Health inspection·June 4, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #2's undated care plan reflected Resident #2 had risk for diversional activity deficit with a goal to participate in group and/or individual activities 2-3 times per week as tolerated. Interventions included to provide 1 on 1 visits to meet activity goal and provide room visits 2-3 times per week. Review of Resident #3's face sheet, printed on 06/04/25, reflected an [AGE] year-old female admitted on [DATE]. Her diagnoses included unspecified dementia, anxiety, depression, and other abnormalities of gait and mobility. Review of Resident #3's significant change in status MDS assessment, dated 05/22/25, reflected a BIMS score of 4 which indicated severe cognitive impairment. Review of Resident #3's undated care plan reflected Resident #3 was at risk for diversional activity deficits with a goal to participate in group and/or individual activities 2-3 times per week as tolerated. Interventions included to provide 1 on 1 visits to meet activity goal. During an observation and interview on 06/03/25 at 12:04 PM, Resident #3 was sitting in the common area at a table getting ready for lunch. Resident #3 stated the lunch looked good. Review of face sheet for Resident #4 reflected an [AGE] year-old female admitted on [DATE] with diagnoses of Alzheimer's disease (progressive neurodegenerative disorder that affects the brain's ability to function), unspecified dementia (decline impacting memory, thinking and social abilities), cognitive communication deficit (difficulty with communication), difficulty walking, and major depressive disorder (serious mental illness characterized by persistent sadness, loss of interested and other symptoms affecting mood or thoughts). Review of Resident #4's quarterly MDS dated [DATE] reflected a BIMS score of 2 which indicated severe cognitive impairment. Review of Resident #4's undated care plan reflected Resident #4 was at risk for diversional activity deficits with a goal to participate in group and/or individual activities 2-3 times per week as tolerated. Interventions included to provide 1 on 1 visits to meet activity goal and provide room visits 2-3 times per week. Observation of Resident #4 on 06/03/2025 at 9:26 AM revealed Resident #4 sat in common area and was group with other residents. Review of Resident #5's face sheet reflected an [AGE] year-old female admitted on [DATE] with diagnosis of unspecified dementia decline impacting memory, thinking and social abilities), other lack of coordination (difficulties with movement, balance and coordination), depression (persistent feeling of sadness or loss of interest in activities), and chronic systolic (congestive) heart failure (long-term condition where the heart's ability to contract and pump blood is impaired). Review of Resident #5's quarterly MDS dated [DATE]/2025 reflected Resident #5 was unable to complete BIMS and is rarely or never understood. Further review reflected Resident #5 had a memory problem unable to recall after 5 minutes and appeared to recall long past. Review of Resident #5's undated care plan reflected Resident #5 had a risk for diversional activity deficit with a goal to participate in group and or individual activities 2-3 times per week. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676471 If continuation sheet Page 2 of 5 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 676471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Valley Inn Health Center 17751 Park Valley Drive Round Rock, TX 78681 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 0656 Interventions included provide 1 on 1 visits to meet activity goal and provide room visits 2-3 times per week. Level of Harm - Minimal harm or potential for actual harm During an attempted interview on 06/03/2025 at 1:53 PM with Resident #5 revealed Resident #5 was confused and did not respond to simple questions. Residents Affected - Some Review of Resident #6's face sheet reflected a [AGE] year-old-female admitted on [DATE] with diagnoses of Alzheimer's disease (progressive neurodegenerative disorder that affects the brain's ability to function), depression (persistent feeling of sadness or loss of interest in activities), anxiety disorder (group of mental health conditions characterized by excessive fear or worry), dementia (persistent feeling of sadness or loss of interest in activities) , and cognitive communication deficit (difficulty with communication). Review of Resident #6's quarterly MDS dated [DATE] reflected a BIMS score of 3 which reflected a severe cognitive impairment. Review of Resident #6's undated care plan reflected Resident #6 had a risk for diversional activity deficit with a goal to participate in group and or individual activities 2-3 times per week. Interventions included provide 1 on 1 visits to meet activity goal and provide room visits 2-3 times per week. During an interview on 06/03/2025 at 9:24 AM revealed Resident #6 was confused and not oriented to time or place. Review of activity logs dated 04/01/2025 and 04/02/2025 reflected Resident #2, Resident #3, Resident #4, and Resident #6 were not provided in-room visits or 1 to 1 activities. Review of activity logs dated 04/03/2025 reflected Resident #2, Resident #3, and Resident #4 were not provided in-room visits or 1 to 1 activities. Review of activity logs dated 04/04/2025 reflected Resident #4 and Resident #6 were not provided in-room visits or 1 to 1 activities. Review of activity logs dated 04/14/2025 reflected Resident #2, Resident #4, and Resident #6 were not provided in-room visits or 1 to 1 activities. Review of activity logs dated 04/21/2025 reflected Resident #3, Resident #4, and Resident #6 were not provided in-room visits or 1 to 1 activities. Review of activity logs dated 04/22/2025 reflected Resident #2, Resident #3, Resident #4, and Resident #6 were not provided in-room visits or 1 to 1 activities Review of activity logs dated 04/23/2025 reflected Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 were not provided in-room visits or 1 to 1 activities. Review of activity logs dated 04/24/2025 reflected Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 were not provided in-room visits or 1 to 1 activities. Review of activity logs dated 04/25/2025 reflected Resident #2, Resident #3, Resident #4, Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676471 If continuation sheet Page 3 of 5 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 676471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Valley Inn Health Center 17751 Park Valley Drive Round Rock, TX 78681 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 0656 #5, and Resident #6 were not provided in-room visits or 1 to 1 activities. Level of Harm - Minimal harm or potential for actual harm Review of activity logs dated 04/29/2025 reflected Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 were not provided in-room visits or 1 to 1 activities. Residents Affected - Some Review of activity logs dated 04/30/2025 reflected Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 were not provided in-room visits or 1 to 1 activities. Review of activity logs dated 05/01/2025 reflected Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 were not provided in-room visits or 1 to 1 activities. Review of activity logs dated 05/02/2025 reflected Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 were not provided in-room visits or 1 to 1 activities. Review of activity logs dated 05/05/2025 reflected Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 were not provided in-room visits or 1 to 1 activities. Review of activity logs dated 05/06/2025 reflected Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 were not provided in-room visits or 1 to 1 activities. Review of activity logs dated 05/07/2025 reflected Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 were not provided in-room visits or 1 to 1 activities. Review of activity logs dated 05/16/2025 reflected Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 were not provided in-room visits or 1 to 1 activities. Review of activity logs dated 05/19/2025 reflected Resident #2, Resident #3, Resident #4, and Resident #6 were not provided in-room visits or 1 to 1 activities. Review of activity logs dated 05/20/2025 reflected Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 were not provided in-room visits or 1 to 1 activities. During an interview on 06/04/2025 at 12:54 PM, the AD stated that she had an assistant (AA) that worked in memory care and provided activities. The AD stated that she visited memory care to ensure the activities were implemented and checked in with the AA daily. The AD stated that the AA was responsible to provide 1:1 activities. The AD did not list Resident #4, Resident #5 or Resident #6 as residents who were provided 1:1 activities. The AD stated that residents in memory care will usually do group activities and if they do not participate for the day then the AA will do 1:1 activities. The AD said 1:1 activities were documented in a binder. The AD stated she was responsible to update the activity part of the care plan. The AD stated a resident who did not come out of their room is what determined that they got a 1:1 activity. During an interview on 06/04/2025 at 1:20 PM, AA stated that she was responsible for activities in memory care Monday through Friday. The AA stated she tried to keep a routine for the residents in memory care. She stated that in room visits or 1:1 activities occurred daily, Monday to Friday, from 1:30 - 2:00 PM. The AA did not include Resident #4, Resident #5 or Resident #6 as residents who received 1:1 activities. The AA stated she reviewed residents' care activity care plans and if the care plan specified the residents to have a 1:1 activity then they should have been having a 1:1 activity. The AA stated that activities were documented in a binder and stated not all of May 2025 activities (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676471 If continuation sheet Page 4 of 5 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 676471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Valley Inn Health Center 17751 Park Valley Drive Round Rock, TX 78681 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 0656 had been documented. Level of Harm - Minimal harm or potential for actual harm During an interview on 06/04/25 at 2:27 PM, the ADM stated that he expected the plans were completed timely. He stated he expected the care plans to be resident-centered and accurate . He stated the IDT was responsible for the care plans. Residents Affected - Some During an interview on 06/04/25 at 2:40 PM, the DON stated each individual resident required different elements of care which were reflected on the care plan. She stated she expected interventions to be implemented and then monitored and revised if needed. She stated everyone was responsible for assisting with care plans and they were monitored in the morning meeting with the IDT. During an interview on 06/04/2025 at 2:55 PM, SW stated that interventions were added to the care plan by the MDS nurse or nursing. SW stated she provided her input at care plan meetings or to the IDT for interventions. During an interview on 06/04/2025 at 4:29 PM, the DON stated that the charge nurse and unit manager were responsible to ensure activities were being conducted and implemented in memory care. The DON stated that the AD or a CNA could provide 1:1 activities. The DON stated that the unit manager role was created to help alleviate or decrease resident to resident behaviors the unit manager was responsible to round frequently and ensure activities were implemented frequently as non-pharmacological interventions. During an interview on 06/04/2025 at 4:41 PM, the ADM stated that 1:1 activities should be documented in the activities binder and he expected them to be documented and implemented. Review of the facility policy titled, Care Plans, Comprehensive Person-Centered revised March 2022, reflected in part, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; e. reflects currently recognized standards of practice for problem areas and conditions . 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676471 If continuation sheet Page 5 of 5