Inspection·October 6, 2025

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few in the locked cabinet in the DON office. She stated the meds were counted and signed by two nurses. A sticker from the medication label was placed on the log sheet and the quantity of medication was added to the log. The medication and log sheet were then locked in the drawer. She stated the DON was responsible for the key to the locked cabinet and now with a second lock on the drawers, the ADM was responsible for the second key. The CN stated it now required both the DON and the ADM to unlock the cabinet. During an interview on 10/02/25 at 11:17 AM, LVN E stated the process was discontinued controlled medications were taken off the medication cart and given to the DON or ADON when they did not have a DON in the building. She stated the medication was counted, both nurses signed the count sheet then the DON stored the medications. During an interview on 10/02/25 at 11:44 AM, CNA G stated she worked as both a CNA and a medication aide. She stated when controlled medications were discontinued, the DON was notified. The medications were counted and the count sheet signed by both staff. The DON then secured the medications. During a telephone interview on 10/02/25 at 12:04 PM, the DON stated she had worked at the facility for about a month. She stated she was not familiar with the policy for medication disposal at the facility as she had not reviewed all the facility policies. She stated she was told ADON H managed discontinued controlled medications, and she did not ask any questions. She stated the medications were supposed to be always double locked. She stated she was responsible for the keys to the locked medication storage. During an interview on 10/02/25 at 3:08 PM, ADON H stated after she discovered the medications were missing, she ran a report for discontinued controlled medications since the previous drug destruction on 08/28/25. Some of the medications on the report were reordered and on the medication cart or otherwise accounted for. She stated there was no way to know how many pills were missing as the control drug count sheets, usually wrapped around the medication cards, were also missing. During an interview on 10/02/25 at 3:53 PM, the ADO stated the DON was responsible for medication storage and destruction. She stated missing controlled medications did not meet her expectations. During an interview on 10/02/25 at 4:18 PM, the ADM stated she left the medication storage to the DON. She stated the DON was experienced and had clinical knowledge regarding controlled mediations and medication storage. She stated she expected the medications were stored properly and secure. The ADM stated the DON was responsible for the controlled medication storage, destruction, and keys. The ADM stated the cabinet for controlled medications waiting for destruction, required her and the DON, or ADON while the DON was out, to access the medications in the drawer. She stated she had the key to the padlocks on the drawers, and the DON had the key to the cabinet lock. She stated the new process required the Drug Destruction Log was copied every time medications were added or removed from the drawer. She stated the Drug Destruction Log was also copied every Friday. The ADM stated the copies of the logs were kept in her office. The ADM stated the code to the DON office had been changed and only a limited number of people had the new code. The ADM stated ADON I had in-serviced the nurses and medication aides on the new procedure. The ADM stated the facility received authorization to terminate the DON. During a telephone interview on 10/06/25 at 9:21 AM, the local Police Department dispatcher stated a detective had not yet been assigned to the case and there was no new information available regarding the report of missing controlled medications. Review of the Abuse/Neglect policy, revised 09/09/24, reflected in part, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. Definitions: 9. Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Prevention: 3. All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility protocol. Review of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 2 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675915 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2025 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Controlled Medication Disposal policy, dated v3-2025, reflected in part, 1. The Director of Nursing and when applicable the Consultant Pharmacist are responsible for the facilities compliance with federal and state laws and regulations in the handling of controlled medications. Only authorized licensed nursing, legally authorized personnel and pharmacy personnel have access to controlled medications. 3. Schedule II, III, IV and V medications remaining in the facility after the resident has been discharged , or the order discontinued, are disposed either in the facility by legally authorized personnel, Director of Nursing, and Consultant Pharmacist. Review of the Drug Destruction policy, dated v3-2025 reflected, Policy - In the event that the facility must destroy medications (Controlled or Non-Controlled) the facility will adhere to the rules and regulations of their specific State Health Department as well as any other regulating body including but not limited to the Drug Enforcement Agency (DEA), State Board of Pharmacy, and OSHA. If contracted with a (Pharmacy) Consultant Pharmacist, they will be able to provide guidance as it to a drug destruction process for the facility. Procedure - 1. Each facility will review and adhere to all governing bodies related to the subject of Drug Destruction. 2. Specific consideration to NIOSH and other Hazardous medications will be strictly adhered to. Event ID: Facility ID: 675915 If continuation sheet Page 3 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675915 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 2 residents reviewed for accidents and supervision. The facility failed to supervise Resident #1 when she exited the facility through a door at the end of a hallway, walked down eight steps, across the parking lot and two traffic lanes then on to the center median of the road on 09/01/25. The speed limit on the road was 40 MPH. The noncompliance was identified as PNC (Past non-compliance). The IJ (Immediate Jeopardy) began on 09/01/25 and ended on 09/03/25. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk of injuries and accidents.Findings included: Review of Resident #1's face sheet, printed on 10/01/25, reflected an [AGE] year-old female readmitted to the facility on [DATE]. Her diagnoses included metabolic encephalopathy (brain dysfunction causing confusion or memory loss), age-related cognitive decline, cerebral infarction (stroke), and vascular dementia (cognitive impairment caused by impaired blood flow to the brain). Review of Resident #1's quarterly MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 7 which indicated severely impaired cognition. Section E (Behavior) reflected no wandering or other behaviors. Section GG (Functional Abilities) reflected Resident #1 was able to walk 150 feet with supervision or touching assistance. Review of Resident #1's comprehensive care plan, dated 07/21/25, reflected entries for impaired cognition, risk for falls, self-care deficit, and others. There were no entries regarding elopement. Review of Resident #1's elopement assessment dated [DATE], reflected a score of 7 which indicated she was not at risk for elopement. Review of Resident #1's progress note dated 09/01/25 at 3:51 PM, written by LVN A, reflected, Res walked out of the premises through the 500 door, res stated hse[sic] was going to sons house, son was already in the building during the incident. Res is ok with no issues. [sic] Review of Resident #1's progress note dated 09/01/25 at 4:11 PM, written by LVN A, reflected, Event - Elopement/Attempted BP-124/75. T-98.0. P-79. R-18. BS-N/A. Door Exited: 500 How long missing: less 10minutes Where was the resident discovered: outside the premises Injuries: No. Cognition / Behavior at Time of Event: Cognitive Impairment, Wanders, Requires cueing, res was walking along the 200 and 500 halls as usual when the family came to visit and the staff could not locate where the res was, seconds later res was noted to have gone out through the 500 back door without any supervision. res redirected back to the facility and head to assessment done, no injuries or bruises noted. np, don/adon aware. Initial Treatment/New Orders: n/a . Resident Statement: ' I WAS GOING TO MY SON HOUSE' [sic]Review of a statement dated 09/01/25, written by LVN V, reflected LVN V saw Resident #1 walking, with her walker, on the 500-hall at 4:20 PM. They spoke briefly and LVN V continued towards the nurses station. Review of a statement dated 09/01/25, written by MA W, reflected MA W was on the 500-hall after a medication pass and saw Resident #1 and LVN V have a brief encounter in the hall. Review of a statement dated 09/01/25, written by HA X, reflected HA X went to open the front door for a visitor around 4:30 PM. The visitor pointed towards the road where a few people were gathered. HA X notified a nurse in case the resident was in need of medical attention. Review of an email dated 09/02/25 at 6:51 PM, written by the ADM, reflected in part, It appears that the alarms on the doors work some of the time and not all the time. The alarm automatically shuts off at 15 seconds and no one heard it even in the offices at the beginning of the hall. During an observation and interview on 10/01/25 at 10:12 AM, MW B stated the door alarms were wired into the fire panel near the nurse's station. He stated if the door was pushed, it would open, and the alarm would sound. He stated staff must enter the proper code to turn off the alarm. MW B (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 4 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675915 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few opened the door at the far end of the 300-hall and the alarm made a very loud constant noise. Several staff were observed responding to the alarm. MW B entered a code into the keypad and the alarm went quiet. During an observation and attempted interview on 10/01/25 at 12:39 PM, Resident #1 was observed lying in her bed in the secured unit. She smiled and stated she liked it in her room. She did not engage in further conversation and did not answer if she remembered walking out of the building. During a telephone interview on 10/02/25 at 9:05 AM, the CN stated as part of the elopement prevention plan, anyone who was at high risk for elopement had care plan interventions in place and that information was available to nurses and aides. She stated prior to the elopement on 09/01/25, Resident #1 was not assessed as being at risk for elopement. During an interview on 10/02/25 at 10:22 AM, the MS stated he started working at the facility on 09/08/25, but he was aware of the elopement on 09/01/25. He stated the old door alarm used batteries, and the new alarms were wired and worked without batteries. He stated the exit doors were all wired into the system and would turn off after a code was entered into the keypad at the door. He stated the staff had the code for the door alarms. He stated he was responsible to change the code every month or more often if needed. He stated they facility had conducted elopement drills three times a week on various shifts since the elopement. During an interview on 10/02/25 at 10:48 AM, MA C stated she received training from ADON I on elopements about a month ago. She stated if she could not find a resident, she notified the nurse or ADM immediately then searched everywhere. She stated any time a door alarm was activated, the area by that door was searched before the alarm was turned off. During an interview on 10/02/25 at 10:57 AM, LVN D stated a Code Orange referred to an elopement. She stated in the in-service she learned when the code orange was called, staff searched and counted every resident. Once it was established that someone was missing, the searchers looked outside and kept looking. She stated there were elopement drills, almost daily and staff actively participated in the drills. She stated she received training on elopements and ANE provided by ADON I. LVN D was able to speak to the ANE policy and gave an example of neglect. During an interview on 10/02/25 at 11:36 AM, LVN E stated she was trained on elopement prevention and response by ADON I. She learned if a resident was missing, she let everyone know and began the search. She stated staff had to look in every room and bathroom then the ADM or other leader gave further directions. She stated when a door alarm sounded, staff checked inside and outside before the alarm was turned off with the code. LVN E stated if a resident got out unnoticed, they could have been injured on the highway out in front of the facility. During an interview on 10/02/25 at 11:36 AM, CNA F stated she had received training on elopement and abuse and neglect from ADON I. She described the process of how they searched for a missing resident and responded to a door alarm. She learned if an alarm sounded, you checked the whole area around the door, inside and outside to make sure someone did not go outside. She stated if someone got out, they could get hurt in the road. She was able to speak to the Abuse and Neglect policy. During an interview on 10/02/25 at 11:44 AM, CNA G learned if a resident was missing, it was reported to the charge nurse and the ADM, and a Code Orange was called and everyone searched for the resident. She stated the facility had frequent elopement drills. She stated she worked with Resident #1 on the secured unit. CNA G stated she received the elopement and Abuse and Neglect training that was provided by ADON I. During a telephone interview on 10/02/25 at 12:04 PM, the DON stated she had worked at the facility for about a month. She described the process for Code Orange, elopement prevention, and elopement response. She stated when Resident #1 eloped on 09/01/25, there was some kind of issue with a door. The DON stated she was in the ADM's office when there was a commotion at the front door of the facility. She stated a passerby saw Resident #1 in the median of the road and came to the facility door to alert staff. She stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 5 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675915 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Resident #1's FM had entered the facility a few minutes before, and the FM had been looking for her in the facility. The DON stated Resident #1 was brought inside and a head-to-toe assessment was conducted with no injuries identified. She stated the resident was assessed and moved to the secured unit. The DON stated the following day she completed new elopement assessments on every resident in the facility. The DON stated the facility had conducted elopement drills three times a week since the elopement. On 10/02/25 at 2:43 PM, a telephone voice message was left for LVN A. A telephone call was not returned prior to exit. During an interview on 10/02/25 at 3:08 PM, ADON H stated when a resident was missing, they completed a room sweep, looked in restrooms, bedrooms, and common areas. The charge nurse who was not assigned to the missing resident, delegated where staff went to look. If the resident was not found inside, they continued the search outside. She stated residents were assessed for elopement risk on admission, quarterly and as needed. She stated if a resident was a high-risk for elopement and actively exit-seeking, the Secure Care team assessed the resident and if appropriate, the resident was moved to the secure unit. During an interview on 10/02/25 at 3:35 PM, the ADO stated Resident #1 went out the hallway door looking for her FM at the same time the FM entered the building. She stated the door alarm sounded briefly then stopped so staff assumed it was okay. The ADO stated they contracted a company to install new locks and alarms. She stated the new alarms were in place. She stated the alarm will continue to sound until staff enter a code. She stated it was her expectation that staff checked the area before they turned off the alarm. During an interview on 10/02/25 at 4:18 PM, the ADM stated staff had been educated on elopement prevention and elopement response. She stated the facility had elopement drills three times per week. She stated after Resident #1 eloped, they checked all the exit doors then monitored the doors every 15 minutes until the new alarm was in place. The ADM stated she sent out messages to all staff when there was an issue. She stated she attached policies to the messages for staff to review. She stated their messaging program showed if the messages were sent and received. She stated the ADONs, and treatment nurse also provided in-services to staff. During an interview on 10/06/25 at 9:36 AM, LVN J stated she was in-serviced on elopement by administration recently. She learned code orange meant someone was missing. She learned to conduct a resident head count and assign staff to search the premises and assign staff to notify administration, police, and the responsible parties. During an interview on 10/06/25 at 9:39 AM, LVN K stated she had been in-serviced on elopement again last week by administration. She learned to check sign-in and sign-out sheets, check common areas, yell out code orange. She stated staff were assigned to search specific areas or notify the ADM, DON, and responsible parties. During an interview on 10/06/25 at 9:42 AM, LA L stated she was in-serviced on elopement by administration. She learned to stop what she was doing and join the staff huddle at the nursing station. Staff would then be assigned specific tasks like searching inside or outside. During an interview on 10/06/25 at 9:45 AM, PTA M stated she was in-serviced on elopement by administration. She learned to stop what she was doing, notify the nurse, and staff huddle at nursing station, where staff got assigned to search for a resident inside and outside premises whenever there was a code orange (missing resident). During an interview on 10/06/25 at 9:47 AM, using an interpreter, HSKP N stated she had been in-serviced on elopement by administration. She stated she learned to search for residents inside and outside facility premises whenever a code orange was called. During an interview on 10/06/25 at 9:50 AM, HSKP O stated she had been in-serviced on elopement by administration. She learned to search for residents inside and outside facility premises whenever there was a code orange. During an interview on 10/06/25 at 9:51 AM, OTA P stated she was in-serviced on elopement by administration recently. She learned if a code orange is called, she was required to search for resident in the facility, alert (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 6 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675915 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the on-call nurse, check the exits, and search for resident inside and outside facility. During an interview on 10/06/25 at 9:53 AM, RN Q stated she was in-serviced last Wednesday during a drill, on elopement by administration. She learned to coordinate staff search parties, search rooms, bathrooms and exit doors, conduct resident head count, and notify ADM, DON, family, and responsible party. She stated she had been in-serviced on Abuse and Neglect and identified the ADM as the abuse coordinator. During an interview on 10/06/25 at 9:56 AM, DA R stated he was in-serviced by the administration on elopement recently. He learned to check sign in and out sheets, notify the ADM and DON , and search inside and outside facility premises. During an interview on 10/06/25 at 9:58 AM, [NAME] S stated he was in-serviced by the administration on elopement. He learned to notify the Administrator, go to nursing station, get assigned search party, and search inside and outside facility premises. During an interview on 10/06/25 at 10:02 AM, ADON I stated she was responsible for most of the training in the facility. She stated the day Resident #1 eloped, she in-serviced staff in the facility on elopement prevention and response, and neglect in general. She stated messages were sent to all staff not in the facility. ADON I stated there were staff assigned to look at the doors, around the clock, until the alarms were installed. On 10/06/25 at 10:20 AM, a telephone voice message was left for LVN A. A telephone call was not returned prior to exit. During a telephone interview on 10/06/25 at 10:23 AM, CNA T stated he was new to the facility, and he worked the night shift. He stated he had been in-serviced by administration on elopement. He learned if a resident was missing, he notified the nurse and began to search as directed by the charge nurse. He stated he had been in-service on Abuse and Neglect and had also received the documents by text. He was able to speak to the ANE policy and named the ADM as the abuse coordinator. During a telephone interview on 10/06/25 at 10:31 AM, CNA U stated she usually worked night shift. She stated she had been in-serviced on elopement and Abuse and Neglect by administration. She learned an elopement was called a code orange. When the code orange was announced, everyone looked for the missing resident. She stated she participated in elopement drills and attended a group in-service. CNA U stated she was in-serviced on ANE by administration. She stated the ADM was the abuse coordinator. She stated she learned abuse must be reported immediately. CNA U verbalized types of abuse and examples. She learned neglect was not doing whatever it was that the resident needed. Review of the facility's self-report to HHSC, dated 09/01/25, reflected the ADM reported Resident #1's elopement the same day it occurred. Review of the AD Hoc QAPI agenda, dated 09/02/25, reflected the ADM, DON, ADON H, ADON I, SSD, DFN, AD, MDSN, HSKP Sup, CN, and two others attended the meeting. The MD participated by telephone. Review of Resident #1's care plan, revised 09/02/25, reflected she was a high elopement risk. Interventions included providing structured activities, and if exit-seeking stay with the resident and call out for assistance. Review of Resident #1's elopement assessment dated [DATE], reflected a score of 27 which indicated she was at high risk for elopement. Review of the progress noted dated 09/02/25 at 5:01 PM, written by the SSD, reflected a Trauma Informed Assessment was completed. The assessment reflected no signs of distress or agitation observed. Review of an email dated 09/02/25 at 9:22 AM, written by ADON H, reflected Resident #1's RP was notified of the room change to the secured unit. Review of a service proposal, dated 09/03/25, reflected the work to be performed by (Company) to add various locks, timers, and power supplies for repair/replacement of current door alarms. The proposal was approved and signed by the ADO. Review of a Midnight Census Report, dated 09/02/25, reflected each resident in the facility had an Elopement Risk Assessment completed. Review of six sampled electronic medical records reflected an Elopement Risk Assessments had been completed on 09/02/25. Review of an in-service, dated 09/01/25 and conducted by ADON I, reflected all staff were in-serviced on Elopement Response. Review of an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675915 If continuation sheet Page 7 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675915 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete in-service, dated 09/01/25 and conducted by ADON I, reflected all staff were in-serviced on Code Orange Elopement Policy, Elopement Response when alarm sounds, Abuse and Neglect Policy, and Abuse Coordinator is the Administrator. Review of an in-service, dated 09/01/25 and conducted by ADON I, reflected all staff were in-serviced on Abuse and Neglect. Review of an employee roster dated 09/02/25 reflected a text message sent by the ADM to all employees on 09/01/25 at 6:23 PM. The message read, Please find attached for your review the In-services on Elopement Prevention and Elopement Response. Review of a screen shot of a group text message, dated 09/03/25 at 2:07 PM, reflected eleven therapy staff had received and reviewed the Elopement response, elopement prevention, and Abuse and Neglect in-services that had recently been sent to all employees. Review of an elopement Prevention QA Check List, dated 09/08/25, reflected in part, (Company) started replacement of door alarms beginning 9/4, 9/5 returned 9/8 ETA completion 9/9. Review of Q 15 Minute Check sheets dated 09/01/25 and 09/02/25, reflected the exit doors on the 100/DR, 200-, 300-, and 500-hall and dining room were monitored every 15 minutes. Review of the 30 Minute Check sheets dated 09/02/25, reflected the monitoring of the exit doors were changed to every 30-minute monitoring at 8:30 PM. Monitoring continued until 09/09/25 at 7:00 PM when the last door alarm was fixed. Review of Resident Elopement Search Drill sign in sheets dated 09/03/25 through 10/01/25, reflected the facility conducted elopement search drills twice the week of the elopement, three times per week for the next three weeks, and twice during the fifth week. Review of a letter from (Company), the work outlined on the service proposal dated 09/03/25, had been completed as of 09/26/25. Review of the undated Elopement Prevention policy reflected in part, Every effort will be made to prevent elopement episodes while maintaining the least restrictive for residents who are at risk for elopement. 1. The Elopement Risk Assessment will be completed upon admission. The Elopement Risk Assessment is to be completed at least quarterly and upon change of condition. 4. The resident's care plan will be modified to indicate the resident is at risk for elopement episodes. 5. Interventions into elopement episodes will be entered onto the resident's care plan and medical record. 6. Should an elopement episode occur, the contributing factors, as well as the interventions tried. will be documented on the nurses' notes. Director of Risk Management and\or Director of Nursing Services should be notified of elopement. 7. If a resident is discovered to be missing, a search shall begin immediately. All facility exits that residents have access to will have a device in place to alert staff of possible elopement attempts.The noncompliance was identified as PNC (Past non-compliance). The IJ (Immediate Jeopardy) began on 09/01/25 and ended on 09/03/25. The facility had corrected the noncompliance before the survey began. Event ID: Facility ID: 675915 If continuation sheet Page 8 of 8