Inspection·April 10, 2025

F 0623 to update them. Level of Harm - Minimal harm or potential for actual harm Review of Resident #1's progress notes dated 02/21/2025 at 11:13 am written by the DON reflected: VM left POA notifying of need to collect resident belongings in a timely manner due to residents permanent DC due to change of residence. Residents Affected - Few During an interview on 04/10/2025 at 09:57 am Resident #1's POA stated Resident #1 was immediately discharged from the facility without 30-day notice after he was taken into custody by the police. Resident #1's POA stated she was called and told Resident #1 was discharged same day because he was in police custody. Resident #1's POA stated Resident #1 was taken into police custody on 2/19/2025 due to warrant that was out, and Resident #1 had his court hearing on 02/28/2025 and was transferred to the ER from the court due to injuries. Resident #1's POA stated the facility refused accepting Resident #1 back to the facility. During an interview on 04/09/2025 at 10:32 am the Social Worker stated Resident #1 was discharged from the facility because he got arrested from the facility for sexual abuse of a minor. The Social Worker stated she did not know if Resident #1 was guilty. The Social Worker stated it was their policy to give 30-day notice for facility-initiated discharge, but she did not give Resident #1 30-day notice because it was out of her hands. During an interview on 04/09/2025 at 11:00 am the Administrator stated Resident #1 was discharged to the county jail. The Administrator stated she was told by the DON that Resident #1 would be in custody until his trial date. The Administrator stated the facility did not accept Resident #1's referrals back to the facility because the facility was next to a school. The Administrator stated she did not know if Resident #1 was found guilty of the charges on him. The Administrator stated Resident #1 or his POA were not issued a 30-day notice of discharge. During an interview on 4/09/2025 at 3:37 pm the DON stated she was present when Resident #1 was taken into custody and was told by the Deputy that Resident #1 would be in police custody until his trial date. The DON stated the facility did not anticipate Resident #1 coming back to the facility because the Deputy stated Resident #1 would be in police custody until his trial date. The DON stated she spoke with the case manager and told the case manager Resident #1 was not going back to the facility because he was permanently discharged from the facility. The DON stated the Administrator made the decision to discharge Resident #1. The DON stated, We notify the POA of what happened. We also notify her to pick up his things. I don't know what he did to post threat to staff or resident, I have to go back and look. During an interview on 04/09/2025 at 4:09 pm, the Ombudsman stated Resident #1 was given a 30-day discharge in the past, appealed and won the appeal on 2/18/2025. The Ombudsman stated Resident #1 should be accepted back to the facility after his arrest and hospital stay. During an interview on 04/10/2025 at 09:32 am the Administrator stated the DON got a call from the Sheriff's office on 04/09/2025 stating Resident #1 cannot be next to a child and the facility was close to a school. The Administrator also stated they had children volunteering at the facility therefore Resident #1 cannot be accepted back to the facility. The Administrator stated, I will have to discuss with my cooperate. Right now, we do not have reason for not readmitting, once we have a reason not to, we will not re-admit him. During an interview on 04/10/2025 at 10:13 am, the Sergeant with the Special Verdict Unit with name (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 2 of 3 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 04/10/2025 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 0623 Level of Harm - Minimal harm or potential for actual harm County (Contact provided by the DON) stated the facility had just made contact with him and he explained Resident #'1s trial findings. He stated, the court would have stipulated in the deferred adjudication that Resident #1 could not be in a certain radius of a school. The Sergeant said he explained to the facility that this was not in the case of Resident #1, Resident #1 was not allowed to live in a residence with a child but a facility next to the school would not apply. Residents Affected - Few During an interview on 04/10/2025 at 10:57 am the Administrator stated Resident #1 will not be allow back in the facility due to the facility's policy on Registered sex offender and the findings from his court hearing on 02/28/2025. Review of facility's policy titled Discharge or Transfer to another facility revised 04/10/2025 reflected: The facility will permit each resident to remain in the facility, and not transfer or discharge the resident from the facility. In the following limited circumstances, this facility may initiate transfers or discharges: A. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility. B. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility. C. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident. D. The health of individuals in the facility would otherwise be endangered. When a resident is temporarily transferred on an emergency basis to an acute care facility, this type of transfer is considered to be a facility-initiated transfer and a notice of transfer will be provided to the resident and resident representative as soon as practicable. Copies of notices for emergency transfers will also still be sent to the ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis. In situations where the facility has decided to discharge the resident while the resident is still hospitalized , the facility will send a notice of discharge to the resident and resident representative and will also send a copy of the discharge notice to a representative of the Office of the State LTC Ombudsman. Review of facility's policy titled Resident Rights undated reflected, The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.) Review of facility's policy titled Registered Sex Offender dated 1/1/2020 reflected, It is the policy of this facility not to admit known registered sex offenders (as defined by Texas Chapter 62 of the Code of Criminal Procedure) into this facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 3 of 3