Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Parkwood Village during CMS and state inspections, most recent first.
Incomplete Investigation of Alleged Abuse: The facility did not have evidence that an allegation that a resident was pinched by staff was thoroughly investigated. The resident had moderate cognitive impairment and bruising to the L forearm. The provider investigation report lacked an identified perpetrator, documentation of who was contacted, and witness statements. The ADM and DON interviewed the resident and completed safe surveys, but no written staff statements were available and the investigation documentation was incomplete.
A facility failed to document the use of bed rails in a resident's care plan, despite the resident's severe cognitive impairment and complex medical conditions. The resident used grab bars for mobility, but no assessment or consent was obtained, violating facility policy. This oversight risked the resident's care continuity and safety.
A resident requiring maximal assistance for transfers was moved using a Hoyer lift by a single CNA, contrary to the facility's policy requiring two-person assistance. The resident's care plan and physician's order specified the need for two or more staff members during transfers. Interviews revealed inconsistencies in staff training, with the CNA stating she was instructed to perform the transfer alone by a preceptor, despite the facility's policy.
The facility failed to assess risks and obtain informed consent for bed rails for two residents, despite policy requirements. Observations confirmed the presence of raised bed rails, but documentation and consent were missing. Interviews with staff revealed inconsistencies in the assessment and consent process.
The facility failed to ensure proper pharmaceutical services in Med Room A, where an expired insulin pen was found. The insulin, opened on 07/25/24, was not discarded after 28 days as required, and lacked a resident's name. The DON acknowledged the oversight, and the expired insulin was discarded immediately. Facility policy mandates that opened multi-dose vials be dated and discarded within 28 days unless specified otherwise.
The facility failed to properly label and store medications, as observed with an unlabeled TB vaccine and food stored next to medications in Med Room B. Additionally, Med Cart C was left unlocked and unattended outside a resident's room, allowing potential unauthorized access. Staff acknowledged these oversights, which violated the facility's policies on medication storage and security.
A facility failed to maintain proper infection control when a CMA alternately fed two residents without performing hand hygiene between interactions. Both residents had severe cognitive impairments and required assistance with meals. Despite the facility's hand hygiene policy, there was no specific guidance on feeding two residents simultaneously, leading to a lapse in infection prevention practices.
The facility failed to store all drugs and biologicals in locked compartments, leaving two medication carts unlocked and unattended. One cart was left with six blister packs of medication cards on top, and the other was positioned outside a resident's room with drawers facing the hallway. Both the medication aide and the RN responsible admitted to forgetting to lock the carts.
The facility failed to provide safe and appropriate respiratory care for two residents, leading to deficiencies in oxygen therapy management. One resident's oxygen tubing was not properly maintained, and another resident's tubing was not changed weekly as ordered. The facility's records and staff interviews confirmed these deficiencies.
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for a resident with Alzheimer's and other health issues. The resident's room had smeared oatmeal, scattered candies, and a blanket obstructing the walkway, which were not promptly cleaned by staff, posing a risk of falls and injuries.
Incomplete Investigation of Alleged Abuse
Penalty
Summary
The facility failed to have evidence that an allegation of abuse involving a resident’s report that a staff member pinched her was thoroughly investigated. Resident #4 was an older female admitted to the facility with a diagnosis of cerebral infarction and a BIMS score of 08, indicating moderate cognitive impairment. Her care plan noted two bruises to the left forearm and included interventions related to monitoring and documenting bruising and skin condition. According to the provider investigation report, on 05/15/2026 Resident #4 told the ADON that she believed a staff member had pinched her during care. The report did not identify an alleged perpetrator, did not document who was contacted about the allegation, and did not include witness statements. The report reflected that safe surveys were completed and abuse and neglect in-services were provided, but it did not contain documentation showing a complete investigative process. During interviews, the ADM stated he interviewed Resident #4, who could not recall a specific date or time of the incident, could not describe the staff member, and could not identify the color of the staff member’s scrubs. The ADM stated he instructed the DON to call staff who worked the relevant night shifts, start in-services, and conduct safe surveys. The DON stated she called staff who worked those shifts and that no staff knew anything about the bruises, but no written statements were available. The DON also stated she believed the bruises may have been caused by the lid of the bedside commode, and staff reported that Resident #4 often transferred herself to the commode despite requiring one-person assistance. The facility policy stated that all reports of abuse, including injuries of unknown origin, are to be thoroughly investigated and that findings of all investigations are to be documented and reported.
Failure to Document Bed Rail Use in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, specifically regarding the use of bed rails or grab bars. The resident, a male with severe cognitive impairment and multiple medical conditions including a history of traumatic brain injury, heart failure, diabetes, and hemiplegia, was observed using bilateral grab bars on his bed. However, the use of these grab bars was not documented in his care plan, which is a critical oversight given his complex medical needs and fall risk status. Interviews with the resident and facility staff revealed that there was no assessment or consent obtained for the use of the grab bars, which is a requirement according to the facility's policy. The Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) indicated that assessments for the safe use of bed rails or grab bars should be conducted at admission, and consent should be obtained from the resident or their representative. The absence of documentation and consent suggests a lapse in the facility's adherence to its own policies and procedures. The facility's policy on bed safety and bed rails emphasizes the need for interdisciplinary evaluation, resident assessment, and informed consent before the use of bed rails. The policy also requires that the care plan be updated to reflect any such interventions. The failure to include the use of grab bars in the resident's care plan placed the resident at risk of not having their individual needs met and not receiving necessary care and services, thereby compromising the continuity of care.
Inadequate Supervision During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure adequate supervision during a mechanical lift transfer for a resident, leading to a deficiency in care. The resident, a male with postural kyphosis, muscle weakness, and on long-term anticoagulants, required maximal assistance for transfers as per his care plan and physician's order. The care plan specified the use of a Hoyer lift with the assistance of two or more staff members for all transfers. However, an observation revealed that a CNA performed the transfer alone, contrary to the facility's policy and the resident's care plan. Interviews with staff indicated inconsistencies in training and adherence to the facility's mechanical lift policy. The CNA involved stated she was instructed by a preceptor to perform the transfer alone, despite the facility's policy requiring two-person assistance. Other staff members, including another CNA and an LVN, confirmed that they were trained to perform Hoyer lift transfers with two people and had not observed any staff performing the task alone. The DON acknowledged the policy and the need for consistent training, highlighting a gap in the preceptor's guidance to new staff.
Failure to Assess and Obtain Consent for Bed Rails
Penalty
Summary
The facility failed to properly assess the risks and benefits of bed rails and grab bars for two residents, Resident #29 and Resident #54, and did not obtain informed consent prior to their installation. For Resident #29, there was no documented assessment or signed consent form for the use of bed rails or grab bars, despite the resident's care plan indicating the use of 1/2 side rails for bed mobility and repositioning. Observations confirmed the presence of raised bed rails in Resident #29's room, but the resident was unavailable for interview due to being asleep or receiving personal care services. Resident #54 also lacked a signed consent form for bed rails or grab bars, although the care plan included the use of 1/2 side rails for bed mobility and repositioning. The resident, who had moderate cognitive impairment, was unable to recall if consent was given by himself or his son. Observations confirmed the presence of raised bed rails in Resident #54's room, and an interview with the resident did not clarify the consent issue. Interviews with facility staff, including the ADM, LVN I, and the DON, revealed inconsistencies in the assessment and consent process for bed rails and grab bars. The ADM acknowledged that the consent form was missing from the electronic health record, and the DON was unaware of the lack of assessments and signed consents for the residents. The facility's policy requires an interdisciplinary evaluation and informed consent before using bed rails, but these procedures were not followed for the residents in question.
Expired Insulin Found in Medication Room
Penalty
Summary
The facility failed to provide adequate pharmaceutical services in Med Room A, as observed during a survey. Specifically, an insulin pen, Insulin Lispro Injection 100 units per ml, was found in the fridge with an expiration issue. The pen was dispensed on 04/28/23, opened on 07/25/24, and was labeled to be discarded 28 days after opening. However, it was not discarded as required, and it did not have a resident's name on it. The Director of Nursing (DON) acknowledged that the insulin pen should have been discarded after 28 days and did not articulate the risk to residents for having expired insulin. Interviews with the DON and the Administrator revealed that the expired insulin was discarded immediately upon discovery. The facility's policy on medication labeling and storage, revised in February, mandates that multi-dose vials be dated and discarded within 28 days unless otherwise specified by the manufacturer. The DON stated that all nursing staff were responsible for maintaining the medication rooms and that moving forward, she and the Assistant Directors of Nursing (ADONs) would ensure compliance by conducting regular rounds.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of drugs and biologicals, as observed in Med Room B where a TB vaccine was found unlabeled and undated. The vaccine, Tuberculin Purified Protein Derivative, was open with the cap removed and lacked an open date, which is necessary to determine its expiration. Additionally, food items, specifically a yogurt belonging to a resident, were stored next to medications in the refrigerator, which is against the facility's policy. LVN D acknowledged the oversight and the potential risk of the vaccine's ineffectiveness due to the lack of proper labeling. In another instance, Med Cart C was found unlocked and unattended outside a resident's room, where residents and family members could potentially access it. The cart was left open while RN E attended to a resident inside the room, which is a violation of the facility's policy that requires medication carts to be locked when not in direct view. RN E admitted to leaving the cart unlocked because she intended to be away for only a short period, but acknowledged the risk of unauthorized access to medications and needles. The Director of Nursing (DON) and the Administrator were interviewed regarding these incidents. The DON confirmed that the facility's expectations were not met, as expired or undated medications should be discarded, and medication carts should be locked when unattended. The Administrator noted that there was another dated and active vaccine available, and only one yogurt was found in the fridge. The facility's policy clearly states that medications should be stored separately from food and that all compartments containing medications must be locked when not in use.
Inadequate Hand Hygiene During Resident Feeding
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CMA F, who did not perform hand hygiene while alternately feeding two residents. During an observation, CMA F was seen sitting between two residents, feeding them alternately without sanitizing her hands between interactions. This practice was contrary to the facility's infection control policies, which require hand hygiene to prevent the spread of infections. Resident #2, a female with severe cognitive impairment and multiple diagnoses including dementia and schizoaffective disorder, required assistance with all activities of daily living (ADLs) and was unable to understand or communicate effectively. Resident #7, also a female with severe cognitive impairment, had a history of falls and required substantial assistance with most ADLs. Both residents were in wheelchairs and needed help with their meals, which CMA F provided without adhering to proper hand hygiene protocols. Interviews with staff, including CMA F, LVN H, the DON, and the Administrator, revealed that while the facility's policy emphasized hand hygiene as a primary means to prevent infection, there was no specific guidance on feeding two residents simultaneously. Despite this, staff were expected to sanitize their hands between residents to avoid cross-contamination. The facility's hand hygiene policy, revised in October 2023, outlined the importance of hand hygiene before and after resident contact, but the Assistance with Meals policy did not address hand hygiene during feeding.
Failure to Secure Medication Carts
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access. Medication cart #1 was observed unlocked and unattended with six blister packs of medication cards left on top unsupervised by a medication aide for four minutes. Two residents were observed sitting approximately 2.5 feet away from the cart. The medication aide admitted to forgetting to lock the cart and stated that the overnight nurse had left the medication packs on top of the cart. Medication cart #2 was also observed unlocked and unattended for two minutes outside a resident's room, with the drawers facing the hallway where individuals passed by. The registered nurse responsible for the cart admitted to forgetting to lock it and was unaware that state surveyors were in the building. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that all medication carts should be locked when unattended to prevent unauthorized access and potential harm. The facility's policy on administering medications emphasized the importance of securing medications to prevent theft or resident access. The failure to lock medication carts and secure medications properly could lead to residents having access to unauthorized medications, posing a risk of harm or drug diversion.
Deficiencies in Respiratory Care Management
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents, leading to deficiencies in oxygen therapy management. Resident #82's oxygen tubing and nasal cannula were observed touching the floor and not bagged when not in use. Additionally, there were no medical orders for oxygen in the resident's electronic medical records, and the resident was unaware of her oxygen usage. The care plan did not address oxygen use, and the resident's oxygen equipment was not properly maintained or monitored by the staff, as confirmed by interviews and observations on the survey date. Resident #83's oxygen tubing was not changed weekly as ordered, and the resident's nasal cannula and water bottle were undated. The resident reported that the tubing had not been changed since her admission from the hospital. The facility's records confirmed that the tubing change was not documented in the electronic medical administration record (e-MAR) for the specified period. Interviews with nursing staff revealed a lack of adherence to the facility's protocol for changing and dating oxygen tubing and water bottles, which could lead to respiratory infections. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged the deficiencies in oxygen therapy management. They confirmed that the nursing staff is expected to change and date oxygen tubing weekly and document the changes in the e-MAR. The DON also stated that the ADON is responsible for auditing and monitoring nursing tasks for compliance. However, the facility failed to provide a policy for oxygen management when requested by the surveyor, indicating a lack of proper documentation and oversight in respiratory care practices.
Failure to Maintain a Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Specifically, Resident #82's room was observed to have smeared oatmeal on the floor, hard colorful candies scattered, and a blanket obstructing the walkway. This was noted during an observation and interview with the resident, who mentioned that she had spilled her breakfast and was waiting for staff to clean it up. The agency CNA who responded to the resident's call only partially cleaned the mess and did not notice the candies and blanket on the floor. Interviews with the RN, ADON, and DON revealed that the expectation is for all resident rooms to be free of clutter and hazards to prevent accidents and injuries, and that all staff are responsible for maintaining this standard and contacting housekeeping as needed. Resident #82, a [AGE] year old female with Alzheimer's disease, congestive heart failure, generalized anxiety disorder, and other mobility and cognitive impairments, was found in a room that did not meet the facility's standards for cleanliness and safety. The resident's care plan included monitoring for COVID-19 symptoms and preventing complications from cardiac disease. Despite these care directives, the resident's environment was not maintained in a manner that ensured her safety and comfort, as evidenced by the presence of food and obstacles on the floor, which could lead to falls and injuries.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bedford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westpark Rehabilitation And Living | 0.4 mi | ★★★★★ | 27 | 0 |
| Forum Parkway Health & Rehabilitation | 1.1 mi | ★★★★★ | 4 | 0 |
| Bedford Wellness & Rehabilitation | 1.1 mi | ★★★★★ | 16 | 0 |
| La Dora Nursing And Rehabilitation Center | 1.1 mi | ★★★★★ | 6 | 0 |
| Hurst Plaza Nursing & Rehab | 2.3 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.