F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, and record review, the facility failed to provide a safe, clean, comfortable, and
homelike environment for 1 of 1 facility reviewed for safe, clean, and comfortable environment.
The facility failed to replace the countertop over a set of cabinets, for about a year, when remodeling in the
dining room.
This failure could place residents at risk for uncomfortable, unhomelike environment, and a diminished
quality of life.
Findings included:
Record review of an annual MDS assessment dated [DATE], Section A (Identification Information) reflected
Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. Section I (Active Diagnoses)
reflected diagnoses including cerebrovascular accident (stroke), non-Alzheimer's dementia, anxiety
(intense and excessive worry and fear), and depression (a mood disorder with persistent feeling of sadness
and loss of interest). Section C (Cognitive Patterns) reflected a BIMS score of 7 indicating severe cognitive
impairment.
An observation in the dining room on 10/31/24 at 10:30 AM revealed a set of cabinets along the wall near
the kitchen. The cabinets did not have a countertop. The top was partially covered with plywood. The
plywood was covered with stained green tablecloths and a bath towel. The area not covered by plywood
revealed two drawers and cabinet hardware. The drawers contained a napkin holder, two condiment
holders, a tin of dominoes, and various pieces of paper and debris.
During an interview on 10/31/24 at 12:40 PM, the Maintenance Director stated he did not know exactly
when the countertop was removed. He stated he had worked at the facility for a couple of months and the
countertop had been gone the whole time. He stated a replacement had been ordered but he did not know
when it was expected. He texted the ADM who then joined the interview. The ADM stated the countertop
had been removed a year ago when a previous company started a renovation. She stated a replacement
had been approved by the corporate office, and they were waiting for [company name] to build and install
the countertop.
During an interview on 10/31/24 at 12:58 PM, DS A stated she had worked at the facility for about seven
years. She stated the countertop in the dining room had been missing for about two years. She stated there
used to be a sink but that was removed when they started the remodel.
(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 2
Event ID:
675915
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
675915
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/31/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Park Place Care Center
121 Fm 971
Georgetown, TX 78626
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 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
During an interview on 10/31/24 at 2:33 PM, MA B stated in August 2023, there was a sink in the dining
room then in September 2023 they removed the sink and the countertop. She stated it did not look very
homelike without a countertop. She stated it had looked bad for a long time and residents had complained
about it in the past.
During an interview on 10/31/24 at 2:36 PM, Resident #1 stated she could not remember how long the
countertop had been missing. She stated it looked bad, junky. She wondered if it would ever be fixed.
During an interview on 10/31/24 at 2:40 PM, the ADM stated the facility had gone through several changes
in owners. A renovation had been started then it got delayed because of a change. She stated they were in
the process of getting the countertop replaced. She stated the current fix of covered plywood was doable
for now, but it was a sore sight. She stated she had talked with the Ombudsman about it and has one
resident that complained about the lack of a countertop. She stated it was not homelike. She stated she had
not seen any adverse effects to the residents other than the one resident complaining.
A review of the undated Residents Rights policy reflected in part, A facility must treat each resident with
respect and dignity and care for each resident in a manner and in an environment that promotes
maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The
facility must protect and promote the rights of the resident . Safe environment - The resident has a right to a
safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and
supports for daily living safely. The facility must provide-1. A safe, clean, comfortable, and homelike
environment, allowing the resident to use his or her personal belongings to the extent possible. a. This
includes ensuring that the resident can receive care and services safely and that the physical layout of the
facility maximizes resident independence and does not pose a safety risk. b. The facility shall exercise
reasonable care for the protection of the resident's property from loss or theft. 2. Housekeeping and
maintenance services necessary to maintain a sanitary, orderly, and comfortable interior .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675915
If continuation sheet
Page 2 of 2
