Health inspection·November 18, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few were not good as she had arguments with them. Resident #2 stated her previous roommate called her names and litter the room with various things. Resident #2 said the SW was trying to find the most suitable placement in another facility with the right kind of people and she stated she was okay with it. She stated she had issues with depression and anxiety and the medications that she had were not fully effective. When the investigator asked about the incident that occurred on 09/27/25 with Resident #1 , she stated Resident #1 was a frequent visitor in her room to meet her roommate and she did not like any other residents entering her room. Resident #2 stated she was angry at that time, shouted at her and tried to push her out of the room. She stated she felt sorry later about the incident and, she apologized to Resident #1. She stated she did not have any intention of hurting anyone. During an interview on 10/15/25 at 3:20pm Resident #1 stated she was visiting her friend who shared the room with Resident #2. She added, without any provocation, Resident #2 approached her screaming and shouting and pulled her hair and pushed her down to the ground. She stated it was a very traumatizing experience mentally and physically and had a skin tear on her elbow area from the fall. She stated she did not retaliate and shouted for help instead as she believed in nonviolence . Resident #1 stated she asked the staff to call the police as Resident # 2 assaulted her. Resident #1 said, next day Resident #2 approached her and apologized, though she was not sure how genuine she was. During a phone interview on 10/15/25 at 2:30pm LVN A stated, on 09/27/25 at about 9:50am she heard a scream from Resident #2's room and upon entering the room she saw Resident #2 was sitting on her bed. LVN A said she was furious and yelled Get the hell out of my room and stop bothering me. I don't want her in my room. LVN A said at that time Resident #1 was lying on the floor. She said Resident #1 reported to her that Resident #2 pushed her, lost her balance and fell. She said the residents were separated and Resident #2 was escorted from the scene and allowed to calm down. LVN A said she conducted a head-to-toe assessment on Resident #1, and it was revealed there was no head injury or contusion, no changes in her vision, no pain or any other complications however she sustained a skin tear on her left elbow, which was cleansed and dressed. She stated she reported the incident to the on-call physician and RP. She said she initiated vital signs observations and frequent neuro checks, and Resident #1 was on frequent observation as part of it. On 10/15/25 at 1:40pm the investigator tried to interview Resident #2's previous room mate who was in the room when the incident occurred on 09/27/25. She was busy with activities (bingo) in the dining hall and stated she was not interested in being interviewed.During an interview on 10/15/25 at 12:55pm MA B stated she was the med aide administering medications in the hall where Resident #2 resides. She stated Resident #2 told her that she pushed Resident #1 to the ground because Resident #1 went into her room and was verbally abusive. MA B stated she did not believe that as she had never seen Resident #1 ever became aggressive and abusive. She stated Resident #1 had a very calm demeanor and had lots of friends at the facility as she was very helpful with the residents physically and emotionally. She said, sometimes Resident #1 went out of the way and helped others more than she could do. MA B said Resident #2 was a loner who kept to herself mostly, however, could be impulsive and became abusive and aggressive when triggered. During an interview on 10/15/25 at 1:17pm the SW stated she was aware of the incident between Resident #1 and Resident #2 that occurred on 09/27/25. The SW said Resident #2 was a difficult resident as she would not get along with everyone. She said Resident #2 had changed her room two times after the incident because she was not compatible with the roommates. The last change was two days ago since she had not liked the roommate. The SW said the facility was in the process of finding an appropriate placement for Resident #2 due to her unsafe behavioral issues. During an interview on 10/15/25 at 1:45pm, the DON stated the facility was doing all levels of care to make sure the residents at the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676471 If continuation sheet Page 2 of 3 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 11/18/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete facility were safe. She said the facility had taken necessary measures to make sure Resident #1 was safe. They were immediately separated and redirected. She stated the incident was reported to the weekend NP , RP and the abuse coordinator immediately after the incident. The DON stated Resident #2 was moved to another hallway away from Resident #1. She stated both the residents were under observation until they were settled down after the incident. The DON said Resident #2 expressed her remorsefulness about the incident.The DON stated , the social worker completed psychosocial assessments with no issues noted . She said Resident #2 received new orders for lab tests and on 09/30/25 the psychiatrist met with her and increased her Depakote to 125mg BID for the diagnosis of schizoaffective disorder. During an interview on 10/15/25 at 10:35 am the ADM stated, on 09/27/25 at about 9:30pm Resident #1 went into Resident #2's roommate who was Resident #1's friend. He added, since Resident #2 did not like it, she pushed Resident #1 to the ground. He said he began an internal investigation and reported the incident to the state. The ADM stated both the residents had undergone psychiatric evaluation and Resident #2 received a modification in her psychotropic medication . The ADM stated he reported the incident to the police, conducted safety surveys and in-service on ‘resident-to-resident abuse and neglect' for the staff as protocol. He stated the situation got better further when Resident #2 went and apologized to Resident #1. The ADM stated a care plan meeting for Resident #2 was held on 9/30/25. The ADM said Resident #2 stated that she received psychiatric counselling for anger management, how to control anger in the future, and that she had since apologized to Resident #1 for the incident. Record review of the in-service record revealed an ongoing in service on Abuse and Neglect started on 09/27/25. The review of the sign-in sheet revealed 47 staff members attended this in-service. Record review of the facility policy Abuse Protocol reflected: The patient [Resident] has the right to be free from abuse, neglect , mistreatment of resident property and exploitation.Our facility will not condone patient abuse, neglect mistreatment or misappropriation of patient property and exploitation (collectively patient Abuse) by anyone including staff members, other patients, consultants, volunteers, staff or other agencies serving the patient, family members, legal guardians, sponsors, friends or other individuals. The facility implemented the following prior to the surveyor's entrance to the facility on [DATE]. Resident #2 was removed from the room immediately after the incident and deescalated.Labs were ordered and psychiatrist conducted a medication review.A care plan meeting conducted on 09/30/25 for Resident #2, met with the RP and ombudsman to discuss behaviors.The SW completed psychosocial assessment on Resident #2 and updated BIMS with a score of 14.Resident#1 was assisted off the floor, physical, neurological and vitals assessment performed.Resident #2 was relocated to another hallway away from Resident #1.The staff were in- serviced on ANE. The noncompliance was identified as PNC. The noncompliance began on 09/27/25 and ended on 09/30/25. The facility had corrected the noncompliance before the survey began. Event ID: Facility ID: 676471 If continuation sheet Page 3 of 3