assessment for Resident #4 was not completed timely. |
| Administrator | Administrator | Acknowledged lack of private meeting space for resident council and responsibility expectations for MDS assessments and kitchen cleanliness. |
| Director of Community Life Services | Director of Community Life Services | Confirmed resident council meetings were held in an open dining room with no private space available. |
| Director of Culinary Services | Director of Culinary Services | Acknowledged kitchen cleanliness issues including dust, grease, unlabeled food, and pest control concerns. |
| MDS RN D | MDS RN | Responsible for signing MDS assessments; noted MDS coordinator did not respond to calls regarding incomplete assessments. |
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