Inspection visit
Health inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to ensure that residents received treatment and
care in accordance with professional standards of practice, the comprehensive person-centered care plan,
and the residents' choices for one (Resident #3) of three residents reviewed for quality of care.
Residents Affected - Some
The facility failed to schedule an appointment in a timely manner with a neurologist as ordered by Resident
#3's cardiologist.
This failure could place residents at risk of not receiving necessary medical care, harm, and hospitalization.
Findings included:
Review of Resident #3's undated face sheet reflected a [AGE] year-old male who was readmitted to the
facility on [DATE], with an original admission date of 11/29/24. Resident #3's diagnoses include: sleep
apnea (pauses/stops in breathing while sleeping), chronic obstructive pulmonary disease (difficulty
breathing), type II diabetes, mild cognitive impairment of uncertain or unknown etiology, cerebral infarction
(interrupted blood flow to the brain causing brain cell death) and PTSD (a mental health condition that
some develop after a traumatic event).
Review of Resident #3's five day scheduled assessment MDS, dated [DATE], reflected a BIMS score of 10,
indicating moderate cognitive impairment.
Review of Resident #3's EHR reflected a referral was faxed on 10/7/24 to the facility by the cardiologist for
an appointment with a neurologist.
Review of Resident #3's facility Physician Orders, revision date of 10/11/24, reflected an order for a
neurologist visit.
During an interview on 11/23/24 at 10:44 am with Resident #3 revealed he was having trouble getting the
facility to make an appointment, his cardiologist wants him to see a neurologist. Resident #3 stated the last
appointment he had with the cardiologist he was given a hard copy of the referral order which he gave to
the nurses. The first time the SW faxed the referral they put he had dementia as a diagnosis which I do not
have, so the neurologist would not see him. Supposedly, the SW faxed a new referral but said they are not
responding. Resident #3 stated he had a history of strokes, which is the reason he wanted the
appointment.
During interviews on 11/23/24 at 3:29 pm and on 11/25/24 at 12:25 pm, the facility SW stated the
(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 6
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
11/25/2024
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 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
first time she faxed the neurologist had been on 10/9/24 after she became aware of the cardiologist having
given a referral order. The SW believed the cardiologist made the referral because Resident #3 requested
to see the neurologist. She stated the first fax request was refused because they did not treat the
diagnoses listed on the referral that the cardiologist had given for Resident #3. The SW stated she
wondered if they just do not want to see him because he can be a difficult patient and they had seen him
before, so they were aware. On 10/11/24 she sent another fax requesting an appointment with different
diagnoses, both faxes had her number and she had requested a call back to make an appointment. She
stated they never called her back. The SW stated she was waiting for the call from them because that
named neurologist was included on the referral order. She left voicemails on the answering machine on
11/01/24 and 11/18/24 asking for a call back, but she had not documented the calls. She stated on
11/21/24 she and Resident #3 called the neurologist together and left another voicemail. The SW stated
she did not call the cardiologist to request a referral to a different neurologist because this specific
cardiologist is on the order .
During an interview on 11/25 10:40 am with Certified Medical Assistant at Resident #3's cardiologist office
stated there were many doctors these days that were not accepting new patients. She stated they
frequently would send the referral to a different doctor if they were notified the one listed was not available.
During an interview on 11/23/24 at 2:23pm and on 11/25/24 at 10:15 am the facility DON stated the SW
had been trying to get Resident #3 an appointment with a neurologist but the ones the SW had reached
had declined. The DON stated she did expect physician orders to be implemented timely but Resident #3
had been hospitalized since the referral and they did not continue to try to do a referral while the resident
was not in the facility.
During an interview on 11/25/24 at 10:05 am the Adm stated the referral for Resident #2 was sent twice but
the neurologist did not like the diagnoses that were on the referral. She stated in addition Resident #3 had
gone to the hospital a couple of times so no referrals occurred during that time. Adm stated they do
referrals regularly for residents, but she knows it takes a long time to get an appointment with a neurologist.
During an interview on 11/25/24 at 1:59 pm, Resident #3's NP stated the referral to the neurologist should
have followed up on sooner. He stated he would work with the SW and the facility to make sure the
appointment was made.
Review of the facility policy, undated, titled Resident Rights reflected the following: Planning and
implementing care - The resident has the right to be informed of, and participate in, his or her treatment,
including:
1.
The right to be fully informed in language that he or she can understand his or her total health status,
including but not limited to, his or her medical condition.
2.
The right to participate in the development and implementation of his or her person-centered plan of care,
including but not limited to:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675915
If continuation sheet
Page 2 of 6
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
11/25/2024
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 0684
a.
Level of Harm - Minimal harm
or potential for actual harm
The right to participate in the planning process, including the right to identify individuals or roles to be
included in the planning process, the right to request meetings and the right to request revisions to the
person-centered plan of care.
Residents Affected - Some
b.
The right to participate in establishing the expected goals and outcomes of care, the type, amount,
frequency, and duration of care, and any other factors related to the effectiveness of the plan of care.
c.
The right to be informed, in advance, of changes to the plan of care.
d.
The right to receive the services and/or items included in the plan of care.
e.
The right to see the care plan, including the right to sign after significant changes to the plan of care.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675915
If continuation sheet
Page 3 of 6
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
11/25/2024
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 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, and record review, the facility failed to ensure that residents who needed
respiratory care were provided such care, consistent with professional standards of practice, for 1 of 3
residents (Residents #3 ) reviewed for quality of care.
Residents Affected - Some
The facility failed to implement Resident #3's Care Plan which included the use of a CPAP for sleep apnea.
This failure could place residents at risk of not receiving necessary medical care, a decrease quality of
sleep and cardiovascular impairments.
Findings included:
Review of Resident #3's undated face sheet reflected a [AGE] year-old male who was readmitted to the
facility on [DATE], with an original admission date of 11/29/24. Resident #3's diagnoses include: sleep
apnea (pauses/stops in breathing while sleeping), chronic obstructive pulmonary disease (difficulty
breathing), type II diabetes, mild cognitive impairment of uncertain or unknown etiology, cerebral infarction
(interrupted blood flow to the brain causing brain cell death) and PTSD (a mental health condition that
some develop after a traumatic event).
Review of Resident #3's five day scheduled assessment MDS, dated [DATE], reflected a BIMS score of 10,
indicating moderate cognitive impairment. Section O (Special Treatments, Procedures, and Programs) did
not include the use of a CPAP.
Review of Resident #3's care plan, updated 10/29/24, reflected a focus area regarding Resident #3's use of
a CPAP/BIPAP during sleep for sleep apnea. The date of initiation of the focus is listed as 10/29/24.
Review of Resident #3's Physician Order Summary, undated, reflected an order to apply CPAP at night. The
order was discontinued 4/29/24. Review of Current and Active Physician Orders revealed there was not a
current order for a CPAP.
During an observation on 11/23/24 at 10:50 am of Resident #3's room, revealed a box of items and in the
room's closet there was not a CPAP machine in the room.
During an interview on 11/23/24 at 10:44 am with Resident #3 revealed he had concerns that he no longer
had his CPAP machine. He stated when he changed his room last time, they did not bring the CPAP to his
new room. Resident #3 stated he sometimes felt like he needed to use the CPAP, but he could not now.
Resident #3 stated they did not ask him if he wanted to use it anymore.
During an interview on 11/23/24 at 2:23 pm and on 11/25/24 at 10:15 am the facility DON stated Resident
#3 had not used a CPAP since she had been working at the facility the last couple of months. She stated
she has not seen any clinical indications that he needs a CPAP machine. The DON stated she did not know
if Resident #3 had a diagnosis of sleep apnea. She stated she did not know that Resident #3's care plan
included the use of a CPAP as it predates her employment.
During an interview on 11/25/24 at 10:05 am the Adm stated Resident #3 does not have a current
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675915
If continuation sheet
Page 4 of 6
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
11/25/2024
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 0695
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
order for the CPAP to be offered, but they plan to add it as a prn order. She did not know why it was
discontinued but suspected probably because he was noncompliant. Adm stated she did not know that the
care plan included the use of the CPAP. She does expect the care plan to be followed.
During an interview on 11/25/24 at 1:59 pm, Resident #3's NP stated he was not aware until recently that
the CPAP order had been discontinued. He had thought the CPAP was being offered nightly but knew
Resident #3 frequently refused treatments. The NP stated the CPAP had been found in the resident's
previous room. The NP stated that he knew the CPAP was previously in Resident #3's room when he would
visit with the resident because they had discussed if he was utilizing the CPAP and Resident #3 stated he
did not tolerate the CPAP . The NP stated they will be implementing a PRN order.
Review of the facility policy, undated, titled Resident Rights reflected the following: Planning and
implementing care - The resident has the right to be informed of, and participate in, his or her treatment,
including:
1.
The right to be fully informed in language that he or she can understand his or her total health status,
including but not limited to, his or her medical condition.
2.
The right to participate in the development and implementation of his or her person-centered plan of care,
including but not limited to:
a.
The right to participate in the planning process, including the right to identify individuals or roles to be
included in the planning process, the right to request meetings and the right to request revisions to the
person-centered plan of care.
b.
The right to participate in establishing the expected goals and outcomes of care, the type, amount,
frequency, and duration of care, and any other factors related to the effectiveness of the plan of care.
c.
The right to be informed, in advance, of changes to the plan of care.
d.
The right to receive the services and/or items included in the plan of care.
e.
The right to see the care plan, including the right to sign after significant changes to the plan of care.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675915
If continuation sheet
Page 5 of 6
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
11/25/2024
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 0695
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Review of the facility policy, undated, titled Comprehensive Care Planning reflected the following: The
services provided or arranged by the facility, as outlined by the comprehensive care plan, will meet
professional standards of quality. And In situations where a resident's choice to decline care or treatment
(e.g., due to preferences, maintain autonomy, etc.) poses a risk to the resident's health or safety, the
comprehensive care plan will identify the care or service being declined, the risk the declination poses to
the resident, and efforts by the interdisciplinary team to educate the resident and the representative, as
appropriate. The facility's attempts to find alternative means to address the identified risk/need should be
documented in the care plan.
Event ID:
Facility ID:
675915
If continuation sheet
Page 6 of 6
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
FAQ · About this visit
Common questions about this visit
What happened during the November 25, 2024 survey of Park Place Care Center?
This was a inspection survey of Park Place Care Center on November 25, 2024. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Park Place Care Center on November 25, 2024?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide safe and appropriate respiratory care for a resident when needed."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.