Inspection·July 10, 2025

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some intact. Review of Resident #3's quarterly care plan, dated 05/05/25, reflected he had an ADL self-care deficit with an intervention of requiring one staff for assistance with bed mobility. During an interview on 07/09/25 at 10:11 AM, Resident #3 was shown a completed safe survey with his name on it. He stated he had never been asked those questions before and had never seen the document. Resident #4Review of Resident #4's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including anxiety disorder, acute respiratory failure, history of falling, and muscle weakness. Review of Resident #4's quarterly MDS, dated [DATE], reflected a BIMS score of 10, indicating a moderate cognitive impairment. Review of Resident #4's quarterly care plan, dated 03/04/25, reflected he had an ADL self-care performance deficit with an intervention of requiring one staff for assistance with bed mobility. Resident #5Review of Resident #5's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including joint disorders, cerebral infraction (stroke), cognitive communication deficit, and muscle weakness. Review of Resident #5's quarterly MDS, dated [DATE], reflected a BIMS score of 15, indicating she was cognitively intact. Review of Resident #5's quarterly care plan, dated 07/08/25, reflected she had an ADL self-care performance deficit with an intervention of requiring one staff for assistance with bed mobility. Review of safe surveys, dated 06/25/25 and included in the facility's 3613 (facility investigation report), from a self-report, dated 06/14/25, reflected the following questions/answers documented by the SW for Residents #2, #3, #4, and #5: 1. Do you feel safe in the facility? Yes2. Do the staff treat you with respect? Yes3. Do you know what to do if you witness or experience any kind of abuse? Tell the nurse4. Do you know who the Abuse Coordinator is? Unsure explained it is the Admin. Review of safe surveys, dated 06/25/25 and included in the facility's 3613 (investigation report), from a self-report, dated 07/01/25, reflected the following questions/answers documented by the SW for Residents #2, #3, #4, and #5, which were photo-copied and identical from the ones completed for the self-report from 06/14/25: 1. Do you feel safe in the facility? Yes2. Do the staff treat you with respect? Yes3. Do you know what to do if you witness or experience any kind of abuse? Tell the nurse4. Do you know who the Abuse Coordinator is? Unsure - explained it is the Admin. Review of in-services entitled Abuse and Neglect and conducted by ADON D, dated 06/14/25, 06/25/25, 07/02/25, and one that was undated, reflected they were photo-copied with the date changed at the top. The staff in-serviced and their signatures were identical. They were included with the facility's 3613s from self-reports dated 06/14/25, 06/22/25, 06/26/25, and 07/02/25. Review of the facility's self-reports from 06/14/25, 06/22/25, 06/26/25, and 07/02/25, reflected the reporter was the DON and her signature was on the 3613s. During an interview on 07/09/25 at 9:41 AM, CNA B stated the management staff were lax when it came to abuse and neglect. She stated the residents were in a vulnerable state and it was not fair to them to not take abuse seriously. She stated a couple of days after she first started working at the facility, on approximately 05/30/25, she was in training and shadowing CNA C. She stated Resident #1 had said something about not getting changed by NA A and CNA C asked Resident #1 about the situation. She stated NA A was walking past the room and heard the conversation. She stated NA A she charged into the room and at the resident and yelled, Keep my mother f****** name out of your mother f****** mouth! She stated Resident #1 was shaking and was terrified. She stated she told NA A she needed to leave Resident #1's room and CNA C had to walk NA A out of the room. She stated she told CNA C to ensure that incident was reported to management as it was verbal abuse. She stated she continued to see NA A working and asked ADON E why nothing had been done and ADON E told her CNA C had changed her statement and stated she had walked NA A out of the room before she said anything to Resident #1. She stated she wrote a statement and had assumed it had gone to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 2 of 19 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 07/10/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some the DON and was self-reported to the state. She was told the DON told ADON E that without two written statements confirming it had happened, they could not do anything about it. CNA B was shown the four in-services (that had her name and signature on them) and she stated, You can tell these are copies! Look at the signatures - they are all the same! She stated she had not worked on any of those four dates and had been out of town on vacation. She stated, None of these are real.Review of NA A's time sheets, from 05/30/25 - 07/09/25, reflected she had worked 26 shifts during that timeframe. During an interview on 07/09/25 at 10:01 AM, Resident #1 stated she remembered NA A was sometimes mean to her. She stated she remembered (her account from the incident on 05/30/25) NA A telling her she was so big and her butt was so big it was hard to change her. She stated she had made her feel humiliated, ashamed, and scared. She stated the DON told her NA A would not work with her anymore, but NA A continued to come and try to change her, and she would tell her no because she did not want her to provide care. She stated she did not believe NA A ever got talked to by management. During an interview and observation on 07/09/25 at 11:50 AM, ADON E stated the ADM was the abuse and neglect coordinator. She stated she did not witness the incident regarding NA A and Resident #1 on 05/30/25 but was told about it by CNA B. She stated she reported it to the DON and the DON told her she found it to be unsubstantiated. She stated she would expect for the incident to have been reported the state if it had not been. She stated the DON told her she would not bring it to corporate's attention unless there were two witnesses confirming it happened. She stated when she initially interviewed CNA C, she confirmed the events of the incident that CNA B had relayed to her. She stated when she wrote her statement, she changed the story and wrote that she never heard anything. She stated she told CNA C to document the truth, but she would not. She stated both witness statements were given to the DON. She stated NA A was never suspended and continued to work on Resident #1's hall. She stated the DON conducted in-services every other Tuesday when they received their paychecks, and ADON D conducted in-services on the floor whenever they were needed. ADON E was shown the in-services and safe surveys that had been photo-copied. She stated they were obviously being copied which meant the staff were not getting appropriately educated and they were not ensuring residents felt safe. She stated it absolutely did not meet her expectations. She stated she did not believe ADON D had conducted them, and she probably had no idea her name was attached to them. ADON E became tearful and stated she could not believe that was going on and that the residents relied on them and they were not being taken care of the way they should be. During an interview on 07/09/25 at 12:24 PM, the DON stated her expectations regarding safe surveys were that the SW conduct new surveys any time there was an incident of abuse or neglect. She stated the surveys should pertain to the residents who were cared for by the staff member that it had been alleged against. She stated, typically, the ADM was responsible for completing self-reports, but for the last five weeks (how long the new ADM had been working at the facility), the responsibility had fallen on the nursing side. She was shown the photo-copied in-services and stated they looked like they were copied. She could not remember who completed those particular in-services, but it did not meet her expectations, as there should be new in-services conducted every time abuse or neglect was alleged. She stated she remembered CNA B had reported (at the end of May 2025) to ADON E that Resident #1 told her NA A had yelled at her. She stated she believed statements were gotten from CNAs B and C. She stated when she interviewed Resident #1, she denied the allegation and she believed her because they had a therapeutic relationship. She stated she would have reported it to the state if Resident #1 had been cognitively impaired, but she had denied it and was cognitively intact. The witness statements for CNAs B and C were requested. During an interview on 07/09/25 at 12:51 PM, the SW stated she was responsible for conducting safe surveys when she was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 3 of 19 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 07/10/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some told to. She was shown the photo-copied safe surveys and stated she never made copies of them and believed they were put in the wrong binders. She stated it was important to interview residents that could have been affected by a staff member who had been accused of possible abuse or neglect and it was important to interview the residents that were cognitively intact. During a telephone interview on 07/09/25 at 12:51 PM, the NP stated if there was an incident of alleged verbal abuse, she would expect the facility to investigate it if the patient was with it. She stated if the resident was confused, she was not sure if they should investigate it. She stated if the abuse was witnessed by another staff member, then that was a different story. She stated they should escalate it through their chain of command. She stated it was very important for staff to be in-serviced regularly on abuse and neglect to refresh them. During an interview on 07/09/25 at 2:11 PM, the ADM stated the DON could only find CNA C's witness statement regarding the incident with Resident #1. She stated that did not meet her expectations to only have the one statement. She stated ADON E told her she gave both statements to the DON and she was not sure what happened. She stated she started working at the facility around the time of the incident and was never notified of the allegation. She stated it did not matter if only one statement had been obtained. She stated the second an allegation of abuse or neglect was made towards a staff member; she would immediately suspend them and start her investigation. She stated if a resident then denied it, she would not go solely on that interview. She stated she would interview other staff that worked the same shift and the roommate of the resident alleging the abuse or neglect. The ADM was shown the photo-copied in-services and safe surveys and she stated they appeared to be duplicates and she considered that to be falsification. She stated that did not meet her expectations. She stated the DON was responsible for all self-reports as she (the DON) was clinical. She stated ADON D only conducted in-services on the weekends when an allegation of abuse or neglect was made, and the DON conducted them during the week. (All four copied in-services reflected week-day dates.) She stated after an allegation was made; she should be made aware immediately. She stated the sooner they could get to the root cause, the sooner she could make the necessary adjustments. She stated not investigating was putting the residents in jeopardy of being harmed. Telephone interviews were attempted with NA A on 07/09/25 at 10:27 AM and 1:32 PM. A returned call was not received prior to exit. Telephone interviews were attempted with CNA C on 07/09/25 at 10:29 AM and 1:35 PM. A returned call was not received prior to exit. Telephone interviews were attempted with ADON D on 07/09/25 at 10:07 AM and 2:12 PM. A returned call was not received prior to exit. Review of CNA C's witness statement, dated 06/04/25, reflected the following: On Friday the 30th [of May], we [CNAs B and C] were passing out morning trays. We went into [Resident #1]'s room and she was telling me something about the day before. As she was talking, [NA A] came in and saying things [sic]. So I politely turn [sic] [NA A] out of the room and let the resident finish talking. Then I went to report what had to place [sic]. It was noted under the statement that CNA C did not want to sign the statement. On the back of the statement, the DON documented, [Resident #1] (BIMS 15) denied hearing any cobe [sic] words or abusive language. Accusation unfounded. Review of the facility's Abuse/Neglect Policy, revised 05/09/17, reflected the following: The resident has the right to be free from abuse. Verbal Abuse: Any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents. Mental Abuse: Includes, but not limited to, humiliation, harassment, threats of punishment or deprivation. Training: The facility will train through orientation and on-going in-services on issues related to abuse/neglect prohibition practices regularly. All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility protocol. Investigations will be reviewed by the facility administrator and/or Abuse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 4 of 19 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 07/10/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Preventionist within 24 hours of complaint. With an allegation of abuse or neglect, the employee(s) will immediately be suspended pending an investigation. Review of the facility's Resident Rights Policy, revised 11/28/16, reflected the following: A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. The ADM was notified on 07/09/25 at 3:24 PM that an IJ situation had been identified and an IJ template was provided. The following POR was approved on 07/10/25 at 1:33 PM and indicated: Problem: FREE FROM ABUSE AND NEGLECT- On 07/09/2025, an abbreviated survey was initiated at the facility. On 07/09/2025 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. Interventions: One on One documented in-service on Abuse Investigation with the Administrator/DON was conducted by the Regional Compliance Nurse on 07/09/2025. This in-service included reviewing and conducting timely investigations for allegations. Staff verbalized understanding One on one documented inservice with DON by regional compliance nurse on events about reporting all allegations of abuse to the administrator as defined in 2014-14. Alleged perpetrators are to be suspended immediately, new inservices and new staff and resident assessments are to be initiated with every new allegation. DON verbalized understanding. Staff working with NA A have been interviewed on 07/09/2025 NA A, was suspended by facility administrator on 07/09/2025, pending investigation for abuse Resident safe surveys were completed on 07/9/2025 by Activity Director. No negative findings. Un-interviewable residents had a head-to-toe assessment completed on 07/09/2025 by charge nurses. No negative findings. The following in-services were initiated, documented and signed to confirm verbal understanding on 07/09/2025 by admin and DON, and any staff member not present or in-serviced on 07/09/2025, will not be allowed to assume their duties until in-services have been completed. Any new employees or agency staff or PRN staff utilized will receive the following in-services before first shift to be worked.o All StaffS Abuse/NeglectS Abuse/Neglect ReportingS Who to Report Abuse/Neglect to Inservice included reporting timelines and abuse and neglect coordinator notification . Staff will be questioned on inservices randomly, 3 x week x 4 weeks or until compliance is met by DON, ADON, Admin or Designee. The medical director was notified of the immediate jeopardy situation on 07/09/2025 at 1709 by ADON. On 07/09/2025, a trauma informed assessment was completed for Resident #1, by social worker which was negative for findings that required follow up interventions. 07/09/2025 Staff that worked with perpetrator were interviewed by Administrator, DON and ADON and asked if they had noted any abuse by the alleged perpetrator, no negative findings. ADHOC QAPI discussed with IDT on 07/09/2025. Monitoring DON/Admin/Designee will interview 5-10 staff weekly x 6-week situational abuse scenarios had how to address effective 07/09/2025 DON/Admin/Designee will interview 5 residents how staff treat them weekly x 6 weeks effective 07/09/2025 ADO/Regional Compliance Nurse will monitor weekly x 6 weeks monitoring tools for staff and resident interviews effective 07/09/2025 The QA committee will review the findings monthly x 3 months and makes changes as needed. The Administrator will resolve once no further issues have been identified. Effective 07/09/2025 The Surveyor monitored the POR on 07/10/25 as followed: During interviews on 07/10/25 from 1:55 PM - 4:29 PM, staff from both shifts were interviewed, which included CNA F, LVN G, CNA H, LVN I, MA J, the SW, and the AD. They all stated they were in-serviced on abuse and neglect before their shifts as well as receiving text message alerts about reporting abuse to the ADM immediately. They all knew their abuse and neglect coordinator was the ADM. All staff stated they have the ADM's personal phone number, and it was also located by the copy machine. The staff stated they were required to notify the ADM of any suspicion of abuse or neglect immediately - any day, any time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 5 of 19 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 07/10/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete They all were able to give examples of abuse which included verbal, mental, physical, and emotional. During an interview on 07/10/25 at 3:53 PM, ADON E stated the abuse and neglect coordinator was the ADM. She stated she had never seen a resident at the facility being abused or neglected. She stated if she had, she would ensure their safety which was the main priority, then would report it to the ADM. She stated it was not their duty to determine if something happened, it was their duty to report it immediately. She stated all residents received either a skin assessment or safe survey on 07/09/25. During an interview on 07/10/25 at 4:29 PM, the ADM stated she was the abuse and neglect coordinator. She stated she expected to be notified immediately of any allegation of abuse or neglect. She stated, if you see something, say something. She stated she was in-serviced the night prior (07/09/25) by their regional corporate nurse regarding abuse and neglect. She stated the team had ensured all staff had her contact information, they sent mass text messages to all staff through their scheduling system, and did follow-up interviews with staff. She stated the DON was suspended because the IJ and not communicating to her the allegation of abuse with Resident #1. She stated NA A was suspended and then terminated due to the allegations made against her. Review of the facility's AD Hoc QAPI agenda, dated 07/09/25, reflected the ADM, the DON, ADON E, the SW, the AD, the HRD, and the MD were in attendance. Review of a Trauma Informed Assessment for Resident #1, dated 07/09/25 and completed by the SW, reflected no concerns. Review of witness statements, dated 07/09/25, reflected seven staff members' statements that had worked with NA A in some capacity alleging they had never seen NA A being abusive towards the residents. Review of safe surveys, dated 07/09/25, reflected interviewable residents had a safe survey completed by the AD with no concerns noted. Review of skin assessments, dated 07/09/25, reflected all non-interviewable residents had a completed skin assessment by a nurse with no concerns noted. Review of an in-service, dated 07/09/25 and conducted by the RCN, reflected the DON was in-serviced on the following: DON must report all allegations of abuse to the administrator as defined in 2014-14, asap. Every new allegation requires Alleged perpetrators to be suspended immediately, new in-services initiated, new staff interviews, and new resident safe surveys. Review of an in-service, dated 07/09/25 and conducted by the RCN, reflected the DON, the ADM, ADON D, and ADON E, were in-serviced on the following: All allegations of abuse require a thorough investigation to include staff interviews and resident safe surveys. Review of an in-service, dated 07/09/25 and conducted by the RCN, reflected the DON, the ADM, ADON D, and ADON E, were in-serviced on the Abuse and Neglect provider letter. Review of an in-serviced, dated 07/09/25 and conducted by ADON E, reflected all staff for all shifts were in-serviced on the facility's Abuse and Neglect Policy. Review of an Employee Disciplinary Report for NA A, dated 07/09/25, reflected the following: [NA A] will be placed on investigatory suspension pending an investigation into allegations of resident mistreatment. Review of a Personnel Action Form for NA A, dated 07/10/25, reflected she was terminated due to failing to adhere to corporate code of conduct. The ADM was notified on 07/10/25 at 5:00 PM that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. Event ID: Facility ID: 675915 If continuation sheet Page 6 of 19 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 07/10/2025 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse and establish policies and procedures to investigate any such allegations for one (Resident #1) of ten residents reviewed for abuse and neglect. The facility failed to: Follow their Abuse and Neglect policy after Resident #1 was verbally/emotionally abused by NA A on or around 05/30/25 by not investigating the incident, not suspending NA A, and not reporting it to the ADM which resulted in psychosocial harm for Resident #1. An Immediate Jeopardy (IJ) was identified on 07/09/25 at 3:24 PM and an IJ template was provided. While the IJ was removed on 07/10/25 at 5:00 PM, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy. These failures could place residents at risk of abuse, neglect, trauma, and psychosocial harm.Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including morbid obesity, need for assistance with personal care, anxiety disorder, and age-related cognitive decline. Review of Resident #1's quarterly MDS assessment, dated 06/12/25, reflected a BIMS score of 15, indicating she was cognitively intact. Section GG (Functional Abilities) reflected she required substantial/maximal assistance for toileting hygiene. Review of Resident #1's quarterly care plan, dated 5/28/25, reflected she had an ADL self-care performance deficit with an intervention of requiring two staff participation to toilet. Review of CNA A's time sheets, from 05/30/25 - 07/09/25, reflected she had worked 26 shifts during that timeframe. During an interview on 07/09/25 at 9:41 AM, CNA B stated the management staff were lax when it came to abuse and neglect. She stated the residents were in a vulnerable state and it was not fair to them to not take abuse seriously. She stated a couple of days after she first started working at the facility, on approximately 05/30/25, she was in training and shadowing CNA C. She stated Resident #1 had said something about not getting changed by NA A and CNA C asked Resident #1 about the situation. She stated NA A was walking past the room and heard the conversation. She stated NA A she charged into the room and at the resident and yelled, Keep my mother f****** name out of your mother f****** mouth! She stated Resident #1 was shaking and was terrified. She stated she told NA A she needed to leave Resident #1's room and CNA C had to walk NA A out of the room. She stated she told CNA C to ensure that incident was reported to management as it was verbal abuse. She stated she continued to see NA A working and asked ADON E why nothing had been done and ADON E told her CNA C had changed her statement and stated she had walked NA A out of the room before she said anything to Resident #1. She stated she wrote a statement and had assumed it had gone to the DON and was self-reported to the state. She was told that the DON told ADON E that without two written statements confirming it had happened, they could not do anything about it. CNA B was shown the four in-services (that had her name and signature on them) and she stated, You can tell these are copies! Look at the signatures - they are all the same! She stated she had not worked on any of those four dates and had been out of town on vacation. She stated, None of these are real. During an interview on 07/09/25 at 10:01 AM, Resident #1 stated she remembered NA A was sometimes mean to her. She stated she remembered (her account from the incident on 05/30/25) NA A telling her she was so big and her butt was so big it was hard to change her. She stated she had made her feel humiliated, ashamed, and scared. She stated the DON told her NA A would not work with her anymore, but NA A continued to come and try to change her, and she would tell her no because she did not want her to provide care. She stated she did not believe NA A every got talked to by management. During an interview and observation on 07/09/25 at 11:50 AM, ADON E Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 7 of 19 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 07/10/2025 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some stated the ADM was the abuse and neglect coordinator. She stated she did not witness the incident regarding NA A and Resident #1 on 05/30/25 but was told about it by CNA B. She stated she reported it to the DON and the DON told her she found it to be unsubstantiated. She stated she would expect for the incident to have been reported the state if it had not been. She stated the DON told her she would not bring it to corporate's attention unless there were two witnesses confirming it happened. She stated when she initially interviewed CNA C, she confirmed the events of the incident that CNA B had relayed to her. She stated when she wrote her statement, she changed the story and wrote that she never heard anything. She stated she told CNA C to document the truth, but she would not. She stated both witness statements were given to the DON. She stated NA A was never suspended and continued to work on Resident #1's hall. During an interview on 07/09/25 at 12:24 PM, the DON stated her expectations regarding safe surveys were that the SW conduct new surveys any time there was an incident of abuse or neglect. She stated the surveys should pertain to the residents who were cared for by the staff member that it had been alleged against. She stated, typically, the ADM was responsible for completing self-reports, but for the last five weeks (how long the new ADM had been working at the facility), the responsibility had fallen on the nursing side. She was shown the photo-copied in-services and stated they looked like they were copied. She could not remember who completed those particular in-services, but it did not meet her expectations, as there should be new in-services conducted every time abuse or neglect was alleged. She stated she remembered CNA B had reported (at the end of May 2025) to the ADON that Resident #1 told her NA A had yelled at her. She stated she believed statements were gotten from CNAs B and C. She stated when she interviewed Resident #1, she denied the allegation and she believed her because they had a therapeutic relationship. She stated she would have reported it to the state if Resident #1 had been cognitively impaired, but she had denied it and was cognitively intact. The witness statements for CNAs B and C were requested.During a telephone interview on 07/09/25 at 12:51 PM, the NP stated if there was an incident of alleged verbal abuse, she would expect the facility to investigate it if the patient was with it. She stated if the resident was confused, she was not sure if they should investigate it. She stated if the abuse was witnessed by another staff member, then that was a different story. She stated they should escalate it through their chain of command. During an interview on 07/09/25 at 2:11 PM, the ADM stated the DON could only find CNA C's witness statement regarding the incident with Resident #1. She stated that did not meet her expectations to only have the one statement. She stated ADON E told her she gave both statements to the DON and she was not sure what happened. She stated she started working at the facility around the time of the incident and was never notified of the allegation. She stated it did not matter if only one statement had been obtained. She stated the second an allegation of abuse or neglect was made towards a staff member; she would immediately suspend them and start her investigation. She stated if a resident then denied it, she would not go solely on that interview. She stated she would interview other staff that worked the same shift and the roommate of the resident alleging the abuse or neglect. She stated after an allegation was made; she should be made aware immediately. She stated the sooner they could get to the root cause, the sooner she could make the necessary adjustments. She stated not investigating was putting the residents in jeopardy of being harmed. Telephone interviews were attempted with NA A on 07/09/25 at 10:27 AM and 1:32 PM. A returned call was not received prior to exit. Telephone interviews were attempted with CNA C on 07/09/25 at 10:29 AM and 1:35 PM. A returned call was not received prior to exit.Review of CNA C's witness statement, dated 06/04/25, reflected the following: On Friday the 30th [of May], we [CNAs B and C] were passing out morning trays. We went into [Resident #1]'s room and she was telling me something about the day before. As (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 8 of 19 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 07/10/2025 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some she was talking, [NA A] came in and saying things [sic]. So I politely turn [sic] [NA A] out of the room and let the resident finish talking. Then I went to report what had to place [sic]. It was noted under the statement that CNA C did not want to sign the statement. On the back of the statement, the DON documented, [Resident #1] (BIMS 15) denied hearing any cobe [sic] words or abusive language. Accusation unfounded. Review of the facility's Abuse/Neglect Policy, revised 05/09/17, reflected the following: The resident has the right to be free from abuse. Verbal Abuse: Any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents. Mental Abuse: Includes, but not limited to, humiliation, harassment, threats of punishment or deprivation. Training: The facility will train through orientation and on-going in-services on issues related to abuse/neglect prohibition practices regularly. All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility protocol. Investigations will be reviewed by the facility administrator and/or Abuse Preventionist within 24 hours of complaint. With an allegation of abuse or neglect, the employee(s) will immediately be suspended pending an investigation. Review of the facility's Resident Rights Policy, revised 11/28/16, reflected the following: A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. The ADM was notified on 07/09/25 at 3:24 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 07/10/25 at 1:33 PM: Problem: On 07/09/2025, an abbreviated survey was initiated at the facility. On 07/09/2025 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The facility must develop and implement written policies and procedures that prohibit and prevent abuse, establish policies and procedures to investigate any such allegations, and include training as required Facility failed to keep resident #1 free from verbal and emotional abuse by NA A on or around 5/28/25 The facility failed to immediately suspend NA A (per their policy) as she has worked at the facility since the incident on 5/28/25. The facility did not investigate the incident because the DON stated Resident #1 later denied the allegation. One to one documented inservice provided to the DON by Regional Compliance Nurse over notification of administrator of any allegation and reporting per state provider letter 2024-14. This was completed on 07/10/2025. Signature confirmed verbal understanding. The facility failed to conduct thorough abuse/neglect investigation as they copied Abuse and Neglect in-service and changed the date without in-servicing the staff for four separate self reports. The facility failed to conduct thorough abuse/neglect investigation as they copied resident safe surveys for residents #2,#3,#4, and #5 for three separate self reports Interventions: One on One documented in-service on Abuse Investigation with the Administrator/DON was conducted by the Regional Compliance Nurse on 07/09/2025. This in-service included reviewing and conducting timely investigations for allegations per CMS provider letter _PL2024-14____. Signature to confirm verbal understanding. Staff working with Alleged perpetrator (NA A) have been interviewed on 07/09/2025 by DON with no negative findings The alleged perpetrator, NA A was suspended by facility administrator on 07/09/2025. Resident safe surveys were completed on 07/09/2025 by Activity Director. No negative outcomes. Administrator and DON and ADON were in-serviced by the Regional Compliance Nurse on conducting staff in-services for each individual self report on 07/09/2025. Administrator and DON and ADON were in-serviced by the Regional Compliance Nurse related to conducting thorough investigation including current safe surveys for each separate self report on 07/09/2025. Un-interviewable residents had a head-to-toe assessment completed on 07/09/2025 and completed by charge nurse. No negative findings. The medical director was notified (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 9 of 19 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 07/10/2025 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some of the immediate jeopardy situation on 07/09/2025 by ADON. On 07/09/2025 a trauma informed assessment was completed for Resident #1 by Social Worker. No negative outcomes. Resident denied past or present trauma. All events / risk management will be reviewed 5 times a week by the IDT members for 6 weeks ADHOC QAPI discussed with IDT on 07/09/2025. Monitoring DON/Admin/Designee will interview 5-10 staff weekly x 6-week situational abuse scenarios had how to address effective 07/09/2025. DON/Admin/Designee will interview 5 residents how staff treat them weekly x 6 weeks effective 07/09/2025. ADO/Compliance Nurse will review all events/risk management to ensure timely/accurate investigation and reporting if needed weekly for 6 weeks. ADO/Regional Compliance Nurse will monitor weekly x 6 weeks monitoring tools for staff and resident interviews effective 07/09/2025. The QA committee will review the findings monthly x 3 months and makes changes as needed. The Administrator will resolve once no further issues have been identified. Effective 07/09/2025. The Surveyor monitored the POR on 07/10/25 as followed: During interviews on 07/10/25 from 1:55 PM - 4:29 PM, staff from both shifts were interviewed, which included CNA F, LVN G, CNA H, LVN I, MA J, the SW, and the AD. They all stated they were in-serviced on abuse and neglect before their shifts as well as receiving text message alerts about reporting abuse to the ADM immediately. They all knew their abuse and neglect coordinator was the ADM. All staff stated they have the ADM's personal phone number, and it was also located by the copy machine. The staff stated they were required to notify the ADM of any suspicion of abuse or neglect immediately any day, any time. They stated that was to ensure all residents were safe and protected. They all were able to give examples of abuse which included verbal, mental, physical, and emotional. During an interview on 07/10/25 at 3:53 PM, ADON E stated the abuse and neglect coordinator was the ADM. She stated she had never seen a resident at the facility being abused or neglected. She stated if she had, she would ensure their safety which was the main priority, then would report it to the ADM. She stated it was not their duty to determine if something happened, it was their duty to report it immediately. She stated all residents received either a skin assessment or safe survey they day prior, 07/09/25. During an interview on 07/10/25 at 4:29 PM, the ADM stated she was the abuse and neglect coordinator. She stated she expected to be notified immediately of any allegation of abuse or neglect. She stated, if you see something, say something. She stated she was in-serviced the night prior (07/09/25) by their regional corporate nurse regarding abuse and neglect. She stated the team had ensured all staff had her contact information, they sent mass text messages to all staff through their scheduling system, and did follow-up interviews with staff. She stated the DON was suspended because the IJ and not communicating to her the allegation of abuse with Resident #1. She stated NA A was suspended and then terminated due to the allegations made against her. Review of the facility's AD Hoc QAPI agenda, dated 07/09/25, reflected the ADM, the DON, ADON E, the SW, the AD, the HRD, and the MD were in attendance. Review of a Trauma Informed Assessment for Resident #1, dated 07/09/25 and completed by the SW, reflected no concerns. Review of witness statements, dated 07/09/25, reflected seven staff members' statements that had worked with NA A in some capacity alleging they had never seen NA A being abusive towards the residents. Review of safe surveys, dated 07/09/25, reflected interviewable residents had a safe survey completed by the AD with no concerns noted. Review of skin assessments, dated 07/09/25, reflected all non-interviewable residents had a completed skin assessment by a nurse with no concerns noted. Review of an in-service, dated 07/09/25 and conducted by the RCN, reflected the DON was in-serviced on the following: DON must report all allegations of abuse to the administrator as defined in 2014-14, asap. Every new allegation requires - Alleged perpetrators to be suspended immediately, new in-services initiated, new staff interviews, and new resident safe surveys. Review of an in-service, dated 07/09/25 and conducted by the RCN, reflected (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 10 of 19 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 07/10/2025 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete the DON, the ADM, ADON D, and ADON E, were in-serviced on the following: All allegations of abuse require a thorough investigation to include staff interviews and resident safe surveys. Review of an in-service, dated 07/09/25 and conducted by the RCN, reflected the DON, the ADM, ADON D, and ADON E, were in-serviced on the Abuse and Neglect provider letter. Review of an in-serviced, dated 07/09/25 and conducted by ADON E, reflected all staff for all shifts were in-serviced on the facility's Abuse and Neglect Policy. Review of an Employee Disciplinary Report for NA A, dated 07/09/25, reflected the following: [NA A] will be placed on investigatory suspension pending an investigation into allegations of resident mistreatment. Review of a Personnel Action Form for NA A, dated 07/10/25, reflected she was terminated due to failing to adhere to corporate code of conduct. The ADM was notified on 07/10/25 at 5:00 PM that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. Event ID: Facility ID: 675915 If continuation sheet Page 11 of 19 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 07/10/2025 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 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made for one (Resident #1) of ten residents reviewed for abuse. The facility failed to: - Ensure Resident #1 was free from verbal and emotional abuse by NA A on or around 05/30/25 and they failed to immediately suspend NA A (per their policy) as she had worked at the facility (26 shifts) since the incident. The facility did not investigate/report (to HHSC) the incident because the DON stated Resident #1 later denied the allegation. - Notify the Abuse and Neglect Coordinator (ADM) of the alleged abuse by NA A towards Resident #1 so it could be investigated and handled appropriately to ensure her safety. An Immediate Jeopardy (IJ) was identified on 07/09/25 at 3:24 PM and an IJ template was provided. While the IJ was removed on 07/10/25 at 5:00 PM, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy. These failures could place residents at risk of abuse, neglect, trauma, and psychosocial harm. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including morbid obesity, need for assistance with personal care, anxiety disorder, and age-related cognitive decline. Review of Resident #1's quarterly MDS assessment, dated 06/12/25, reflected a BIMS score of 15, indicating she was cognitively intact. Section GG (Functional Abilities) reflected she required substantial/maximal assistance for toileting hygiene. Review of Resident #1's quarterly care plan, dated 5/28/25, reflected she had an ADL self-care performance deficit with an intervention of requiring two staff participation to toilet. Review of the facility's self-reports to HHSC from 05/01/25 - 07/01/25, reflected no self-report regarding Resident #1 and NA A from 05/30/25. During an interview on 07/09/25 at 9:41 AM, CNA B stated the management staff were lax when it came to abuse and neglect. She stated the residents were in a vulnerable state and it was not fair to them to not take abuse seriously. She stated a couple of days after she first started working at the facility, on approximately 05/30/25, she was in training and shadowing CNA C. She stated Resident #1 had said something about not getting changed by NA A and CNA C asked Resident #1 about the situation. She stated NA A was walking past the room and heard the conversation. She stated NA A she charged into the room and at the resident and yelled, Keep my mother f****** name out of your mother f****** mouth! She stated Resident #1 was shaking and was terrified. She stated she told NA A she needed to leave Resident #1's room and CNA C had to walk NA A out of the room. She stated she told CNA C to ensure that incident was reported to management as it was verbal abuse. She stated she continued to see NA A working and asked ADON E why nothing had been done and ADON E told her CNA C had changed her statement and stated she had walked NA A out of the room before she said anything to Resident #1. She stated she wrote a statement and had assumed it had gone to the DON and was self-reported to the state. She was told that the DON told ADON E that without two written statements confirming it had happened, they could not do anything about it. CNA B was shown the four in-services (that had her name and signature on them) and she stated, You can tell these are copies! Look at the signatures - they are all the same! She stated she had not worked on any of those four dates and had been out of town on vacation. She stated, None of these are real. During an interview on 07/09/25 at 10:01 AM, Resident #1 stated she remembered NA A was sometimes mean to her. She stated she remembered (her recollection from the incident on 05/30/25) NA A telling her she was so big and her butt was so big it was hard to change her. She stated she had made her feel humiliated, ashamed, and scared. She stated the DON told her NA A would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 12 of 19 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 07/10/2025 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 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some not work with her anymore, but NA A continued to come and try to change her, and she would tell her no because she did not want her to provide care. She stated she did not believe NA A every got talked to by management. During an interview on 07/09/25 at 11:50 AM, ADON E stated the ADM was the abuse and neglect coordinator. She stated she did not witness the incident regarding NA A and Resident #1 on 05/30/25 but was told about it by CNA B. She stated she reported it to the DON and the DON told her she found it to be unsubstantiated. She stated she would expect for the incident to have been reported the state if it had not been. She stated the DON told her she would not bring it to corporate's attention unless there were two witnesses confirming it happened. She stated when she initially interviewed CNA C, she confirmed the events of the incident that CNA B had relayed to her. She stated when she wrote her statement, she changed the story and wrote that she never heard anything. She stated she told CNA C to document the truth, but she would not. She stated both witness statements were given to the DON. She stated NA A was never suspended and continued to work on Resident #1's hall. During an interview on 07/09/25 at 12:24 PM, the DON stated her expectations regarding safe surveys were that the SW conduct new surveys any time there was an incident of abuse or neglect. She stated the surveys should pertain to the residents who were cared for by the staff member that it had been alleged against. She stated, typically, the ADM was responsible for completing self-reports, but for the last five weeks (how long the new ADM had been working at the facility), the responsibility had fallen on the nursing side. She stated she remembered CNA B had reported (at the end of May 2025) to the ADON that Resident #1 told her NA A had yelled at her. She stated she believed statements were gotten from CNAs B and C. She stated when she interviewed Resident #1, she denied the allegation and she believed her because they had a therapeutic relationship. She stated she would have reported it to the state if Resident #1 had been cognitively impaired, but she had denied it and was cognitively intact. The witness statements for CNAs B and C were requested.During a telephone interview on 07/09/25 at 12:51 PM, the NP stated if there was an incident of alleged verbal abuse, she would expect the facility to investigate it if the patient was with it. She stated if the resident was confused, she was not sure if they should investigate it. She stated if the abuse was witnessed by another staff member, then that was a different story. She stated they should escalate it through their chain of command. She stated it was very important for staff to be in-serviced regularly on abuse and neglect to refresh them. During an interview on 07/09/25 at 2:11 PM, the ADM stated the DON could only find CNA C's witness statement regarding the incident with Resident #1. She stated that did not meet her expectations to only have the one statement. She stated ADON E told her she gave both statements to the DON and she was not sure what happened. She stated she started working at the facility around the time of the incident and was never notified of the allegation. She stated it did not matter if only one statement had been obtained. She stated the second an allegation of abuse or neglect was made towards a staff member; she would immediately suspend them and start her investigation. She stated if a resident then denied it, she would not go solely on that interview. She stated she would interview other staff that worked the same shift and the roommate of the resident alleging the abuse or neglect. She stated she would report all allegations of abuse or neglect to HHSC within two hours. She stated the DON was responsible for all self-reports as she (the DON) was clinical. She stated after an allegation was made; she should be made aware immediately. She stated the sooner they could get to the root cause, the sooner she could make the necessary adjustments. She stated not investigating was putting the residents in jeopardy of being harmed. Telephone interviews were attempted with NA A on 07/09/25 at 10:27 AM and 1:32 PM. A returned call was not received prior to exit. Telephone interviews were attempted with CNA C on 07/09/25 at 10:29 AM and 1:35 PM. A returned call was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 13 of 19 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 07/10/2025 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 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some not received prior to exit. Review of CNA C's witness statement, dated 06/04/25, reflected the following: On Friday the 30th [of May], we [CNAs B and C] were passing out morning trays. We went into [Resident #1]'s room and she was telling me something about the day before. As she was talking, [NA A] came in and saying things [sic]. So I politely turn [sic] [NA A] out of the room and let the resident finish talking. Then I went to report what had to place [sic]. It was noted under the statement that CNA C did not want to sign the statement. On the back of the statement, the DON documented, [Resident #1] (BIMS 15) denied hearing any cobe [sic] words or abusive language. Accusation unfounded. Review of the (reporting website), from 05/28/25 - 07/09/25, reflected no self-report for the incident on 05/30/25. Review of the facility's Abuse/Neglect Policy, revised 05/09/17, reflected the following: The resident has the right to be free from abuse. Verbal Abuse: Any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents. Mental Abuse: Includes, but not limited to, humiliation, harassment, threats of punishment or deprivation. Training: The facility will train through orientation and on-going in-services on issues related to abuse/neglect prohibition practices regularly. All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility protocol. Investigations will be reviewed by the facility administrator and/or Abuse Preventionist within 24 hours of complaint. With an allegation of abuse or neglect, the employee(s) will immediately be suspended pending an investigation. Review of the facility's Resident Rights Policy, revised 11/28/16, reflected the following: A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. The ADM was notified on 07/09/25 at 3:24 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 07/10/25 at 1:33 PM: The Surveyor monitored the POR on 07/10/25 as followed: Problem: On 07/09/2025 an abbreviated survey was initiated at the facility. On 07/09/2025, the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. Facility failed to notify the ADM (the abuse and neglect coordinator) when NA A verbally abused Resident #1 on or about 5/28/25 Interventions: One on One documented in-service on Abuse Investigation with the Administrator/DON was conducted by the Regional Compliance Nurse on 07/09/2025. This in-service included reviewing and conducting timely investigations and reporting for allegations per CMS provider letter PL-2024-14. Signatures confirmed verbal understanding. NA A suspended pending investigation on 07/09/2025 by facility administrator. Administrator and DON and ADON were provided a documented in-serviced by the Regional Compliance Nurse on conducting staff in-services for each individual self report on 07/09/2025, signatures confirmed verbal understanding. One on one documented inservice with DON on events about reporting all allegations of abuse to the administrator as defined in 2014-14. Alleged perpetrators are to be suspended immediately, new inservices and new staff and resident assessments are to be initiated with every new allegation. Signatures confirmed verbal understanding. Administrator and DON and ADON were in-serviced by the Regional Compliance Nurse related to conducting thorough investigation including current safe surveys for each separate self report on 07/09/2025. The medical director was notified of the immediate jeopardy situation on 07/09/2025 by ADON. On 07/09/2025 a trauma informed assessment was completed for Resident #1 BY SOCIAL WORKER. The resident denies all past and current trauma. ADHOC QAPI discussed with IDT on 07/09/2025.Monitoring All events / risk management will be reviewed 5 times a week by the IDT members for 6 weeks DON/Admin/Designee will interview 5-10 staff weekly x 6-week situational abuse scenarios had how to address effective 07/09/2025. DON/Admin/Designee will interview 5 residents how staff treat (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 14 of 19 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 07/10/2025 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 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some them weekly x 6 weeks effective 07/09/2025. ADO/Compliance Nurse will review all events/risk management to ensure timely/accurate investigation and reporting if needed weekly for 6 weeks effective 07/09/2025. ADO/Regional Compliance Nurse will monitor weekly x 6 weeks monitoring tools for staff and resident interviews effective 07/09/2025. The QA committee will review the findings monthly x 3 months and makes changes as needed. The Administrator will resolve once no further issues have been identified. Effective 07/09/2025. During interviews on 07/10/25 from 1:55 PM - 4:29 PM, staff from both shifts were interviewed, which included CNA F, LVN G, CNA H, LVN I, MA J, the SW, and the AD. They all stated they were in-serviced on abuse and neglect before their shifts as well as receiving text message alerts about reporting abuse to the ADM immediately. They all knew their abuse and neglect coordinator was the ADM. All staff stated they have the ADM's personal phone number, and it was also located by the copy machine. The staff stated they were required to notify the ADM of any suspicion of abuse or neglect immediately any day, any time. They stated that was to ensure all residents were safe and protected. They all were able to give examples of abuse which included verbal, mental, physical, and emotional. During an interview on 07/10/25 at 3:53 PM, ADON E stated the abuse and neglect coordinator was the ADM. She stated she had never seen a resident at the facility being abused or neglected. She stated if she had, she would ensure their safety which was the main priority, then would report it to the ADM. She stated it was not their duty to determine if something happened, it was their duty to report it immediately. She stated all residents received either a skin assessment or safe survey they day prior, 07/09/25. During an interview on 07/10/25 at 4:29 PM, the ADM stated she was the abuse and neglect coordinator. She stated she expected to be notified immediately of any allegation of abuse or neglect. She stated, if you see something, say something. She stated she was in-serviced the night prior (07/09/25) by their regional corporate nurse regarding abuse and neglect. She stated the team had ensured all staff had her contact information, they sent mass text messages to all staff through their scheduling system, and did follow-up interviews with staff. She stated the DON was suspended because the IJ and not communicating to her the allegation of abuse with Resident #1. She stated NA A was suspended and then terminated due to the allegations made against her. Review of the facility's AD Hoc QAPI agenda, dated 07/09/25, reflected the ADM, the DON, ADON E, the SW, the AD, the HRD, and the MD were in attendance. Review of a Trauma Informed Assessment for Resident #1, dated 07/09/25 and completed by the SW, reflected no concerns. Review of witness statements, dated 07/09/25, reflected seven staff members' statements that had worked with NA A in some capacity alleging they had never seen NA A being abusive towards the residents. Review of safe surveys, dated 07/09/25, reflected interviewable residents had a safe survey completed by the AD with no concerns noted. Review of skin assessments, dated 07/09/25, reflected all non-interviewable residents had a completed skin assessment by a nurse with no concerns noted. Review of an in-service, dated 07/09/25 and conducted by the RCN, reflected the DON was in-serviced on the following: DON must report all allegations of abuse to the administrator as defined in 2014-14, asap. Every new allegation requires - Alleged perpetrators to be suspended immediately, new in-services initiated, new staff interviews, and new resident safe surveys. Review of an in-service, dated 07/09/25 and conducted by the RCN, reflected the DON, the ADM, ADON D, and ADON E, were in-serviced on the following: All allegations of abuse require a thorough investigation to include staff interviews and resident safe surveys. Review of an in-service, dated 07/09/25 and conducted by the RCN, reflected the DON, the ADM, ADON D, and ADON E, were in-serviced on the Abuse and Neglect provider letter. Review of an in-serviced, dated 07/09/25 and conducted by ADON E, reflected all staff for all shifts were in-serviced on the facility's Abuse and Neglect Policy. Review of an Employee Disciplinary Report for NA A, dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 15 of 19 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 07/10/2025 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 0609 Level of Harm - Immediate jeopardy to resident health or safety 07/09/25, reflected the following: [NA A] will be placed on investigatory suspension pending an investigation into allegations of resident mistreatment. Review of a Personnel Action Form for NA A, dated 07/10/25, reflected she was terminated due to failing to adhere to corporate code of conduct. The ADM was notified on 07/10/25 at 5:00 PM that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 16 of 19 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 07/10/2025 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews the facility failed to ensure in response to allegations of abuse, neglect, or mistreatment, have evidence that all alleged violations were thoroughly investigated and report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for two of ten (Resident #6 and Resident #7) residents reviewed for Abuse and Neglect. The facility failed to thoroughly investigate and report within 5 working days, when Resident #6 reported her roommate, Resident #7, hit her and twisted her arm on 06/14/25. The Provider Investigation Report was due on 06/19/25 but was not submitted until 07/09/25 This failure could place residents at risk for abuse, neglect, and exploitation. Residents Affected - Some Findings included: Resident #6 Review of Resident #6’s undated face sheet reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Her primary diagnosis was unspecified dementia, moderate, without behavioral disturbance, mood disturbance, and anxiety. Secondary diagnoses included major depressive disorder, hypertension (high blood pressure), rheumatoid arthritis (chronic inflammation, usually in the joints causing pain and swelling but can affect the eyes, lungs, and heart), heart failure, and insomnia. Review of Resident #6’s quarterly MDS assessment, dated 04/02/25, reflected a BIMS score of 11 which indicated moderately impaired cognition. The MDS reflected some feelings of isolation but no other mood or behavior symptoms. The MDS reflected no hallucinations or delusions. Review of Resident #6’s comprehensive care plan, revised 02/11/25, reflected in part, “Focus – The resident has impaired cognitive function and impaired thought process due to dementia. Goal – The resident will be able to communicate basic needs on a daily basis through the next review date. Interventions – Administer meds as ordered. Communicate with the resident//family/caregivers regarding residents’ capabilities and needs…” Review of Resident #6’s progress note written by LVN K, dated 06/14/25 at 11:51 AM, reflected, “This nurse was notified by (Resident #6) that her roommate (Resident #7) twisted her right arm while they were both in their room. Resident (#6) stated, (Resident #7) held my arm and twisted it and she was hitting my arm and now my arm is twitching. Assessed resident's arm, no bruising, no swelling, or redness noted. Resident rates right arm pain 4/10, PRN Tylenol 325mg x2=650mg admin. Resident able to move arm without any facial grimacing. VS 100/68, 77, 16, 98.4 97% on room air. Resident's room was changed to (number). On call NP (name) notified, received new order for X-ray to right arm and to call back with results. DON notified, administrator was notified by DON. RP (Name) Notified.” [sic] Resident #7 Review of Resident #7’s undated face sheet reflected an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted [DATE]. Her diagnoses included vascular dementia unspecified severity with agitation, unspecified fracture of right femur (large bone in the top of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 17 of 19 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 07/10/2025 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 0610 leg), hypertension (high blood pressure), and diabetes. Level of Harm - Minimal harm or potential for actual harm Review of Resident #7’s quarterly MDS assessment, dated 06/26/25, reflected a BIMS score of 3 which indicated severely impaired cognition. The assessment reflected no inattention, no disorganized thinking, and no behavior symptoms. Residents Affected - Some Review of Resident #7’s comprehensive care plan, revised 04/02/25, reflected in part, “Focus – The resident has potential to demonstrate physical behaviors Dementia [sic]. Goal – The resident will not harm self or others through the review date. Interventions – Assess and address for contributing sensory deficits. Assess and anticipate resident’s needs… Communication: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation…” Review of Resident #7’s progress note written by LVN K, dated 06/14/25 at 2:44 PM, reflected, “this writer was notified by (Resident #6) that (Resident #7) twisted her right arm while hitting her. Resident (#7) stated, ‘I didn’t do it, that’s a lie.’ Resident is alert and confused, does not appear to be in distress or discomfort. Resident keeps following roommate everywhere she goes… DON/Administrator notified, called RP (name) notified, NP notified by communication form…” Review of the facility’s self-report binder reflected the initial Self Reporting Template but no Provider Investigation Report – form 3613 -A. Review of the intake reporting system reflected the PIR was submitted on 07/09/25. During an interview on 07/08/25 at 3:06 PM, the Provider Investigation Report (PIR) was requested from the DON. During an interview on 07/09/25 at 12:23 PM, the DON stated for last 5 weeks, nursing had been investigating and completing the self-reports. Regarding the incident on 06/14/25 between Resident #6 and Resident #7, the DON stated she had reported and investigated the allegation. The DON stated she was told, “Resident #6 reported someone came in the room and hit her.” The DON stated she asked Resident #7 if anyone had been in the room and Resident #7 denied anyone else being in the room. The DON stated she was not aware that Resident #7 was the person accused of hitting Resident #6. The DON stated the SW was responsible for completing safe surveys. She stated it did not meet her expectations that the surveys were completed 11 days after the allegation was made. She stated the surveys should have been done the next practicable business day. The DON stated the Abuse Coordinator was responsible for investing and reporting. During an interview on 07/09/25 at 2:10 PM, the ADM stated she was the Abuse Coordinator. She stated the DON was not able to locate the Provider Investigation Report yesterday after the document was requested. The ADM stated she checked her email and did not find a copy of the report. The ADM stated she submitted a PIR report to HHSC on the evening of 07/08/25. She stated it was her expectation that every allegation was thoroughly investigated, safe surveys were conducted, and staff were in-serviced within the five-day period. Review of the facility’s Abuse/Neglect policy, revised 05/09/17, reflected in part, “D. Identification. The facility will identify and investigate events that may constitute abuse/neglect. The facility will determine the direction of the investigation based on a thorough examination of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 18 of 19 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 07/10/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete events… F. Investigation. Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist. All allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknow source will be investigated. 1. The administrator in consultation with Risk Management Department will be responsible for investigating and reporting cases to the HHSC… 3… The written report must be sent to HHSC no later than the fifth working day after the initial report. The facility will use the designated state reporting form. 6. The Abuse Preventionist and/or administrator will conduct a thorough investigation of the incidents(s)… Resident to Resident. The above policy will apply to potential resident-to-resident abuse. Provider letter 17-18 will be reviewed to determine if resident-to-resident abuse occurred.” Event ID: Facility ID: 675915 If continuation sheet Page 19 of 19