Inspection·December 12, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on the right side of the resident; there was a small metal clip on the call light bell's wire. The call light bell was not reachable with either of the resident's hands. This investigator exited the room to get a CNA to get a nurse to address the resident's pain. RN A entered the room to address the resident's pain. While in the room, RN A saw the location of the call light bell and stated, the call light bell was supposed to be close to the resident. She was observed placing the call light bell on the resident's bed and having attached the metal clip on the call bell's cord to her pillow. The RN told the resident, To press the button whenever she needed help. After RN A exited the room, further interview with Resident #88 revealed the location of the call bell, which was on the floor, made her feel sad. Interview on 12/12/2024 at 9:07 AM with CNA M, revealed residents had call light bells in their rooms to let staff know they had a need. Some examples of resident's needs were pain management, thirst, body adjustment, or a general health question. A resident's call light bell was supposed to be as close to the resident as possible, within arm's reach. The metal clip, which was attached to the wire, was supposed to clip on a stationary spot and secure the call light bell close. CNA M stated, No, the floor would not be an appropriate location for a call light bell. Negative outcomes for residents who could not call for help would be thirst, hunger, skin breakdown, and mental frustration. Safeguards in place to ensure residents had access to their call light were room rounds, spot checks, and training for proper call light bell placement before exiting the room. Observation on 12/12/2024 at 9:48 AM with Resident #88, revealed her in her room, sitting in her chair sleeping. No distress noted. Resident had her call light bell in her hand. Interview on 12/12/2024 at 9:55 AM with the DON revealed, facility staff was trained to make sure the resident's call light bell was always within the resident's reach. If the resident was in a chair, the call light bell would be accessible while in the chair. If the resident was in the bed, the call light bell would be accessible while in the bed. The use of the call light bell was a resident's right; and residents had needs. Some examples of resident needs were clothing change, hydration, or a general care concern. Resident who did not have access to call staff for help risked skin breakdown, other unmet needs, and frustration. An intervention in place, to ensure proper call light bell placement, was the use of manager rounds, regular room rounds, and training. Interview on 12/12/2024 at 11:29 AM with the ADM revealed, the facility did not have a call light bell policy. The facility trained staff was to ensure the call light bell was always within the resident's reach. An intervention in place, to ensure proper call light bell placement, was the use of management rounds, regular room rounds, and training. Negative outcomes for a resident unable to call for help could have resulted in their needs going unmet. Record review of the facility's Resident Right Policy, revised 11/28/2016, reflected resident had the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. Residents had the right to reside and receive services in the facility with reasonable accommodation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 2 of 25 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 12/12/2024 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 0567 Honor the resident's right to manage his or her financial affairs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to manage the personal funds of the resident deposited with the facility for 1 (Resident #25) of 5 residents reviewed for trust funds. Residents Affected - Few The facility failed to ensure Resident #25 had ready access to her personal funds upon request in a timely manner. This failure could place all residents whose funds are managed by the facility of not receiving funds deposited with the facility and not having their rights and preferences honored. Findings Included: Record review of Resident # 25 admission face sheet dated 12/12/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] and then readmitted on [DATE]. Resident #25 had diagnoses of non-pressure chronic ulcer of unspecified part of lower left leg, need for assistance with personal care, repeated falls, unspecified abnormalities of gait and mobility, hypertension, fibromyalgia (a long term condition that involves widespread body pain and tiredness), cognitive communication deficit, major depressive disorder, protein calorie malnutrition, intervertebral disc stenosis, rotator cuff tear of right shoulder, chronic pain syndrome, muscle weakness, borderline personality disorder, dementia, hypermetropia (farsighted), dysphagia(difficulty swallowing), anxiety disorder, hypothyroidism (underactive thyroid), osteoarthritis (degenerative joint disease), peripheral vascular disease (a circulatory condition with reduced blood flow to the limbs), and polyneuropathy (a condition that affects multiple peripheral nerves throughout the body simultaneously causing malfunction). Record review of Resident # 25 quarterly MDS dated [DATE] reflected a BIMS score of 15 indicating intact cognition. Resident # 25's vision was documented as adequate with no corrective lens usage under the Hearing, Speech, And Vision section of the MDS. Record review of Resident # 25's care plan dated 7/16/2024 indicated Resident # 25 had problem of impaired visual function with interventions of arrange consultation with eye practitioner as required. Monitor/document/report to MD the s/s of acute eye problems: change in ability to perform ADL's, decline in mobility, sudden vision loss, pupils dilated, gray or milky in eyes, complaints of halos around lights, double vision, tunnel vision, blurred or hazy vision. Review medications for side effects which affect vision. Resident # 25 will wear glasses as she chooses. Record review of Resident # 25's clinical physician orders dated 9/5/2023 with next review date to be 12/31/2024 reflected Resident # 25 had order stating may have ophthalmologist care PRN. Interview on 12/10/2024 at 3:30 p.m., Resident Council members revealed Resident # 25 stated they had some concerns with their personal funds being made available to them in a timely manner that they would like to discuss further privately. Interview on 12/11/2024 at 2:45 PM, the BOM stated residents can immediately receive amounts up to $75 anything above that requires a special request. The BOM stated if a request is received before noon, then request will be processed next day if request is received after noon, then request will be processed in 2 days. The BOM stated business hours are not posted but BOM works M-F 8 to 5. The BOM stated on the weekend the weekend supervisor is available Sat & Sun 8 to 5. The BOM stated after 5 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 3 of 25 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 12/12/2024 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 0567 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few no one is available to pass out funds. The BOM stated documentation is not posted about special requests only communicated verbally. The BOM stated if a request comes in at end of day and is needed for the next day residents would have to wait until the request was processed to receive entire amount requested. The BOM stated she would give resident the available amount she had at the time. BOM stated residents are given statements quarterly and can be given upon request. The BOM stated she never has any residents ask for amounts over $75 except one resident. The BOM remembers of one incident when one resident asked for amounts over $75 came and asked for money for a dentist appointment. The BOM told the resident since it was over the $75 amount a special request would have to be processed in order to receive a check, that the BOM could then go cash and be able to give the resident the cash requested. The BOM stated she was out of the office the next day due to being sick but when she came back BOM stated the resident was able to receive her funds. Interview on 12/12/2024 at 10:48 AM, Resident # 25 stated she does not remember the exact date but remembers she needed the money in October for a dental visit and was unable to receive the money in time for the dental visit. Resident stated the SW had set up the appointment and arranged transportation. Resident #25 stated after receiving confirmation of the appointment she went to the BOM to request the co-pay needed and was told by the BOM that the facility did not have that amount of money on hand and a request would have to be submitted to get a check issued for the amount. The resident stated she told the BOM the appointment date and was told the money would be available. The resident stated the day of the appointment came, and she had not received the co-pay amount, so she went to the BOM office and the BOM was out of the office on the day of her appointment and was unable to be reached by anyone at the facility. Resident #25 stated her appointment had to be canceled due to not having the funds available for the co-pay. The resident stated Medicaid does not cover her implants, so she must pay out of pocket for the co-pay. Resident #25 stated she received the money a few days later after her appointment had been canceled due to funds not being available on the day of her appointment. Interview on 12/12/2024 at 11:03 AM, the SW revealed she was aware Resident # 25 had a dental visit scheduled for 10/11/24 and was unable to attend due to not having the co-pay amount. No new visit had been scheduled. Interview on 12/12/2024 at 12:19 PM, the BOM revealed there are other staff at the facility that have access to the financial system to be able to print the check and take it to the bank to cash so residents can have their money. The BOM stated the ADM had access and the SW could have been walked thru the process to print a check for residents to receive funds in a timely manner. Interview on 12/12/2024 at 4:55 PM, the ADM it was their expectation that concerning residents' personal funds that residents should be able to receive their funds according to policy. The ADM stated by residents not being able to receive their personal funds this could negatively affect them by the residents would be unable to pay for whatever they are trying to pay for. Record review of Trust fund policy and procedure dated 3/25/2024 reflected: Objective: The objective is to ensure that proper procedure is followed for the daily record keeping of the resident trust fund. The petty cash kept in the business office will be a designated amount per facility that must be signed for by either the resident or the court appointed Guardian for disbursement. Funds Availability: The trust fund will be accessible during normal business hours M-F 8 to 5. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 4 of 25 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 12/12/2024 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 0567 Trust Withdrawals: Level of Harm - Minimal harm or potential for actual harm Cash Disbursement log: Residents Affected - Few The form is to be started with a beginning balance after the last replenishment and a running of the cash box after each disbursement. Records of cash disbursements are to be recorded on the trust petty cash disbursement log; each cash transaction must be signed by the resident. All withdrawal transactions should be entered into software system daily. When applicable trust fund petty cash will need to be replenished and the disbursement log totaled. The sum of the distributed cash on the disbursement log will equal the amount in which the cash replenishment check should be written for. This should balance to the amount in the software system for the petty cash vendor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 5 of 25 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 12/12/2024 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 0576 Ensure residents have reasonable access to and privacy in their use of communication methods. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that the residents had the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the residents through the means other than a postal service for 2 (Resident #14 and Resident #253) of 11 residents in a group meeting reviewed for resident rights. Residents Affected - Few The facility failed to ensure Residents #14 and #253 received packages unopened. This failure could affect residents by placing them at risk of not receiving packages unopened that could result in residents experiencing diminished psychosocial well-being and quality of life. The findings included: Record review of Resident # 14's admission face sheet dated 12/12/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] with a readmission date of 05/02/2023. Resident # 14 had diagnoses of spondylosis without myelopathy or radiculopathy cervical region(age related wear and tear of spinal discs), muscle weakness, major depressive disorder, chronic pain, need for assistance with personal care, morbid obesity, anxiety disorder, hypokalemia (low potassium), spinal stenosis (spinal narrowing), cognitive communication deficit, polyneuropathy (a condition that affects multiple peripheral nerves throughout the body simultaneously causing malfunction), obstructive sleep apnea, type 2 diabetes, irritable bowel syndrome, gastro-esophageal reflux disease, muscle wasting and atrophy, hyperglycemia, and diverticulitis ( an inflammation or infection in one or more small pouches in the digestive tract). Record review of Resident # 14's Quarterly MDS dated [DATE] reflected a BIMS score of 15 indicating intact cognition. Record review of Resident # 253's admission face sheet dated 12/12/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident # 253 had diagnoses of hemiplegia and hemiparesis (muscle weakness or partial paralysis) following cerebral infarction affecting left dominant side, major depressive disorder, muscle weakness, opioid abuse in remission, repeated falls, alcohol abuse in remission, chronic pain syndrome, cardiomegaly, chronic pulmonary edema, atherosclerotic heart disease, benign prostatic hyperplasia, chronic pain syndrome, mild cognitive impairment, post-traumatic stress disorder, morbid obesity, type 2 diabetes, congestive heart failure, respiratory failure with hypoxia, hypertension, cognitive communication deficit, bipolar disorder, anxiety disorder, cerebral infarction, and protein calorie malnutrition. Record review of Resident # 253's Quarterly MDS dated [DATE] reflected a BIMS score of 13 indicating intact cognition. During Resident Council interview on 12/10/2024 at 3:30 PM, Resident # 14 and Resident # 253 had concerns about when they receive packages that the packages was already opened upon receipt. Resident # 14 and Resident # 253 both stated they wished to discuss this matter further in private. Interview on 12/11/2024 at 2:02 PM, Resident # 14 stated usually someone in the business office checks the mail and gives it to them. Resident # 14 stated it is never one person, it is whoever checks it that day. Resident # 14 said the packages are usually open and it may be due to someone that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 6 of 25 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 12/12/2024 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 0576 Level of Harm - Minimal harm or potential for actual harm hurt themselves at the facility, so they check the packages. Resident # 14 stated she thinks it is for safety purposes. Resident # 14 stated the resident was in the 200 hall, but that resident moved somewhere else from what she knows and Resident # 14 thinks the facility is just being cautious. Resident # 14 stated the mail or letters are not opened just the packages. Resident # 14 stated the only concern they have with the packages being opened is that she wants to make sure she always receives everything she orders. Residents Affected - Few Interview on 12/12/2024 at 10:17 AM, Resident # 253 stated staff opens packages because they fear contraband or anything that can cause harm. Resident # 253 stated staff took away resident's nail clippers and anything that can cause harm to self or others. Resident # 253 stated that he ordered a hammer in which staff took it away when it was delivered. It was a small hammer and he demonstrated with his hands measuring approximately about 7 to 8 inches. Resident # 253 stated wanted to hang stuff on his wall that is why he ordered a hammer, but they took it away from him. Resident # 253 stated he feels that this started when the new Administrator started around 4 months ago. Resident # 253 stated staff never open the letters or any mail besides packages. Resident # 253 stated has heard concerns from other residents in the facility but could not provide names. Resident # 253 stated staff opens the packages in front of him or he will get packages already opened sent to him in his room. Resident # 253 stated he has addressed it with the facility. Resident # 253 stated its always different individuals bringing his packages, he feels they are being nosey. Resident # 253 stated it makes him feel like they are invading his privacy. Resident # 253 stated it makes him feel like himself and other residents are animals in a zoo. Interview on 12/12/2024 at 10:27 AM, the BOM stated when residents receive mail, she checks the mail and then takes it to the residents. The BOM stated as for packages any staff member that answers the facility door can receive a resident package. The BOM stated packages are then left at the receptionist desk until receptionist or transportation driver take package to resident rooms. The BOM stated resident mail and packages are to be delivered unopened. The BOM stated when they deliver mail or packages, they stay in the room for a few minutes to see if the resident needs any assistance opening the package or having mail read to them. Interview on 12/12/2024 at 4:55 PM, the ADM stated her expectations is for mail and packages to be delivered unopened. The ADM stated packages are received by any staff that answers the front door then taken to the reception desk to be delivered to residents by the BOM or AD. The ADM stated that residents receiving packages opened could negatively affect them depending on what is in the package they are receiving. Record review of Residents Rights undated reflected: Exercise of Rights-The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. Information and Communication: 7. The resident has the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through means other than the postal service. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 7 of 25 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 12/12/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and records reviewed, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment reviewed for care plans for 1 of 4 (Resident #47) reviewed for daily activities. The facility failed to ensure Resident # 47's care plan addressed daily activities. This failure placed residents at risk of social isolation and diminished quality of life. Findings included: Record review of Resident # 47's face sheet dated 11/20/2024 reflected an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Parkinson's Disease, Fracture of one Rib, Fracture of Pubis(one of three bones that make up the hip bone and pelvis), Displaced Intertrochanteric Fracture of Femur (a break in the upper thigh bone), Polyneuropathy(a condition that affects multiple peripheral nerves throughout the body simultaneously causing malfunction), Type 2 Diabetes Mellitus, Atherosclerotic Heart Disease (coronary artery disease), Depression, Dysthymic Disorder,(persistent depressive disorder) Cognitive Communication Deficit, Muscle Weakness, and History of Falling. Record review of Resident # 47's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 99 due to the resident was unable to complete the interview indicating significant cognitive impairment. Under Mood heading Social Isolation documented as Sometimes. No documentation recorded under Behavior heading. Record review of care plan for Resident # 47 dated 10/31/2024 reflected no documentation regarding daily activities. During an observation and interview on 12/09/2024 at 11:37 AM, Resident # 47 was observed in bed watching television. Refused to answer questions, stating he was busy. No concerns or red flags noted. Call light was within reach, and the room environment was appropriate with no foul odors. During observation on 12/09/2024 at 1:11 PM, Resident # 47 was in bed, not participating in activities or socializing. No indication of activities being offered, and resident appeared isolated. During an observation on 12/10/2024 at 10:07 AM, Resident # 47 was observed sleeping in bed. Call light was on the wheelchair next to the bed. Cell phone was charging on the bedside table. No safety or environmental concerns noted. During an observation and interview on 12/12/2024 at 10:30 AM, Resident # 47 was laying down in bed to themselves. An additional attempt to interview Resident # 47 took place, but resident declined, stating that they did not wish to answer questions moving forward. In an interview on 12/10/2024 at 10:14 AM, CNA A stated stated Resident # 47 prefers to stay in bed and sometimes refuses care, medications, or meals. Resident # 47's daughter visits to provide (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 8 of 25 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 12/12/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm support. CNA A reported no concerns about Resident # 47's care or treatment and stated that the residents isolation would not negatively impact their quality of life. In an interview on 12/10/2024 at 12:26 PM, LVN A stated that Resident # 47 occasionally leaves the room and participates in activities or socialization on certain days. Residents Affected - Few In an interview on 12/12/2024 at 10:45 AM, with the Activity Director stated sometimes Resident # 47 leaves their room to visit the dining area or lobby but does so on their own terms. Resident prefers cereal and milk over regular meals. Resident does not engage much with staff or other residents. Not care-planned for 1:1 activity due to resident refusal, but staff check on and motivate the resident daily. Resident # 47 had a private caregiver who the resident listens to more than staff, but the resident has exhibited discriminatory behavior, refusing care from staff of color. In an interview on 12/12/2024 at 2:11 PM, the Administrator stated baseline care plans are expected to be completed within 24 or 48 hours depending on the date of admission, 2 weeks for a comprehensive care plan, and do a more long-term care plan for the resident. Administrator stated if a resident does not have a care plan area for activities, it would be educated to them and completed immediately. Administrator stated depending on the individual, if not having a certain care plan, it would cause isolation or effect their quality of life. It is their expectation as the Administrator to have the Activity Director to learn what the resident likes and does not like, and once they figure out what the resident may or may not like, they are to make a certain activity care plan area to be addressed. They can adjust the activities and outings every other week on the calendar. Record review of the facility Comprehensive Care Planning policy undated reflected that each resident in a facility has a person-centered, comprehensive care plan addressing their medical, nursing, mental, and psychosocial needs. Care plans must respect resident rights and preferences while focusing on their highest practicable quality of life. Key Components of the Comprehensive Care Plan: 1. Content: Goals for admission and desired outcomes. Services to maintain or improve well-being. Specialized services or rehabilitative needs per PASARR findings. Discharge preferences and planning, including the potential for community return. 2. Development: Based on assessments identifying risks, needs, and preferences. Collaborative effort involving the interdisciplinary team, resident, and representative. Must be initiated within 7 days of completing a comprehensive assessment. 3. Implementation: Documented interventions to achieve measurable objectives for the resident's goals. Include alternatives for residents who decline treatment or services. Reflect ongoing adjustments for changing resident needs and preferences. 4. Interdisciplinary Team: Includes the attending physician, registered nurse, nurse aide, nutrition staff, and others relevant to the resident's care. Must involve the resident and representative, with documentation if their participation is not practicable. 5. Ongoing Review and Updates: Care plans are reviewed and updated after Admission, Quarterly, Annual, or Significant Change MDS assessments to address changes in goals, preferences, or needs. Person-Centered Approach. Recognizes residents as the center of control. Supports individual choices in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 9 of 25 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 12/12/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete daily routines and activities. Facilitates resident and representative participation through advance notice, flexible scheduling, and alternative communication methods. 6. Standards and Quality Assurance: Care must adhere to professional standards of practice, delivered by qualified personnel. Facility must provide evidence-based services aligned with guidelines from professional organizations or clinical literature. This policy emphasizes individualized care, regular communication with residents and representatives, and adherence to high standards to ensure each resident's well-being and dignity. Event ID: Facility ID: 675915 If continuation sheet Page 10 of 25 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 12/12/2024 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 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 1 (Resident #66) of 3 residents reviewed for quality of care. Residents Affected - Few The facility failed to ensure repairs was made to Resident #66's custom wheelchair in a timely manner. This failure could place residents at risk of not receiving care to maintain optimum health and placing them at risk for decline in health. Findings included: Record review of Resident # 66's admission face sheet dated 12/12/2024 reflected a [AGE] year-old female admitted to the facility on [DATE]. Resident # 66 had diagnoses of Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (muscle weakness and partial paralysis following stroke affecting right dominant side), cerebral infarction (stroke), dysphagia (difficulty swallowing), seizures, anxiety disorder, polyneuropathy(a condition that affects multiple peripheral nerves throughout the body simultaneously causing malfunction) , ataxia (impaired coordination), protein calorie malnutrition, aphasia (a language disorder affecting one's ability to communicate), hypertension (high blood pressure), gastro-esophageal reflux disease (acid reflux), dysarthria (slurred speech), muscle weakness, need for assistance with personal care, history of falling, speech and language deficits following cerebral infarction, major depressive disorder, and abnormalities of gait and mobility. Record review of Resident # 66's Quarterly MDS dated [DATE] reflected a BIMS score of 13 indicating intact cognition. Under section functional abilities documented Resident # 66 has limited range of motion in upper and lower extremities. Mobility device documented as wheelchair. Resident # 66 is documented as partial/moderate assistance for transfer, personal hygiene, upper body dressing, putting on/off footwear, and toileting hygiene. Resident # 66 is documented as substantial/maximal assistance for lower body dressing and shower/bathe self. Record review of Resident # 66's care plan dated 09/03/2024 reflected problem of ADL self-care performance deficit impaired balance, limited mobility, stroke. Interventions of 1 person staff assist for transfer, bed mobility, and bathing. The resident uses a wheelchair. Resident # 66 has limited physical mobility related to contractures, stroke, and neurological deficits. Interventions of mobility the resident is totally dependent on staff for ambulation/locomotion. Resident uses a wheelchair for locomotion. Monitor/document/report signs and symptoms of immobility: contractures forming or worsening, thrombus formation, skin breakdown, and fall related injury. Observation on 12/12/2024 at 10:46 AM, Resident # 66's personal wheelchair was outside of room in hallway with sign on back stating awaiting repair therapy dated 8/2024. Interview on 12/10/2024 at 10:46 AM, Resident # 66's RP revealed the resident had brought the concern up about the residents' custom wheelchair that was broken and been sitting in her room for 3 months awaiting repair. RP stated she had been told it is still awaiting repair but had been given no time frame. Resident is currently using a loaner wheelchair, but it is not custom made for her to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 11 of 25 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 12/12/2024 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 address her ROM limitations and provide the needed support. Level of Harm - Minimal harm or potential for actual harm Interview on 12/12/2024 at 11:03 AM, the SW revealed Resident # 66's RP contacted the SW yesterday with concerns about wheelchair repair for Resident # 66's custom wheelchair. The SW stated the DOR said they had conducted a video conference with the repair people about getting the wheelchair repaired no estimated timeframe for repair was given. The SW did not have date the video conference was held. Residents Affected - Few Interview on 12/12/2024 at 11:23 AM, the DOR revealed the initial report about Resident # 66's wheelchair needing repair was received on 8/21/24 when a video conference call was held with repair company. The DOR unsure of repair status at this time stated she would have to contact the BOM to see about financial status. Interview on 12/12/2024 at 3:45 PM, the OT revealed they held the initial conference call with the repair company to start the repair process for Resident # 66's custom wheelchair. The OT stated there had been no communication from the repair company since the initial repair call was held. OT stated she does not feel it could negatively affect the resident since a loaner chair had been provided that was the correct size for Resident # 66. Interview on 12/12/2024 at 3:45 PM, the DOR revealed Resident # 66 was no longer on therapy. The DOR stated after the initial repair call was made and the resident was provided a loaner wheelchair that fit her then it was basically in the hands of the repair company to take the steps and complete a repair invoice and send it to the facility at which time it would be reviewed and the payer source would be identified and payment would be secured then company would come out and make repairs to the wheelchair. The DOR stated no repair invoice had been provided to the facility. The DOR stated after the initial call made on 8/21/24 no communication was attempted from facility until the DOR asked the BOM on 10/23/24 to reach out to the repair company to inquire if they had a repair invoice and when repairs would be made. The DOR stated the BOM told the DOR today on 12/12/24 that the repair company had not replied to her email inquiry. The DOR asked the BOM to reach out to the repair company again today and see if she gets a response of a repair invoice being provided and an estimation as to when repairs will be completed. Interview on 12/12/2024 at 4:55 PM, the ADM revealed it was their expectation that a call to the service company to have repairs made and to follow up with repair company until repairs are completed. The ADM stated yes this could negatively affect residents. The ADM stated it would depend on the repair needed of the wheelchair as to how it could negatively affect the resident. Attempted record review of positioning/ mobility equipment policy unavailable as ADM stated the facility does not have a specific policy covering this situation. Policy was requested on 12/12/2024 at 4:55 PM during interview with ADM. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 12 of 25 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 12/12/2024 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 residents that required respiratory care were provided such care consistent with professional standards of practice, person-centered care plan, and resident's goals and preferences for 1 of 2 residents (Resident #253) reviewed for respiratory care. Residents Affected - Few The facility failed to maintain Resident #253's BIPAP (Bilevel Positive Airway Pressure) machine in an unusable condition. This failure could place residents at risk of complications from respiratory distress. Findings included: Record review or Resident #253's AR, dated 10/10/2024, reflected a [AGE] year-old male. He admitted to the facility on [DATE]. He was diagnosed with Respiratory Failure (which was a medical condition where the lungs could not deliver enough oxygen to the body or removing enough carbon dioxide from the body) and Other Sleep Apnea (which was a medical condition marked by throat muscles having relaxed and having blocked the person's airway.) Record review of Resident #253's Discharge MDS Assessment, dated 11/15/2024, reflected the resident had a BIMS Score of 14 which indicated the resident had no cognitive impairment. Record review of Resident #253's CCP reflected a Focus area for BiPAP machine use, initiated on 10/29/2024, R/T Sleep Apnea. The Focus area reflected the resident disliked using the BiPAP machine and did not use it. The BiPAP use was PRN and resident used at their discretion. The Goal, revised on 11/25/2024, reflected oxygen saturations goals of 90 percent or better. The Intervention, revised on 11/25/2024, delegated the resident to use BiPAP machine as ordered. Record review of Resident #253's Order Summary Report reflected an order, started on 11/25/2024, for BiPAP use at bedtime every 24 hours as needed. The order reflected the resident had never complied with wearing device, offer nightly, document refusal. Interview and observation on 12/09/24 at 1:17 PM with Resident #253, revealed him in his room on his bed. He was clean, no orders in room, and no distress noted. Resident #253 stated, I have a doctor's order for BiPAP therapy. Observations of the resident's BiPAP machine revealed the machine on a sink counter several feet from the resident's bed. The machine had no wall outlet plug; the head gear did not have a nasal mask; and the filter for the air intake was discolored and dirty. Prior to having received the order for PRN BiPAP on 11/25/2024, the resident had possession of a BiPAP machine. His BiPAP machine was in the resident's storage at the facility. He stated staff brought him his BiPAP machine from storage, on 11/25/2024, without an outlet plug; the head gear without a nasal mask; and the discolored and dirty air intake filter. He stated the BiPAP machine would not operate in the condition it was in. He stated he had been non-compliant with the BiPAP machine in the past, and even refused to wear it, but he would like to wear it now. He stated he was angry the staff had not helped him with his BiPAP machine. Observation on 12/12/2024 at 8:40 AM, revealed Resident #253's BiPAP machine on a sink counter several feet from the resident's bed. The machine had no wall outlet plug; the head gear did not have a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 13 of 25 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 12/12/2024 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 nasal mask; and the filter for the air intake was discolored and dirty. Level of Harm - Minimal harm or potential for actual harm Interview on 12/12/2024 at 10:30 AM with the DON revealed, the resident had a PRN order for his BiPAP machine use, which started on 11/25/2024. Prior to 11/25/2024, the resident's BiPAP machine had been in resident storage. The DON stated she returned the BiPAP machine, from storage, to the resident with all the required pieces on 11/25/2024. The resident did not report to the DON personally, but the DON later heard he was missing a power cord to his machine. The DON stated the general upkeep of the BiPAP machine was left to the resident, and the company who provided it. Residents Affected - Few Interview on 12/12/2024 at 2:45 PM with LVN B revealed that the resident's BiPAP cord was found earlier today, 12/12/2024, in a drawer in his room. She plugged it in, and it worked. The machine was still missing nasal mask and a clean filter. LVN B stated the facility had the responsibility to make sure resident's BiPAP machine was working properly. LVN B stated the MRC was getting the required parts to make Resident #253's BiPAP machine work properly. Interview on 12/12/2024 at 3:39 PM with the ADM revealed, the facility staff was trained per policy on resident's BiPAP machine care. The facility's responsibility for resident's BiPAP machines was to provide ongoing therapy and clean the BiPAP system. The upkeep was the facility's responsibility as well as to communicate to the supplier any issues and concerns. Safeguards in place to make sure residents BiPAPs worked properly was manager room rounds and regular equipment maintenance. Resident #253 had been non-compliant with BiPAP therapy in the past; but his non-compliance did not equate his machine did not have to work properly. It was the resident's choice to use the BiPAP or not, it was the facility's responsibility to make sure the BiPAP worked. Interview and observation on 12/12/2024 at 5:20 PM with MRC revealed, the required pieces for the resident's BiPAP machine were bought from a local drug store. The BiPAP machine was fully operational. Observations in Resident #253's room reflected Resident #253 with the new BiPAP machine equipment. He was being test fitted for the face mask, the power cord was supplying power, and the air filter was new. Resident #253 stated the facility had addressed his needs with the BiPAP machine and that he was satisfied. Record review on 12/12/2024 of https://www.Sleepfoundation.org ; BiPAP machines was a device to provide a form of positive airway pressure therapy, which used compressed air to open and support the upper airway during sleep. A portable machine generated the pressurized air and directed it to the user's airway via a hose and mask system. Record review of the facility's Respiratory BiPAP/CPAP Policy, dated 7/1/2007, reflected the facility provided ongoing BiPAP Therapy by applying mask to resident, adjusting for comfort, assess for tolerance, and note adverse reactions. The facility provided BiPAP machine maintenance weekly by cleaning the outside of the machine, wash, and rinse face mask with warm soapy water solution, hand wash cloth parts with mild detergent, replace face masks as needed, and change intake filter per manufacturers instructions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 14 of 25 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 12/12/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. 1.The facility failed to ensure sanitation practices was occurring including cleaning the ice machine, cleaning the microwave, cleaning the meat slicer and utilizing a meat slicer that had a rusty slicing blade, having trash receptacles without lids secured, having ingredient bins with scoops in them, utilizing a ice scoop holding receptacle with no lid and that had dirt and debris in the bottom touching the ice scoop, cleaning the juice gun nozzle, and proper hair restraints. 2.The facility failed to label and date all food items in the kitchen. 3.The facility failed to have hand wash sinks that did not leak. 4.The facility failed to ensure food items was covered, secured, and stored properly. These failures could place residents at risk of foodborne illness. Findings included: Observation on 12/9/2024 at 9:12 AM, of the kitchen revealed the hand washing sink outside of dish room to be leaking when in use from the pipes underneath. Observation on 12/9/2024 at 9:14 AM, of the kitchen microwave revealed the interior top of the microwave to not be clean. Interior top had what appeared to be dried splattered food debris caked on surface. Observation on 12/9/2024 at 9:15 AM, of kitchen meat slicer revealed the slicer to be dirty with what appeared to be dried food debris on the slicing arm near blade. Further observation revealed the slicing blade to be rusty. Observation on 12/9/2024 at 9:16 AM, of kitchen preparation area revealed a 55-gallon trash can in preparation without a lid. Observation on 12/9/2024 at 9:20 AM, of kitchen walk-in freezer revealed the following: -Box contained what appeared to be 1 bag of frozen hushpuppies unsealed not labeled and dated, -1 bag of what appeared to be breaded onion rings not labeled and dated, -1 bag of what appeared to be breaded chicken tenders unsealed not labeled and date, -1 bag of what appeared to be breaded fish fillets not labeled and dated, -1 bag of broccoli cuts not labeled and dated, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 15 of 25 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 12/12/2024 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 0812 -1 bag of what appeared to be individual cherry pies unlabeled and undated. Level of Harm - Minimal harm or potential for actual harm Observation on 12/9/2024 at 9:22 AM of kitchen revealed a 55-gallon trash can near the door of the dry storage without a lid. Residents Affected - Some Observation on 12/9/2024 at 9:23 AM of kitchen dry storage area revealed: - an open bag of brown sugar unlabeled and undated, -an opened bag of bowtie pasta unlabeled and undated, -an opened bag of macaroni pasta unlabeled and undated, -an opened bag of yellow cake mix, unlabeled and undated inside of a gallon storage bag, -an opened bag of cherry gelatin dated 11/1 unsure if this is open date or discard date inside a gallon storage bag with a plastic spoon in storage bag with dry gelatin mix on spoon, -an opened bag of granulated peanuts dated 4/1/24 unsure if this is open date or discard date inside a gallon storage bag, -an opened bag of pistachio pudding mix, dated 8/22 unsure if this is open date or discard date inside a gallon storage bag, a gallon storage bag with an opened bag of cocoa and powdered sugar with a date on the gallon storage bag of 2/1/24 unsure if this is open date or discard date or for which product this is for, and -2 packages of tortillas unlabeled and undated. Observation on 12/9/2024 at 9:28 AM, of chest deep freezer revealed what appeared to be 2 unopened bags of tater tots unlabeled and undated, 1 unopened bag of what appeared to hushpuppies unlabeled and undated, 2 unopened bags of chicken nuggets unlabeled and undated. Observation on 12/9/2024 at 9:30 AM of kitchen hand washing sink by preparation table leaking from faucet. Observation on 12/9/2024 at 9:31 AM of kitchen storage bin of sugar with scoop inside of bin pushed halfway down into sugar. Observation on 12/9/2024 at 9:31 AM of kitchen storage bin of tea bags uncovered, unlabeled, and undated. Observation on 12/9/2024 at 9:33 AM of kitchen ice scoop storage receptacle revealed storage receptacle did not have lid and storage receptacle to have what appeared to be a black mold substance and white string in the bottom of the storage receptacle. Observation on 12/9/2024 at 9:35 AM of kitchen ice machine revealed seal on top of ice machine door to have a crack in it approximately 2 inches long. Further observation revealed ice machine to have what appeared to be a brown, black, and white mold type substance on the inside door and inner (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 16 of 25 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 12/12/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm upper wall of ice machine. A pink and black mold type substance was observed on the inside on the shield to guard where the ice falls from. Observation on 12/9/2024 at 9:40 AM of kitchen juice gun nozzle revealed an orange and red substance buildup on the inside of the juice gun. Residents Affected - Some Observation on 12/10/2024 at 9:25 AM of kitchen revealed DM wearing a ball cap as hair restraint with hair extending below ball cap approximately 2 inches. Observation on 12/12/2024 at 4:30 PM of kitchen revealed [NAME] F with beard guard under chin and beard exposed. Interview on 2/12/2024 at 1:49 PM, of kitchen DM revealed DM was asked about cleaning logs/ cleaning schedule, labeling, and dating policy, ice machine cleaning log and or policy, and hair restraint policy. DM stated that he will get them for me. DM stated they do in-service online trainings, but he cannot see them. DM stated his expectation is to have everything in the kitchen, and for the kitchen to be clean and sanitized as well as for it to remain a safe environment. DM stated if the kitchen and dining is not cleaned or sanitized appropriately, it may cause foodborne illnesses. DM stated that the kitchen staff follow the first in and first out policy for all food products unless it has a used by date printed on it. DM stated if food was not appropriately labeled or dated, it can be bad to give out that food or give someone the wrong food if you do not know what it is. DM stated that his expectation is anyone that enters the kitchen area is to wear hair nets as you can have food fall in the food during preparation and can cause cross contamination. DM stated the food slicer is cleaned after each use, there is no logs to track who cleans it after usage, but if there was any leftover food on it, they would clean and sanitized before usage. DM stated as for rust on the food preparation equipment such as, the food slicer, he does not know what exactly rust would do to the residents since he is not a medical professional. DM stated that he thinks if rust is directly consumed by an individual, it could harm the individual, but he does not know in what way. Interview on 12/12/2024 at 4:30 PM, revealed [NAME] F stated that everyone who enters the kitchen must wear a hair restraint. [NAME] F stated that for staff members with facial hair a beard guard must be worn to cover the facial hair. [NAME] F stated they were trained about hair restraints upon hire. Interview on 12/12/2024 at 4:45 PM, revealed the DM stated they do not complete daily or monthly cleaning logs. DM states they only complete the weekly logs. DM states the ice machine interior was cleaned last month. DM stated there is no documentation of the ice machine cleaning log as they do not keep that log. Interview on 12/12/2024 at 4:55 PM, revealed the ADM stated for general kitchen sanitation and cleaning that their expectation was that the kitchen staff would follow company policies. ADM stated if policies for general kitchen sanitation and cleaning are not followed that this could negatively affect residents by uncleanliness. ADM stated concerning hair restraints she expects everyone who enters the kitchen is required to wear a hair restraint and beard restraint, for staff wearing hats hair restraint would be required if hair extends out from hat and is shoulder length. The ADM stated by staff not wearing hair restraints it could negatively affect residents by hair getting into the food. ADM states they expect all kitchen equipment to be properly maintained according to manufacturer and policies. ADM was unsure how rust on a meat slicer blade could be a negative effect on residents besides possibly not cutting the meat properly. ADM stated her expectation regarding food labeling (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 17 of 25 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 12/12/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and dating is that all food items was labeled and dated and that the company policies was being followed. ADM stated it could negatively affect residents if food is not being labeled and dated by residents possibly getting sick. Record review of Food Storage and Supplies policy undated reflected: All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin, and insects. Procedure: 3. Dry bulk foods (example: flour, sugar) are stored in seamless metal or plastic containers with tight covers or bins which are easily sanitized. Containers are labeled. Best practice is that scoops should not be left in food containers or bins, but if so, handles should be upright and not contacting the food item. Containers are cleaned regularly. 4. Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened. 6. When items are received from the vendor, they should be first examined for expiration date, and if an expiration date is present, it is beneficial to mark it by circling it so it is readily visible and noticeable. It is important to distinguish between an expiration date and a production date, or a best by or use by date. Production dates indicate when the product was manufactured, not when it expires, and should not be interpreted as a best by or use by date. Best by or use by dates indicate when a product will have best flavor or quality and are not an indicator of the product's safety. As the quality may deteriorate after the date passes, the dietary manager should closely inspect any products that are past the best by date to determine if they are still good quality. If in doubt, discard the product. If any stamped date is unclear, contact the food vendor for clarification. If an item does not have a date designated by the manufacturer as an expiration date, then the item should be dated as to when it is received, and shelf-stable items will be stored in a first in, first out manner, to be used within one year. After one year, any product that is shelf stable will be inspected by the dietary manager to ensure that it is good quality before it is used. Any product with a stamped expiration date will be discarded once that date passes. Sanitation and Food Handling: 1. All employees receive instruction on sanitation during orientation and thru in-service training programs. 2. Hair nets or hats covering the hairline are worn at all times. [NAME] guards are required for facial hair. 3. Wash your hands (with soap and hot water) before starting work, after coughing or sneezing, handling garbage, picking up an article from the floor, after handling soaps or detergents, after using the toilet, after smoking, and after all breaks. Touching something that is not clean and then handling food can cause food poisoning. 4. Handle all utensils and dishes so the food or customer contact surfaces are not touched. All disposables are opened from the bottom of the package. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 18 of 25 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 12/12/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 5. Do not handle food with bare hands. Use the proper utensil or wear disposable gloves. Remember to change gloves after touching anything that should not contact food, including clothing, hair, doorknobs, etcetera. 6. Wash and sanitize any utensil or non-food supply that has fallen on the floor before allowing it to contact food. 7. Dispose of food that has fallen on the floor. Any food that has come in contact with broken dishes will be discarded, and another food substituted. 8. Work surfaces must be kept as neat and clean as possible during preparation and service. Clean up your area as you work, and do not let sinks become full of [NAME] utensils and bowls. 9. All utensils, pots, and pans must be properly washed and sanitized after use. I 0. All work areas must be thoroughly cleaned and sanitized after use. Red sanitation buckets with moist cleaning cloths should be prepared and the sanitation concentration verified every four hours. 11. All unused food must be securely covered. All items are to be dated and labeled as to their content. Store items in their original container unless instructed to do otherwise. Plastic containers from pickles, salad dressings, etc. are to be discarded as they are emptied, unless otherwise instructed. 12. Do not leave any serving tools in refrigerated or dry storage food containers. Record review of Equipment Sanitation policy undated reflected: We will provide clean and sanitized equipment for food preparation. The facility will clean all food service equipment in a sanitary manner. Procedure: 5. Meat slicer and meat preparation areas. a. Slicing of cooked meat (ready for serving) should not follow the slicing of raw foods or uncooked meat. b. Slicer parts are removed and washed after each use with sanitizer, rinsed well, and allowed to air dry. c. Counter on which uncooked meat has been placed should be thoroughly cleaned with detergent after use. d. Meat preparation areas should be cleaned and sanitized at the end of preparation of each product. Record review of the Cleaning of the Ice Machine policy undated reflected: The ice machine shall be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 19 of 25 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 12/12/2024 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 0812 cleaned and sanitized according to manufacturer's instructions to maintain sanitary conditions in order to prevent food contamination and the growth of disease producing organisms and toxins. Level of Harm - Minimal harm or potential for actual harm Procedure: Residents Affected - Some 1. Unplug from electricity and/or turn off. 2. Empty, dispose of ice and drain completely. 3. Clean any hard water deposits with de-[NAME], per manufacturer instructions for mixing and use, and rinse well. 4. If any type of soil/food stains are present, wash with all-purpose cleaner and rinse well. 5. Wipe down all food/ice contact surfaces with a sanitizer solution, per manufacturer instructions, DO NOT rinse. Iodine: 12.5 to 25 ppm Chlorine: 50 to I 00 ppm Quaternary ammonia: 150 -400 ppm 6. Allow to air dry. 7. Turn ice machine back on. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 20 of 25 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 12/12/2024 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 0880 Provide and implement an infection prevention and control program. 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 provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 5 of 11 residents (Resident #40, Resident #3, Resident #18, Resident #25, and Resident #253) reviewed for infection control. Residents Affected - Some 1. LVN B did not label wound care dressings, per facility stated policy, for Resident #40, Resident #18, Resident #3, and Resident #25. 2. LVN B did not place a barrier, between the resident's body part and the bedding, prior to Resident #40's wound care and rested Resident #40's foot on the blanket. 3. LVN N provided catheter care to Resident #253 with without wearing EBP. These failures could place the residents at risk of infection transmission, sepsis, and hospitalization. Findings included: Resident #40 Record review of Resident #40's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included cellulitis (skin infection), protein-calorie malnutrition, hyperlipidemia (elevated lipids in blood), hypertension (high blood pressure), chronic ulcer of right foot, cognitive communication deficit, and need for assistance with personal care. Record review of Resident #40's MDS assessment, dated 10/16/24 revealed a BIMS score of 14, indicating her cognition was intact. Further review of the MDS revealed Resident #40 had a stage 3 pressure injury, no venous or arterial ulcers present, and an infection of the foot (cellulitis and purulent drainage). Record review of Resident #40's Care Plan dated 11/27/24 reflected Resident #40 had a stage 3 venous stasis ulcer to right upper thigh, and the goal was for the ulcer to heal by a target date of 01/23/25. The Care Plan further reflected: Evaluation of wound for size, depth, and margins including peri-wound skin, sinuses, undermining, exudate, edema, granulation, infection, necrosis, eschar, and gangrene. Document progress in wound healing on an ongoing basis. Notify Physician as indicated. Monitor/document/report to MD PRN for signs and symptoms of infection: green drainage, foul odor, redness and swelling, red lines coming from the wound, excessive pain, and fever. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 21 of 25 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 12/12/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Order Summary Report dated 12/10/24 for Resident #40 reflected a post-surgical wound of the left distal foot with wound care orders: Clean with wound cleanser pat dry pack with alginate calcium with silver and may sub packing with methylene blue or iodoform gauze and compression wrap one time a day for wound healing. An observation on 12/10/24 on 09:32 AM of wound care for Resident #40 conducted by LVN B revealed, Resident #40's left foot dressing had no initials or date on the dressing. Further observation revealed LVN B did not place a barrier under the left foot wound prior to wound care being provided. Resident #40's blanket was under her foot and rested on the blanket while LVN B prepared the iodoform gauze to pack into the wound. Interview on 12/10/24 on 09:53 AM with LVN B revealed, Resident #40 admitted with left foot surgical amputation of toes and the wound had opened or dehisced. LVN B stated she had forgotten to initial and date the dressing on Resident #40's left foot. LVN B further stated not having a barrier between the wound and bedspread could lead to cross-contamination. Resident #18 Record review of Resident #18's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included lymphedema (a condition of localized swelling caused by a compromised lymphatic system), atrial fibrillation (rapid and irregular beating of the atrial chambers of the heart), benign prostatic hypertrophy (enlarged prostate gland), and a non-pressure chronic ulcer of right and left lower leg. Record review of Resident #18's MDS assessment, dated 09/13/24 revealed a BIMS score of 15, which indicated the resident had no cognitive impairment. The MDS also reflected an infection of the foot and pressure ulcer injury care with the interventions of an application of non-surgical dressings, surgical wound care, and a pressure reducing device for the bed. Record review of Resident #18's Care Plan dated 10/30/24 reflected the resident had impaired skin related to lymphedema to bilateral lower extremities. The goal reflected Resident #18 would have intact skin, free of redness, blisters, or discoloration with a target date of 10/15/24. Interventions included administration of treatments as ordered and monitor for effectiveness, assess/monitor/record wound healing weekly. Measure length, width, and depth where possible. Monitor the dressing to ensure it is intact and adhering. Review of Order Summary Report dated 12/12/24 for Resident #18 reflected a lymphademic wound of the right, lower shin full thickness. Wound care orders reflected to have resident scrub in shower or clean with wound cleanser, dap dry and apply ammonium lactate first than petroleum-based moisturizer, cover with alginate calcium w/silver with compression wrap 3 times a day and/or as needed one time a day every Mon, Wed, Fri for Wound care AND as needed for wound care. Review of Order Summary Report dated 12/12/24 for Resident #18 reflected a lymphatic wound to the left medial ankle full thickness. Wound care orders reflected to have resident wash/scrub lower extremities, first apply ammonium lactate lotion than petroleum based and alginate calcium w/silver with compression wrap one time a day every Mon, Wed, Fri for WOUND CARE AND as needed for wound care. An observation on 12/11/24 at 7:34 AM, LVN B provided wound care for Resident #18. It was noted the old dressings to the right leg and left leg did not display the date and initials. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 22 of 25 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 12/12/2024 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 0880 Resident #3 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #3's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included paraplegia and hemiplegia, protein - calorie malnutrition, diabetes mellitus type 2, hypertension (high blood pressure), cerebrovascular disease, chronic pain syndrome, and cognitive communication deficit. Residents Affected - Some Record review of Resident #3's MDS dated [DATE] reflected a BIMS Score of 3, which indicated the resident had a severe cognitive impairment. The MDS further reflected Resident #3 was at risk of developing pressure ulcers/injuries, and treatment included an application of dressings to feet and a pressure reducing device for the bed. Record review of Resident #3's Care Plan dated 10/22/24 reflected Resident #3 was at risk for skin integrity related to history of pressure ulcer and skin tear. Resident #3 had wounds to left 1st toe, left 3rd toes, and left heel. The Goal reflected resident's wounds will heal without further complications with a target date of 11/05/24. Interventions included: Monitor/document location, size, and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection to MD. Wound care as ordered and report any changes. Review of Order Summary Report dated 12/12/24 for Resident #3 reflected he had a stage 4 pressure wound of the right coccyx and an unstageable deep tissue injury of the left heel. Wound care orders reflected to clean the wound with wound cleanser and apply alginate calcium with silver and cover with island dressing one time a day every Monday, Wednesday, and Friday for wound healing. Wound care orders reflected an unstageable deep tissue injury of the left heel. Wound care orders reflected to clean the wound with cleanser and pat dry, apply alginate calcium with silver and cover with island dressing every Monday, Wednesday, and Friday for wound care. An observation on 12/10/24 at 10:01 AM, LVN B provided wound care for Resident #3, and the old dressing to coccyx wound and the heel wound did not display a date and initials. Resident #25 Record review of Resident #25's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included a non-pressure chronic ulcer of left lower leg, fibromyalgia (a medical syndrome that causes widespread pain, fatigue, awakening unrefreshed, and cognitive symptoms), hypertension (high blood pressure), cellulitis of left lower limb (skin infection), and osteoarthritis. Record review of Resident #25's care plan dated 12/01/23 reflected the resident had MRSA (methicillin-resistant staphylococcus aureus) colonization of the left lower extremity and a venous stasis ulcer to left lower extremity. The goal was for the ulcer and infection to heal without complications. Interventions included education of residents, families, and caregivers regarding the importance of hand washing. Use antibacterial soap and disposable towels. Wash hands immediately after activities of daily living, care tasks and activities. Record review of Resident #25's Quarterly MDS assessment, dated 11/25/24 reflected a BIMS score of 15 which indicated the resident had no cognitive impairment. Further review of the MDS revealed Resident #25 used a motorized wheelchair for mobility. The MDS reflected Resident #25 was at risk of developing pressure ulcers/injuries, with interventions of a pressure reducing device for the bed. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 23 of 25 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 12/12/2024 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 0880 MDS further reflected Resident #3 had 3 venous and arterial ulcers present. Level of Harm - Minimal harm or potential for actual harm An observation on 12/11/24 at 08:11 AM, wound care provided by LVN B for Resident #25 revealed the old dressing did not display a date and initials. Residents Affected - Some An interview on 12/11/24 at 8:26 AM, revealed LVN B had forgotten to date and initial the dressings the day before. LVN B stated the importance of initials and a date on the wound dressing would inform other staff of when the wound care had last been done, and if there was any drainage it would let us know how long the drainage had been there. Resident #253 Record review of Resident #253's AR, dated 10/10/2024, reflected a [AGE] year-old male who admitted to the facility on [DATE]. He had diagnoses of hemiplegia (which was one-sided paralysis; left side,) and hemiparesis (which was one-sided muscle weakness; left side;) and, the need for assistance with personal care. Record review of Resident #253's Discharge MDS Assessment, dated 11/15/2024, reflected the resident had a BIMS Score of 14, which indicated the resident had no cognitive impairment. The resident had an indwelling catheter. Record review of Resident #253's CCP reflected a Focus area for a catheter, initiated on 11/1/2024, evidenced by bladder function. The Goal, initiated on 11/1/2024 reflected the resident would be free, and remain free, from catheter related trauma. The Intervention, initiated on 11/1/2024, delegated nursing home staff to check the catheter tubing for kinks and to maintain the drainage off the floor; a Focus area for EBP, initiated on 12/9/2024. The Goal, initiated on 12/9/2024, reflected the resident would be free from the risk of infection transmission. The Intervention, initiated on 12/9/2024, delegated nursing home staff to wear gloves and gowns for catheter care. Record review of Resident #253's Order Summary Report reflected an order, started on 11/15/2024, for catheter care every shift. Interview and observation on 12/9/2024 at 2:53 PM with Resident #253, revealed him in his room in his bed. The resident was clean, the room was free from odors, and there was no distress noted. LVN N entered his room to perform catheter care. She entered the room in her nurse's uniform. She did not have on rubber gloves, and she did not have on an EBP gown. She was observed taking the resident's catheter line with both hands to inspect the urine in the line. She maintained physical control of the resident's catheter line with one hand and used to the other to reach for the catheter bag from its low hanging position. She was observed taking the catheter bag in both hands to check for obstructions. She was observed inspecting the catheter tubing from the bag to the point of insertion. In her inspection, she was observed removing some white medical tape, adjusting the tube at the resident's groin area, and placing the catheter bag to its low hanging position. There was a plastic container outside of the resident's door with gloves, and gowns; there was a sign on the door to educate staff, and visitors, that the resident required EBP. Interview on 12/12/2024 at 8:55 AM, Resident #253 revealed his awareness that the facility staff was supposed to wear gowns and gloves when he received catheter care. He stated, they never do it. They changed out his catheter often and he did not appreciate the facility did not practice better infection control. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 24 of 25 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 12/12/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 12/12/2024 at 9:15 AM, CNA M revealed EBP required hand cleaning before entering the room. High contact activities, such as incontinent care, emptying a catheter bag, and changing bedding required clean hands, gloves, and a gown. Residents on EBP was more susceptible to infection and EBP protected both the resident, and the staff member, from infection transmission. Interview on 12/12/2024 at 10:04 AM, the DON revealed EBP was a program in place to protect specific residents from the risk of infection. Residents who had unique medical characteristics, such as wounds, catheter, intravenous lines, or tube feeding required an enhanced level of infection control. Staff who provided high contact activities, such as dressing, bathing, wound care, and device care should have worn gloves, and a gown, to help prevent the spread of infection. Staff was trained in orientation class and pre-shift training to know of EPB requirements and when to wear the proper PPE. Some risks for residents exposed to inadequate infection control would be the spread of infection. EBP was in place to protect the resident, but any barrier of precaution also helped to protect staff. An interview on 12/12/2024 at 3:15 PM, the ADM revealed the facility staff was trained, per policy, for EBP requirements. Any staff member who entered a resident's room to perform high contact care, such as catheter care, should have worn gloves and a gown to help prevent the spread of infection. Safeguards in place to ensure staff wore the proper PPE was laminated signs by the door, PPE in nearby plastic bins, and nearby hand sanitizer available. The failure for staff to wear the proper PPE started at the level of following infection control measures and making sure staff was trained. An interview on 12/12/24 at 05:11 PM, the ADM revealed her expectation was for all wound dressings to be labeled and dated. The effect on the resident would include not knowing when the wound care was last done, and when the dressing was placed on the resident. The ADM further revealed her expectation was for a barrier to be placed to protect the wound during wound care, because not having a clean barrier could lead to an infection. An interview on 12/12/24 at 05:31 PM, the DON revealed her expectation was for wound dressings to be labeled and dated. The effect on the resident would include not knowing when the wound care was last done, and when the dressing was placed on the resident. The DON further revealed her expectation was for a clean barrier to be placed to protect the wound, and the wound not having a clean barrier could lead to a wound infection and cross-contamination. The DON stated she started in-servicing on labeling the wound bandage and would also start an in-service on enhanced barrier precautions. Record review of the facility's undated Dressing Change Checklist reflected under Cleansing Wound (Clean Technique) Apply new gloves and cleanse wound per orders and facility policy (place barrier under resident only if the wound has drainage and will come in contact with linens. Record review of the facility's Catheter Care Policy, revised 2/13/2007, reflected to check the resident's catheter frequently to avoid kinks and minimize the catheter movements. Record review of the facility's Enhanced Barrier Precautions Policy, undated, reflected EBP referred to an infection control intervention designed to reduce transmission of multidrug resistant organisms that employed targeted gown and glove use during high contact resident care activities. EBP were required for high contact activities for residents with an indwelling medical device. Device care for an indwelling medical device required the care provider to use hand sanitizing, gloves, and gown. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 25 of 25