Parkwood in the Pines

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of medications for 3 of 6 medication carts (medication cart for halls 400, 500, and 600, nurse cart for odd room numbers on hall 100 and 200, and medication cart for hall 100 and 200) reviewed for pharmacy services. The facility failed to remove (1) bottle of expired aspirin 325 mg and (1) box of arginaid powder (medication used to aid in wound healing) and a plastic bag of a white powder without a date from the medication cart for halls 100 and 200 on 4/20/2026. The facility failed to remove (1) box of arginaid powder from the medication cart for halls 400, 500, and 600 on 4/20/2026. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety for facility's only kitchen reviewed for food storage. The facility did not ensure foods in the freezer and dry storage area were stored, labeled and dated when opened or removed from their original packaging or opened on 4/19/2026. This failure could place residents who received their meals from the kitchen at risk of food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's right to personal privacy for 1 of 6 residents reviewed for resident rights. (Resident #64)The facility failed to ensure Resident #64 was treated with dignity and respect when the Treatment Nurse failed to provide privacy during wound care on 4/21/26. This failure could place residents at risk for feeling disrespected, a decreased sense of self-worth, and depression.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident's right to a safe, clean, and comfortable environment for residents for 1 of 24 residents (Resident #27) observed for resident environment. The facility failed to ensure the floor in Resident #27's room did not have standing water and was without odors from 4/19/2026-4/21/2026. These failures could place residents at risk for an unsanitary environment.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents received care and services in accordance with professional standards of practice for 1 of 6 residents (Resident #64) reviewed for quality of care. The facility failed to ensure Resident #64's surgical site was monitored for signs and symptoms of infection each shift while a non-removable dressing was in place from 4/9/26 to 4/20/26. This failure could place residents at risk of not receiving appropriate care and treatment and/or decline in their health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 1 of 1 facility (3 of 7 mechanical lift slings) reviewed for hazards:The facility failed to remove faded, worn and damaged mechanical lift slings from service. This failure could result in a loss of quality of life due to injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent infections and to restore continence to the extent possible for 1 of 5 (Resident #7) residents observed for urinary catheter (tube placed in the bladder that drains into a bag outside of the body) care. LVN D did not provide appropriate catheter care for Resident #7 when she did not use the proper cleaning agent or clean the catheter tubing on 4/21/2026. This failure could place residents at risk for bacterial infections from improper catheter care.

Inspectors wroteBased on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 6 staff (CNA C and LVN D) and 2 of 5 resident (Resident #5 and Resident #7) reviewed for infection control.1. The facility failed to ensure CNA C washed or sanitized her hands between glove changes and did not touch clean items with dirty gloves when incontinent care was provided to Resident #5 on 4/19/2026.2. The facility failed to ensure LVN D washed or sanitized her hands between gloves changes during urinary catheter care to Resident #7 on 4/21/2026These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.

Inspectors wroteBased 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 of 1 dining area reviewed for environmental concerns. 1. The facility failed to ensure the dining room ceiling was in good repair and without damage and peeling paint. 2. The facility failed to ensure the dining room lighting and ceiling were free from thick cobwebs and dust. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe.

Inspectors wroteBased on observation and interview, the facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors with all required information for 1 of 3 days reviewed (4/19/26) for nurse staffing posting. The facility failed to post the daily staffing information in a prominent place on 4/19/26. This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts.

Inspectors wroteBased on interview and record review the facility failed to, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete and accurately documented for 1 of 6 residents (Residents #1) reviewed for medical records. The facility failed to ensure Resident #1's physician's orders were updated to include the resident was a DNR status and was uploaded in his medical record. This deficient practice could place residents at risk of improper care due to inaccurate medical records.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for 4 of 12 residents (Residents #75, #61, #58 and #79) reviewed for accidents/hazards. The facility failed to remove worn and damaged mechanical lift slings from service from 2/10/2025-2/12/2025. This deficient practice could place residents at risk of a loss of quality of life due to injuries.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure drugs and biologicals were store in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 3 of 12 residents (Resident #17, #18 and # 86) reviewed for medication storage. 1. The facility failed to ensure Total Beets soft chews was not stored at the bedside of Resident #17 on 2/10/25 . 2. The facility failed to ensure a bottle of OTC (over the counter) throat spray was not stored at the bedside of Resident #18 on 2/10/25. 3. The facility failed to ensure aspercreme with lidocaine and nasal spray was not stored at the bedside of Resident #86 from 2/10/2025-2/11/2025. These failures could place residents at risk for adverse effects and reduced therapeutic effects of medication and supplies.

Inspectors wroteBased on observation, interview, and record review, the facility failed to immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the representative when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 4 residents (Resident #39) reviewed for resident rights. The facility failed to ensure Resident #39's Responsible Party was notified after she experienced pain in her right leg and had an X-ray ordered. This failure could place residents at risk of not being informed of illness, injury, and uncontrolled pain.

Inspectors wroteBased on interviews and record review, the facility failed to complete a significant change MDS assessment within 14 days after a significant change in the resident's mental and physical condition for 1 of 6 residents (Resident #82) reviewed for assessments. The facility failed to reassess Resident #82 following a hospice admission (specific care for the sick or terminally ill) on 12/17/2024. This failure could place residents at risk for not having their individual needs met due to inaccurate assessments.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming, and personal and oral hygiene were provided for 1 of 6 residents (Resident #6) reviewed for ADL care. The facility failed to ensure Resident #6 had nail care done on 2/12/25 and 2/13/25. This failure could place residents at risk of not receiving care/services, decreased quality of life, and loss of dignity.

Inspectors wroteBased on interviews and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and follow a policy to provide pharmacy services in accordance with State and Federal laws or rules of the Drug Enforcement Administration for 1 of 4 months (July 2024) reviewed for pharmacy services. The facility failed to document the number of pages that were included and did not have the required witness signatures for drug destruction on 7/12/2024. This failure could put residents at risk for misappropriation and drug diversion.

Inspectors wroteBased on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #62) and1 of 5 staff (CNA D) reviewed for infection control. The facility failed to ensure CNA D washed their hands before providing incontinent care to Resident #62 on 2/11/25. The facility failed to ensure CNA D appropriately changed gloves and washed hands while providing incontinent care to Resident #62 on 2/11/15. The facility failed to ensure CNA D properly cleaned the penis of Resident #62 while providing incontinent care on 2/11/25. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide adequate supervision and assistance devices to prevent accidents for 1 of 8 residents reviewed for accidents/supervision. (Resident #1) The facility failed to ensure Resident #1 was transferred to her bed using a mechanical lift on 10/2/24, causing pain to her right leg. This failure could place residents at risk of severe injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions in 1 of 1 kitchen reviewed for kitchen sanitation in that: During the initial observation on in the kitchen the low temperature, chemical sanitation dish machine, did not reach the manufacturer's recommended minimal water temperature of 120 degrees Fahrenheit, (F) during the final rinse cycle This failure could place the residents at risk of foodborne illnesses.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to treat residents with respect and dignity and care for them in a manner and in an environment that promoted maintenance or enhancement of their quality of life for 1 of 12 residents (Resident #286) reviewed for resident rights. CNA C and CNA D failed to provide privacy to Resident #286 when providing incontinent care on 01/09/2024 . This failure could place residents at risk for decreased quality of life, decreased self-esteem and increased anxiety.

Inspectors wroteBased on observation, interview and record review the facility failed to immediately inform the resident's responsible party when there was an accident involving the resident which resulted in injury or had the potential for requiring physician intervention for 1 of 5 residents (Resident #18) reviewed for notification of change of condition. The facility failed to notify Resident #18's responsible party when Resident #18 sustained an unwitnessed fall on 12/29/2023 on or about 3:30 AM in her room when she slid out of bed to the floor. This failure placed residents' caregivers at risk of not being aware of any changes in their conditions and could result in a delay in treatment and decline in residents' health and well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 6 residents (Resident #57) reviewed for appropriate treatment and services to prevent urinary tract infections (an infection in any part of the urinary system, the kidneys, bladder, or urethra (is a hollow tube that lets urine leave your body) and quality of care. The facility failed to ensure Residents #57's indwelling catheter (drains urine from your bladder into a bag outside your body) was secure and stabilized on 01/09/2023. This failure could place residents at risk for urinary tract infections and catheter related injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders for 1 of 1 (Resident #43) residents reviewed for intravenous fluids. The facility failed to ensure Resident #43 received PICC (a soft, flexible catheter inserted into a central vein used for prolonged antibiotic therapy) line dressing changes with a dressing dated 12/28/2023 This failure could affect residents by placing them at risk for infection.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 6 residents (Resident # 25 and Resident #286) reviewed for infection control. The treatment nurse failed to perform proper hand hygiene while providing wound care to Resident #25 on 01/10/2024. CNA C failed to perform proper hand hygiene while providing incontinent care to Resident #286 on 01/09/2024. These failures could place residents at risk of exposure to communicable diseases and infections.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 3 of 7 residents (Residents #1, #2, and #3) reviewed for call lights. The facility failed to ensure Residents #1, #2, and #3's call light was accessible and in reach. Resident #1's call light was attached to the privacy curtain at the foot of the bed, Resident #2's call light was hanging on the floor at the end of the bed, and Resident #3's call light was wrapped around the assist bar and hanging off the side of the bed. These failures could affect residents who used their call light or desire to use the call light and place them at risk of not being able to notify staff of their needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity for 1 of 7 residents (Resident # 1) reviewed for dignity. The facility failed to ensure Resident # 1's urinary drainage bag had a dignity/privacy cover. This failure could place residents in the facility at risk for a diminished quality of life, loss of dignity and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 7 residents (Resident #1) reviewed for ADL's. The facility failed to ensure Resident #1's face, mouth and nails were kept clean. This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health.

Inspectors wroteBased on interview and record review the facility failed to implement written policies and procedures that prohibit and prevent abuse and neglect of residents for 1 of 4 residents (Resident #1) reviewed for neglect. The facility failed to implement their Abuse policy and ensure all allegations that resulted in serious bodily injury were reported to HHSC within 2 hours of the allegation for Resident #1 who had a fall on 10/21/2023 at 4:53 AM. This failure could place residents at risk of being neglected and lack of oversight by a state agency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily for 1 of 4 residents (Resident #1) reviewed for neglect. The facility did not report to the state agency within 2 hours when an allegation of neglect occurred on 10/21/2023 that involved Resident #1 who had a fall and sustained a small cut to her left ear and two brain bleeds. This failure could place vulnerable residents at risk of harm due to delays in reporting an allegation of neglect.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents were free from sexual and physical abuse for 2 of 9 residents (Resident #1 and Resident #3) reviewed for abuse. The facility failed to prevent sexual abuse for Resident #1 found crying in her room with Resident #2's hand under her brief in perineal area on 10/8/23. The facility failed to prevent physical abuse for Resident #3 that was hit in the face in his room by Resident #4 and sustained injuries to include a bloody nose, skin tear to left side of nose, and swelling to his left ear on 10/11/23. The noncompliance was identified as PNC. The IJ began on 10/08/2023 and ended on 10/12/2023. The facility had corrected the noncompliance before the investigation began. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents for 2 of 9 residents (Resident #1 and Resident #3) reviewed for abuse. The facility failed to implement policies and procedures to prevent sexual abuse for Resident #1 found crying in her room with Resident #2's hand under her brief in perineal area. The facility failed to implement policies and procedures to prevent physical abuse for Resident #3 that was hit in the face in his room by Resident #4 and sustained injuries to include a bloody nose, skin tear to left side of nose, and swelling to his left ear. The noncompliance was identified as PNC. The IJ began on 10/08/2023 and ended on 10/12/2023. The facility had corrected the noncompliance before the investigation began. [...]