Park Place Care Center

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.

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Printed: 04/13/2026 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

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.

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