Health inspection·February 17, 2026

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bruises and cuts to his arms. Observed resident sitting in his wheelchair using his left hand to point at his spilled coffee cup on the floor. Resident appeared well groomed. In an interview on 02/12/2026 at 7:27 p.m., LVN B said at around 5:30 a.m. CNA A came to the nurse's station, and he told me he noticed bruises on Resident # 1's arms. LVN B stated, {CNA A} just asked me to come and see, he didn't tell me that the resident fell or got tangled. LVN B stated, I looked at Resident #1 and I asked him what happened? Resident # 1 didn't answer. LVN B stated he found just bruises, no cuts and he put moisturizer cream on Resident #1's arms. He stated, I called the NP, and he said to just monitor, he didn't order x-rays because there was no fall. I was off for 2 days and when I came back to work, I noticed that x-rays had been ordered on 02/10/2026. LVN B stated on 02/10/2026 his shift was over at 6:00 a.m. and he left the facility at the end of his shift. LVN B said he returned to the facility approximately 8 hours after he was notified of Resident # 1's incident and on that date at 1:24 p.m. he made a late entry in the progress notes for Resident # 1. Per witness statement on 02/12/2026, LVN B wrote on 02/2026, {CNA A} on the hall called me into resident room, noted discoloration to bilateral arms, resident could not state how it happened. Incident report was completed RP/ NP notified. Signed and dated 02/12/2026. In an interview on 2/13/2026 at 11:56 a.m., TN revealed that the 24-hour report indicated that Resident # 1 needed to be assessed. Per statement on 02/12/2026, CNA A wrote: when I was doing my last walk thru on Tuesday morning 2/10/26 I found Resident # 1 between bed rail and mattress not on floor. I put him back in bed and reported it to nurse. Per record review of progress notes on 02/10/2026 at 1:24 p.m., LVN B noted Resident presented with decolorated area to bilateral arm, resident could not state how it happened. Notified RP/NP. Per Record review of Telehealth Visit dated 02/10/2026 at 11:29 a.m. and Telehealth Facilitator was DON. The date and time of visit with NP was 02/10/2026 9:43 a.m. In an interview on 02/13/2026 at 10:07 a.m., DON said CNA A reported the incident to the Charge Nurse (LVN B). DON stated, his expectation was that staff were to report immediately to the NP of any incidents or changes occurred to a resident. DON stated, LVN B did not enter progress notes in a timely manner and that notes were entered 8 hours after LVN B was notified of the incident. DON stated he had facilitated the call with the NP at 9:43 a.m. and that this was approximately 4 hours after the incident with Resident # 1. In an Interview on 02/13/2026 at 11:29 a.m., UD revealed that around 7:30 - 8:00 a.m. on 02/10/2026 Charge Nurse, (LVN C) asked if I knew anything about the bruises on Resident # 1's hands. UD placed call to CNA A to inquire about the bruises on Resident #1's hands. CNA A explained he found resident hands tangled in the assist bed rail during the early hours of the morning on 02/10/2026 and he had reported it to LVN B. UD stated she went to the dining room, and she observed Resident #1's sitting in the dining room eating breakfast, he was wearing a long sleeve shirt so she couldn't see his forearms or elbows, but his hands were visible, and she saw he had bruising on them. UD said occasionally, Resident # 1 will get a little discoloration but, the hand bruising she saw on 02/10/2026 was unusual for Resident # 1. In an interview on 02/13/2026 at 12:11 p.m., LVN C stated, on 02/10/2026 I arrived for work for my shift 6 a.m. to 6 p.m. I looked in PCC to see if there was a note about {Resident # 1's} bruising from the night shift. There were no notes entered by the night charge nurse. LVN C stated, the bruises were worse than what I usually saw so I reported it immediately to the ADM. In an interview on 02/17/2026 at 3:51 p.m., RD stated it was her expectation that if a Nurse has been notified of an injury or incident or fall, they are to immediately perform an assessment of the resident. RD stated LVN B should have assessed Resident # 1, documented the assessment, notified the NP, family, Administrator and the DON and that was not done. RD stated, LVN B should not have left the assessment to the Treatment Nurse. Policy Incident and Accidents. Dated 10/01/2025 reviewed / revised 12/1/2025 It is 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 02/17/2026 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete policy of this facility for staff to utilize the risk management - incident report in the electronic health record to report, investigate, and review any accident of incident that occurred allegedly occurred, on facility property and may involve or allegedly involve a resident.Policy Explanation:The purpose of incident reporting can include:assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrence and improve the management of resident care.Conducting roof cause analysis to ascertain causative/ contributing to avoid further occurrences. Alert risk management and/ or administration of occurrences that could result in claims or further reporting requirements.Meeting regulatory requirements for analysis and reporting of incident and accidentCompliance Guidelines4. Any injuries will be assessed by the licensed nurse or practitioner, and the effect individual will not be moved until safe to do so. First aid will be given for minor injuries such as cuts or abrasions.5- the supervisor or other designee will be notified of the incident/ accident. If necessary, law enforcement may be contacted for specific events.6. The Nure will contact the residents' practitioner to inform them of the incident/ accident, report any injury so other findings, and obtain orders if indicated which may include transportation to the hospital dependent upon the nature of the injury.8. The residents' family or representatives will be notified. (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17)S483.10(g)(14) Notification of Changes.(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention. Event ID: Facility ID: 676471 If continuation sheet Page 3 of 3