Health inspection·February 26, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and fear about everyday situations), weakness, major depressive disorder (feeling of sadness), protein-calorie malnutrition, myopia (near sightedness), pain and catatonic disorder (disorder that disrupts how the brain works). Record review of Resident #83's Quarterly MDS dated [DATE] revealed that Resident #83's BIMS score was a 14 indicating intact cognitive responses. The MDS also revealed that Resident #83 had supervision or touching assistance with eating. Observation of lunch hall trays being passed on 02/24/2025 at 12:49 p.m., revealed CNA A did not knock on Resident #83's door before entering. Observation of lunch hall trays on 02/24/2025 at 12:55 p.m., revealed CNA B walked into Resident #58, and Resident #83's rooms without knocking. During an interview with Resident #83 on 02/25/2025 at 2:27 p.m., revealed that staff do not always knock on his door before coming in. He said he would prefer for staff to knock all the time when they come to check on him. He said he does not get upset when staff do not knock. During an interview with Resident #63 on 02/26/2025 at 8:10 a.m., revealed that she did not want to talk to surveyor. She said staff aways knocked. During an interview with Resident #58 on 02/26/2025 at 8:15 a.m., revealed that staff do not knock on his door before entering. He said he tried to stop the staff but said staff do not listen to him. He said staff not knocking happened all the time. He said that it would really upset him when staff just came in his room. He said it especially upsets him if he is doing something or sleeping. He said he wanted staff to knock all the time. During an interview with CNA A on 02/26/2025 at 9:05 a.m., revealed that she had been trained on resident rights. She said the policy for knocking was that staff were supposed to knock and wait for a response to come in. She also said if they do not answer to knock again. She said staff were to knock anytime they wanted to enter a resident's room. She said if staff do not knock the resident may feel like his or her rights are being violated. She said that management monitors to ensure staff are knocking on the resident's doors by observation and keeping an eye on staff. She said she realized after going in Resident #63's room that she did not knock on the door. She said that her mind was somewhere else, and she knew she should have knocked. During an interview with the DON on 02/26/2025 at 10:53 a.m., revealed she and staff had been trained on resident rights. She said the policy was that staff were to knock and wait for a response before entering the resident's room. She said all staff were required to always knock on the resident's door before entering. She said the resident may not feel like their privacy is being invaded. She said that all staff were responsible for monitoring to ensure staff are knocking when doing rounds. She said she did not know why staff were not knocking on the residents' doors. She said she thought the staff were just nervous about the surveyor being there. During an interview with CNA B on 02/26/2025 at 11:18 a.m., revealed that she had been trained on resident rights. She said that staff were supposed to knock on all residents' doors before entering. She also said that staff were supposed to introduce themselves and tell the resident what they were there for. She said there was no reason staff should not knock on the resident's door before entering. She said by staff not knocking the resident may feel as if their privacy is being invaded. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675596 If continuation sheet Page 2 of 12 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 675596 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Barton Valley Rehabilitation and Healthcare Center 4501 Dudmar Dr Austin, TX 78735 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some also said that she would want someone to knock on the door and staff should be respectful. She said the nurses usually sat at the nurse's station and watched to ensure staff were knocking. She said on Resident #58 and Resident #83 she just wanted to get their meal trays to them because the meal trays were late and sometimes the residents would get upset. During an interview with the ADM on 02/26/2025 at 11:33 a.m., revealed that she and staff had been trained on resident rights and knocking on residents' doors. she said the policy was to knock on the door and wait to be invited in, she said all staff were supposed to knock before entering the resident's room. She said that there was not a reason for staff not to knock on the resident's door. She said residents could feel like they did not have privacy if staff did not knock. She said that everyone should be monitoring that staff are knocking on the door but mainly management. She said management monitors it by reviewing grievances, resident council minutes, and observation. She said she did not know why staff were not knocking on resident's doors before entering. Record review of Resident Rights Policy revised 12/2016 revealed the resident has a right to a dignified existence; be treated with respect, kindness and dignity; privacy and confidentiality. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675596 If continuation sheet Page 3 of 12 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 675596 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Barton Valley Rehabilitation and Healthcare Center 4501 Dudmar Dr Austin, TX 78735 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to conduct a comprehensive assessment of a resident in accordance with the timeframes, within 14 calendar days after admission, excluding readmission in which there is no significant change in the resident's physical or mental condition and not less than once every 12 months for 1 of 18 residents (Resident #47) reviewed for comprehensive annual assessments. The facility failed to ensure Resident #48's annual MDS Assessment was completed within 14 days of the ARD. This failure could place residents at-risk of not having their assessments completed timely, which could result in denial of services and or payment for services. The findings include: Record review of Resident #48's admission Record, dated 02/26/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #48 had diagnoses which included respiratory failure, heart failure, weakness, long term use of blood thinners, edema (swelling), viral hepatitis C, retention of urine, protein-calorie malnutrition, insomnia (difficulty sleeping), morbid obesity, and high blood pressure. Record review of Resident #48's Annual/5 Day Assessment MDS with an ARD of 02/18/2025, revealed Section Z of the MDS, Z0400 revealed sections B, C, D, E, and Q were done by the SW and signed on 02/17/2025. Section K was done by the KM and F was completed by the AD and signed on 2/17/2025. Section M was the last section completed by the UM and signed on 02/18/2025. Section Z of the MDS, Z0400. Signature of RN Assessment Coordinator Verifying Assessment Completion had not been completed as of exit on 02/26/2025. During an interview with the DON on 02/26/2025 at 11:00 a.m., revealed that she had been trained on MDS. She said that corporate was doing the MDS's at this time. She said she knows there are certain times that the MDS had to be done in, but she would have to look it up to see the time for each MDS. She said an MDS was completed quarterly, annually, when the resident had a change in condition, discharge, admission and if the resident had a significate change. She said the negative outcome for not completing the MDS was that the facility would not get paid. She said the facility had a schedule, and policy and procedures and the facility were to follow them. She said corporate was responsible for doing the MDS's timely. She said that corporate would monitor it through the electronic records. She said she did not know why Resident #48's MDS had not been completed. During an interview with the ADM on 02/26/2025 at 11:36 a.m., revealed she had been trained on MDS. She said that the facility currently did not have a MDS coordinator. She said the MDS coordinator would have been the one to communicate with corporate about the MDS since corporate was doing the MDS. She said that the facility had 21 days to complete the MDS. She said a negative outcome was the facility would not get paid. She said she could not think how it would affect the resident. She said that the DON and herself were responsible for ensuring the MDS was done timely. She said that her and the DON monitored it through their morning meeting. She said that Resident #48's MDS was not late she said she had 14 days started from the time the facility closed the Entry MDS. She said that the facility had until 3/3/2025 to finish the MDS. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675596 If continuation sheet Page 4 of 12 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 675596 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Barton Valley Rehabilitation and Healthcare Center 4501 Dudmar Dr Austin, TX 78735 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with CN C on 02/26/2025 at 11:57 a.m., revealed that she had been trained on MDS. She said she had been doing MDS since 2013. She said she was responsible for doing the MDS's because the facility currently did not have an MDS nurse. She also said some of the other facilities the company had would also help. She said MDS were updated daily. She said the time for completing the MDS was at entry within 7 days of coming in, must be completed within 14 days of admission, 92 days for quarterly or significate change. She said if an MDS was not done, it would be considered late. She said it was important to have the MDS done timely as it reflected what treatment the facility was doing for the resident. She said it would also reflect their diagnosis or if there was a decline. She said it was an IDT team group effort. She stated she is responsible for monitoring to ensure MDS are done timely. She stated it was monitored by her Monday through Friday and she would look at the in-progress list of individuals who needed to have their MDS done. She said that the MDS for Resident #48 was not due until 3/3/2025. Record review of the CMS RAI Version 3.0 Manual Chapter 2: 5-Day Assessment and OBRA admission assessment dated 0ctober 2024 revealed Comprehensive item set. o ARD (item A2300) must be set for days 1 through 8 of the Part A SNF stay. o Must be completed (item Z0500B) by the end of day 14 of the stay (admission date plus 13 calendar days). o See Section 2.7 and Chapter 4 for requirements for CAA process and care plan completion. Record review of MDS Coding Policy (not dated) revealed the facility utilized the most up to date Resident Assessment Instrument (RAI) manual for determination of coding each section of the Resident Assessment, timely and accurately. The most current RAI manual may be found on the CMS,gov website. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675596 If continuation sheet Page 5 of 12 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 675596 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Barton Valley Rehabilitation and Healthcare Center 4501 Dudmar Dr Austin, TX 78735 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to identify a diagnosis of mental illness on the preadmission screening and resident review (PASRR) assessment for 2 of 6 residents (Resident #78 and Resident #85) whose records were reviewed for PASRR services. Residents Affected - Few The facility failed to get PASRR eval when Resident #78's Level 1 PASRR screening indicated the resident had mental illness diagnoses of schizoaffective disorder bipolar type, and anxiety. The facility failed to complete a PASRR screening on Resident #85. This deficient practice could place residents with mental illness at risk for not obtaining the services needed to treat their mental health diagnoses. The findings include: 1. Record review of Resident #78's admission sheet, dated 02/25/2025, revealed a [AGE] year-old female who was readmitted to the facility on [DATE] and initial admission on [DATE] with diagnoses including respiratory failure, encounter with tracheostomy (a procedure that puts a hole in the neck so air can get into the lungs, obstructive pulmonary disease (lung disease that blocks air flow making it difficult to breath, schizoaffective disorder bipolar type (mental disorder with delusions, hallucinations, disorganized speech and grossly disorganized behavior), morbid obesity, heart disease, tobacco use, high blood pressure, voice and resonance disorder (affects how your voice sounds and air flow through your nose and mouth) and anxiety (intense or persistent worry and fear about everyday situations). Record review of Resident #78's quarterly MDS assessment, dated 01/09/2025, noted the resident BIMS was 15, indicating intact cognitive response; mood indicators were present including feeling lonely or isolated from those around you, verbal behavioral symptoms directed towards other and not directed towards others. The MDS also had schizophrenia and anxiety as active diagnosis. Record review of Resident #78's care plan, updated on 01/24/2025 noted the resident uses and antidepressant r/t Depression. One of the approaches was to monitor and document the change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal. The resident uses psychotropic medications r/t schizoaffective disorder. One of the approaches were monitor/document/report PRN any adverse reactions of PSYCHOTROPIC medications: unsteady gait, tardive dyskinesia (uncontrolled body movements), shuffling gait, rigid muscles, shaking, frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. Record review of Resident #78's PASRR 1 dated 06/10/2024 revealed that the facility marked no for mental illness. Attempted to interview Resident #78 on 02/24/2025, 02/25/2025 and 02/26/2025 resident was unavailable for interview. 2. Record review of Resident #85's admission sheet, dated 02/25/2025, revealed a [AGE] year-old (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675596 If continuation sheet Page 6 of 12 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 675596 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Barton Valley Rehabilitation and Healthcare Center 4501 Dudmar Dr Austin, TX 78735 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few male who was admitted to the facility on [DATE] diagnoses including major depressive disorder (loss of interests in activities causing significant impairment in daily life), developmental disorder of scholastic skills (condition characterized by a significant discrepancy between an individuals perceived level of intellect and their ability to acquire new language and other cognitive skills), autistic disorder (lifelong developmental disability that affects how a person communicates interacts with others, learns and behaves), high blood pressure, lack of expected normal physiological development in childhood, cognitive communication deficit (difficulty communicating), weakness, and anxiety disorder (intense or persistent worry and fear about everyday situations). Record review of Resident #85's quarterly MDS assessment, dated 12/21/2024, noted the resident BIMS was 05, indicating severe cognitive impairment; mood indicators were not present. The MDS also had depression and anxiety as active diagnosis. Record review of Resident #85's care plan, updated on 01/15/2025 noted the resident uses and antidepressant r/t Depression. One of the approaches was to monitor and document the change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal. The resident uses psychotropic medications r/t behavior management. One of the approaches were monitor/document/report PRN any adverse reactions of PSYCHOTROPIC medications: unsteady gait, tardive dyskinesia (uncontrolled body movements), shuffling gait, rigid muscles, shaking, frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. The care plan also revealed the resident had impaired cognitive function or impaired thought process r/t developmentally delayed. One of the approaches was to monitor/document/report PRN any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Record review revealed that Resident #85 did not have a PASRR completed. Interview attempted with Resident #85 on 02/24/2025 at 10:13 a.m., Resident #85 was not interviewable. During an interview with the ADM on 02/26/2025 at 11:40 a.m., revealed that she had been trained on PASRR. She said that the MDS nurse was responsible for doing PASRRs. She also said that corporate was doing the PASRRs because the facility does not have an MDS nurse. She said a PASRR I was done before admission and PASRR II is done if the PASRR I is positive. She said that for a PASRR I to be positive that the resident had to have a mental disorder or Intellectual and development disability (IDD), She said that it was important to do the PASRR so that the resident had the opportunity to receive services for which they are eligible. She said that for Resident #85 a PASRR was not done due to him coming from home. She said the facility rushed Resident #85's admission and was overlooked. She also said for Resident #78's PASRR was done at the hospital and was negative. She said the MDS person the facility was new at the time and did not flag her PASRR. During an interview with the CN C on 02/26/2025 at 12:07 p.m., revealed that she had been trained on PASRR. She said that for a PASRR I to be positive the resident had to have a mental illness. She said that a PASRR was done on all residents at the time they are admitted . She stated to be responsible for doing the PASRRs or individuals in the case mix. She said that she was responsible for completing the PASRR if the resident had a new mental illness diagnosis. She said the facility would complete form 1012 and determine if the individual has dementia, then complete mental health illness (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675596 If continuation sheet Page 7 of 12 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 675596 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Barton Valley Rehabilitation and Healthcare Center 4501 Dudmar Dr Austin, TX 78735 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few check to put in a PASRR. She stated it is important to do a PASRR for individuals that have a mental health illness to receive the extra support they need if the individual meet's certain criteria for services. She did not know why the PASRRs for Resident #78 and Resident #85 were not done. Record review of the PASRR Policy and Procedure revised on 07/18/2018 and reviewed 02/26/2025 revealed the facility uses the most current version of [NAME] Rules, TAC Title 26, Part 1 Chapter 554, Sub-chapter BB as they pertain to PASRR Level 1, Level 2 (PE), Specialized Services and IDT meetings. This TAC may be found on the Texas Health and Human Services website. Record review of the TAC Title 26, Part 1 Chapter 554, Sub-chapter BB dated 12/11/2020 revealed if an individual seeks admission to a nursing facility, the nursing facility: (1) must coordinate with the referring entity to ensure the referring entity conducts a PL1; and (2) may provide assistance in completing the PL1, if the referring entity is a family member, LAR, other personal representative selected by the individual, or a representative from an emergency placement source and requests assistance in completing the PL1. (b) A nursing facility must not admit an individual who has not had a PL1 conducted before the individual is admitted to the facility. (c) If an individual's PL1 indicates the individual is not suspected of having MI, ID, or DD, a nursing facility must enter the PL1 from the referring entity into the LTC Online Portal. The nursing facility may admit the individual into the facility through the routine admission process. (d) For an individual whose PL1 indicates the individual is suspected of having MI, ID, or DD, a nursing facility: (1) must enter the PL1 into the LTC Online Portal if the individual's admission category is: (A) expedited admission; or (B) exempted hospital discharge; and (2) must not enter the PL1 into the LTC Online Portal if the individual's admission category is pre-admission. (e) Except as provided by subsection (f) of this section, a nursing facility must not admit an individual whose PL1 indicates a suspicion of MI, ID, or DD without a complete PE and PASRR determination. (f) A nursing facility may admit an individual whose PL1 indicates a suspicion of MI, ID, or DD without a complete PE and PASRR determination only if the individual: (1) is admitted as an expedited admission. (2) is admitted as an exempted hospital discharge; or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675596 If continuation sheet Page 8 of 12 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 675596 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Barton Valley Rehabilitation and Healthcare Center 4501 Dudmar Dr Austin, TX 78735 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 0645 Level of Harm - Minimal harm or potential for actual harm (3) has not had an interruption in continuous nursing facility residence other than for acute care lasting fewer than 30 days and is returning to the same nursing facility. (g) A nursing facility must check the LTC Online Portal daily for messages related to admissions and directives related to the PASRR process. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675596 If continuation sheet Page 9 of 12 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 675596 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Barton Valley Rehabilitation and Healthcare Center 4501 Dudmar Dr Austin, TX 78735 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #47) reviewed for transmission-based precautions, in that: Residents Affected - Few The facility failed to provide Enhanced Barrier Precautions for Resident #47, who had a chronic wound with drainage that could not be covered with a dressing. This deficient practice could put the resident at risk for infection. Finding included: Review of Resident #47's face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses Diabetes Mellitus with Diabetic neuropathy (A condition results from insufficient production of insulin, causing high blood sugar, and decreased feeling in the hands and feet.), peripheral vascular disease (is a common condition in which narrowed arteries reduce blood flow to the arms or legs.) and intellectual disabilities (A condition that limits intelligence and disrupts abilities necessary for living independently.). Review of Resident #47's quarterly MDS assessments dated 02/10/2025 reflected he was assessed to have a BIMS score of 5 indicating severe cognitive impairment. Resident #47 was further assessed to have applications of ointments or medications to areas other than feet. Review of Resident #47's comprehensive care plan reflected a focus area dated 08/05/2024 The resident has a wound to left posterior lateral upper thigh. Further review of his plan of care reflected a focus are dated 01/22/2025 Resident requires enhanced barrier precautions related to wounds. Interventions included: Apply signage outside resident room ; EBP (Enhanced Barrier Precautions) used during high-contact resident care activities as applicable, such as: dressing, bathing/showering, transferring; providing hygiene; changing linens; changing briefs or assisting with toileting; device care or use: (central line/urinary catheter/feeding tube/trach/vent); wound care (any skin opening requiring a dressing); other areas determined to require EBP . Review of Resident #47's consolidated physician orders reflected an order dated 01/27/2025 wound to left posterior lateral upper thigh, cleanse with wound cleanser, apply lotrisone cream and leave open to air. Further review of Resident #47's physician orders reflected an order dated 08/29/2024 enhanced barrier precautions - gown and gloves required for high-contact activities: dressing, bathing, transfers, providing hygiene, changing linens, incontinent care, toileting, therapy .and wound care every shift for infection control. Review of Resident #47's wound assessment report dated 02/24/2025 conducted by Resident #47's NP reflected his wound was on his left thigh, it was re-opened partial thickness wound (involves damage to the outer layers of the skin, specifically the epidermis and part of the dermis.) with sanguineous drainage (is the initial discharge produced after an injury or an open wound where the skin is broken.) Review of Resident #47's wound care MD assessment and progress note reflected Resident #47 had a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675596 If continuation sheet Page 10 of 12 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 675596 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Barton Valley Rehabilitation and Healthcare Center 4501 Dudmar Dr Austin, TX 78735 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm wound on his left lateral thigh which had drainage and was greater than 122 days old. (A chronic wound is one that has failed to progress through the phases of healing in an orderly and timely fashion in 30 days.) Observation on 02/24/2025 at 9:42 AM, revealed Resident #47 did not have a sign for EBP outside of his room door. Residents Affected - Few Observation on 02/25/2025 at 1:52 PM, revealed Resident #47 in room. The Treatment Nurse entered room to preform wound care with CNA D to assist. The Treatment nurse nor CNA D donned PPE prior to entering the room. The Treatment nurse exposed Resident #47's left thigh to reveal a wound that was approximately 8 X 4 region of scarred tissue with scattered, small, round open areas. Drainage was observed on the wound. In an interview on 2/26/25 at 9:20 AM, the Treatment nurse stated that Resident #47 had open areas on his wound. She stated it was her understanding of the facility's policy on EBP that it was used only for pressure sore wounds of stage 2 or above, and did not include skin tears, or any other types of wounds. The Treatment nurse stated after reviewing the facility policy, that the resident should have been on EBP for his current wound. She stated that not initiating EBP for Resident #47 could place him at risk of exposure to pathogens which could cause infections. In an interview on 2/26/25 at 9:25 AM, the DON stated that EBP should be initiated for patients with indwelling catheters, PEG tubes, and serious breaks in the skin, including some skin tears. She stated they have not been doing EBP for minor skin breaks. The DON stated that EBP have not been initiated on Resident #47. The DON stated after reviewing the facility policy, that I probably wouldn't have [started EBP], but I will look into it. The DON stated that the resident had behaviors of scratching that area and reopening the wound. She stated that the facility is in the process of doing additional training with quizzes and in-services regarding EBP. The DON stated she was unsure if the Treatment nurse has completed the training. Interview on 02/26/2025 at 12:23 PM, the Corporate Nurse IP, stated that she was the interim IP for the facility from August 2024 until approximately two weeks ago. She stated that it was her expectation that EBP be started for all residents with chronic wounds, PEG tubes, foley catheters. She stated she was familiar with Resident #47 and stated that he had several open areas on the left thigh region that would heal and reopen. She stated that the orders and care plan interventions were likely initiated from her instructions and not discontinued appropriately. She stated that if the wound had drainage with an order for OTA, that EBP should be initiated. She stated that not initiating EBP appropriately puts the resident at risk for infections. Review of the in-service dated 02/26/2025 reflected the Treatment nurse was in-serviced on EBP. Review of the facility's policy Enhanced Barrier precautions dated 04/01/2024 reflected Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. A single set of PPE cannot be used for more than one patient. EBP are indicated for residents with any of the following: Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO . Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675596 If continuation sheet Page 11 of 12 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 675596 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Barton Valley Rehabilitation and Healthcare Center 4501 Dudmar Dr Austin, TX 78735 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 with an adhesive bandage, or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675596 If continuation sheet Page 12 of 12