Health inspection·April 5, 2023

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to Resident #27. MA J was observed to administer one (1) drop to each eye (Resident #27). MA J returned the bottle to the cart. The MAR was not available. MA J proceeded to the next resident. Resident #3, an [AGE] year-old female, was admitted on [DATE] with diagnoses including heart failure. During observation of medication administration on 04/03/2023 at 12:45 PM, MA J was observed to remove a card of medication identified as Potassium Chloride 10 mEq (milliequivalents) from the medication cart and punch out 1 (one) tablet. She put the card back into the cart and delivered the oral medication to Resident #3. The MAR was not available. During an interview with the DON on 04/03/2023 at 02:00 PM , surveyor made the DON aware of the medication aide administering medications without the Medication Administration Record that is the tool used to meet the standard of verifying the accuracy of medications prior to administration. The DON said the aide gave the medications from memory and that she would do an in-service on what to do when the computers are not working. During an interview with MA J on 04/04/2023 at 11:00 AM, MA J acknowledged she had given the medications based on her memory. When asked what she is supposed to do when the computers are not working, MA J said she should have gotten paper copies to work with. A review of the April 2023 physicians' orders for Residents #5, #27, and #3 indicated that all three residents had received the right medications in the right form, at the right dose, and at the right time. No resident on the same hall as those three residents was identified as having missed a dose of medication. Resident #42, a [AGE] year-old female, was admitted to the facility on [DATE] with diagnoses including stroke, weakness, respiratory failure, diabetes, inability to speak or swallow, heart failure, Vitamin D deficiency, and gastrostomy tube placement. Resident # 43, a [AGE] year-old male, was admitted on [DATE] and re-admitted on [DATE] with diagnoses including left hip fracture, diabetes, multiple ulcerations, pressure ulcers, malnutrition, urination difficulty, and sepsis (a life threatening complication of infection. An MDS (minimum data set) dated 03/07/2023 noted Resident #43 to have a BIMS (Brief Interview for Mental Status) score of 15 indicating he is cognitively intact. Resident was noted to have a urinary catheter for draining urine from the bladder, a gastrostomy tube for nutrition, and a PICC line for IV antibiotic therapy. Resident # 53 is also being treated for a stage IV pressure ulcer to his sacral area which was debrided while in the hospital. During observation of medication administration on 04/04/2023 at 08:01 AM, LVN A was observed to administer (three) medications to Resident #42 via the gastrostomy tube (G-Tube) route. LVN A did not wash or sanitize her hands prior to donning gloves in preparation for administering medications via the G-Tube nor after completion of giving the medications and removing the gloves. LVN A did not wash or sanitize her hands before administering medications to the next resident (Resident #43). LVN A did not check Resident #42's G-Tube for tube patency (tube obstruction) prior to flushing the tube with water and administering medications. LVN A was observed to disconnect the G-Tube from the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 2 of 17 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 676184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Park Rehabilitation and Skilled Nursing 5505 New Copeland Rd Tyler, TX 75703 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 0658 Level of Harm - Minimal harm or potential for actual harm feeding pump, flush the tube with water, administer medications, flushing with water between each medication, and flush the tube with water after administering the medications. She did not use a stethoscope placed on the resident's abdomen to listen for air inserted through the tube portal nor did she use a syringe to aspirate stomach contents to check for tube patency and position prior to performing medication administration. Residents Affected - Some At the conclusion of the medication pass observations, LVN A was asked if, in retrospect, she would have done anything differently (such as performing hand sanitation before and after each resident contact to decrease the risk for spreading infection and checking the vascular line and G-tube to ensure no obstructions were present before attempting to administer medications. She said she did not think so. During an interview with LVN A on 04/04/2023 at 1:45 PM, LVN A was made aware of the observed failures to cleanse/sanitize her hands during the medication pass and check for intravenous catheter and gastrotomy tube patency (free of obstruction). LVN A did not offer any explanation for these acts of omission except to say that she did not feel well and should not have come to work that day. The DON was present during this interview. During an interview with the DON on 04/05/2025 at 05:00 PM, she said she could not locate any documentation of training nor skill check-offs for G-Tube and vascular routes of medication administration. During the initial tour of the facility on 04/03/2023 at 10:45 AM, Resident #42 was observe lying on her back with the head of the bed elevated and a bolster pillow under her knees. Her legs were bent at the knees over the pillow and crossed at the ankles. Her feet were drawn close to the pillow's edge. A sign was posted on the wall over the bed with instructions to place black ankle braces on the resident daily and to place a Bolster pillow under the knees. Resident #42 did not have any braces on. A review of physician's orders dated 01/24/2023 indicated a black ankle brace was to be applied at 07:00 AM and removed at 07:00 PM daily. Resident #42 was observed again 04/03/2023 at 12:15 PM, 02:30 PM, and 03:20 PM and no braces were noted to her lower extremities. Resident #42 was observed for braces on 04/04/2023 at 8:01 AM, 09:20 AM, 12;10 PM, and 03:00 PM with none being noted. Resident #42 was observed again on 04/05/2023 at 09:00AM and no braces were noted on her legs. A review of the April, 2023 electronic Medication Administration Record indicated RN E documented the braces had been applied on 04/03/2023. LVN A documented the braces were applied on 04/04/2023. LVN C documented the braces were applied on 04/05/2023. During an interview on 04/05/2023 at 10:47 AM, LVN C stated, No, the braces are not on. When asked about the documentation of the braces being applied, LVN C said, It was an oversight. During observation of medication administration on 04/04/2023 at 08:01, LVN A took Resident #42's blood pressure and verbalized the blood pressure was 115/56 and the pulse was 58. Surveyor repeated the numbers back to the nurse. LVN A confirmed the blood pressure and pulse readings were 115/56 and 58, respectively. Then, LVN A was observed to administer 1 capsule of Vitamin D 5000 units and 1 tablet of carvedilol 3.125 mg (milligrams) to Resident #42 via the gastrostomy tube route. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 3 of 17 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 676184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Park Rehabilitation and Skilled Nursing 5505 New Copeland Rd Tyler, TX 75703 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of a Resident #42's physician's order dated 02/07/2022 indicated an order for Vitamin D3 5000 units one time a day. A review of Resident #42's physician's order dated 12/12/2021 indicated an order for carvedilol 3.125 mg to be given two times a day. Hold if systolic blood pressure is less than 100 or if diastolic blood pressure is less than 60 or if pulse is less than 60. During a review of the electronic Medication Administration Record dated 04/04, LVN A documented a blood pressure reading of 136/76 and a pulse of 67 instead of the verbalized readings of blood pressure 115/56 and pulse 58. During further review of the medication Administration Record dated 04/04/2023, LVN D recorded a blood pressure 111/67 and a pulse of 67 later that same day. No adverse effects of receiving the carvedilol medication were noted. Attempts to contact LVN A by phone on 04/05/2023 at 11:00 AM to discuss the discrepancies between the verbalized vital sign readings and the documented readings were unsuccessful. Resident # 6, a [AGE] year-old male, was admitted on [DATE] with diagnoses including diabetes and congestive heart failure (heart failure due to excess fluid volume). During observation of medication administration on 04/04/2023 at 07:30 AM, LVN A was observed to obtain a Novalog insulin pen, a Basaglar insulin pen, and 1 tablet of furosemide 20mg (milligram) from the nurses' cart. LVN A then put on a pair of medical gloves and took the medications into the room of Resident #6. She gave him his pill and then pulled his shirt up to expose his abdomen. LVN A injected the 2 insulins into the residents right upper abdominal quadrant, pulled his shirt down, and left the room. When she returned to the cart, she removed the gloves from her hands and discarded them. She completed her documentation and proceeded to prepare for the next medication task. LVN A did not wash her hands nor use hand sanitizer before applying gloves and before beginning medication administration nor after completion of the medication administration. LVNA was observed to touch the arm of the resident's chair, the resident's clothes, the resident's abdomen, the nurses' cart, opened and shut drawers on the cart, prepared medications for administration, and administered medications without performing any hand hygiene measures. Resident # 41, an [AGE] year-old male, was admitted to the facility on [DATE] with diagnoses including congestive heart failure. During observation of medication administration on 04/04/2023 at 07:45 AM, LVN A obtained 1 tablet of furosemide 20mg from the cart without performing any hand hygiene prior to obtaining the medication. She entered Resident #41's room, gave him his medication, and left the room. She returned to the cart. LVN A failed to wash her hands or use hand sanitizer to cleanse hands prior to nor after performing the medication administration task. Resident #61, an [AGE] year-old male, was admitted to the facility on [DATE] with diagnoses including an irregular heart rhythm, congestive heart failure, and shortness of breath. During observation of medication administration on 04/04/2023 at 07:52 AM, LVN A obtained 2 oral medications (Eliquis 5 mg tablet and Bumex 5 mg tablet) and 1 inhaler (fluticasone furoate nasal spray) from the nurses' cart. She then put on a pair of medical gloves without cleansing her hands before (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 4 of 17 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 676184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Park Rehabilitation and Skilled Nursing 5505 New Copeland Rd Tyler, TX 75703 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 0658 Level of Harm - Minimal harm or potential for actual harm doing so. She did not perform hand hygiene after contact with the previous resident nor prior to obtaining the medications from her cart. She entered Resident #61's room, assisted the resident to take a drink of water by holding the cup to his lips/mouth. She then assisted him to take his medications by holding the medicine cup to his mouth. LVN A returned to the cart, removed the gloves from her hands and discarded them into the trash bin on the side of the cart. She did not perform hand hygiene afterwards. Residents Affected - Some During observation of medication administration on 04/04/2023 at 08:01 AM, LVN A was observed to administer 3 (three) medications to Resident #42 via the gastrostomy tube (G-Tube) route. During this process, LVN A was observed to use the resident's right forearm to obtain the resident's blood pressure and pulse, then she proceeded to pull the bed linens covering the resident down and raise the resident's gown to expose the gastrostomy tube. The nurse then disconnected the G-Tube from the formula tubing and administered the medications. LVN A did not wash or sanitize her hands prior to donning (putting on) gloves in preparation for administering medications via the G-Tube route nor after completion of giving the medications and removing the gloves. LVN A was observed to touch the feeding pump and the pole it was on, the nightstand beside the bed, the resident's clothes and bed linen, and the gastrostomy tube, without ever performing hand hygiene measures. During observation of medication administration on 04/04/2023 at 09:00 AM, LVN A obtained a syringe with a normal saline solution in it and a small bag containing an antibiotic solution from the cart. She did not have the tubing needed to administer the antibiotic via the intravenous (IV) route. After looking throughout the cart, LVN A went to the medication room and looked for the appropriate tubing, using her hands to open cabinets and drawers. After obtaining tubing from the DON, LVN A proceeded to administer the antibiotic. She donned (put on) medical gloves without performing any hand hygiene measures and went into Resident #43's room. LVN A removed the cap from the Resident's peripherally inserted central catheter (PICC) line, cleansed the port with an alcohol swab, flushed the line with the normal saline solution, and connected the bag containing the antibiotic to the central line's port. LVN A returned to the cart, removed the gloves and discarded them into the trash bin attached to the cart. LVN A did not wash nor sanitize her hands before, during, or after the process of administering the intravenous antibiotic. LVN A failed to check the central line for patency (free of obstruction) by aspirating for blood prior to flushing the line with water and administering the medications. During an interview on 04/04/2023 at 09:20 AM, LVN A was asked if, in retrospect, would she have done anything differently, she said she did not think so. A review of the facility's policy titled Medication Administration: General Guidelines provided the following instructions: A review of the facility's policy titled Medication Administration: General Guidelines revealed the following: POLICY Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices . PROCEDURES (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 5 of 17 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 676184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Park Rehabilitation and Skilled Nursing 5505 New Copeland Rd Tyler, TX 75703 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 0658 Medication Preparation Level of Harm - Minimal harm or potential for actual harm 3. Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record. Compare the medication and dosage schedule on the resident's MAR with the medication label. Residents Affected - Some Medication Administration 9. Verify medication is correct three (3) times before administering the medication. 11. Hands are washed with soap and water and gloves applied before administration of topical, ophthalmic (eye), otic (ear), parenteral (IV), enteral (gastrostomy tubes), rectal, and vaginal medications. Hands are washed with soap and water again after administration and with any resident contact. Antimicrobial sanitizer may be used in place of soap and water as allowed. A review of the facility's policy titled Hand Hygiene indicated hand hygiene was to be completed: Before: A resident contact . D. taking part in a medical or surgical procedure After: A. contact with soiled or contaminated articles, such as articles that are contaminated with body fluids B. resident contact C. contact with a contaminated object or source where there is a concentration of microorganisms . H. removal of medical/surgical gloves I. Contact with resident's intact skin (e.g taking a pulse or blood pressure) J. Contact with environmental surfaces in the immediate vicinity of resident. A review of the facility's procedure titled FEEDING TUBES: MEDICATION ADMINISTRATION CHECK-OFF noted the steps to be taken during administration of medications via feeding tubes. The first step reads as follows: 1. Washes hands/puts on gloves. A review of the facility's policy titled Maintaining Patency 0r Peripheral and Central Vascular Access Devices provided the following instructions: 1. Vascular access devices are aspirated and flushed for a blood return prior to each infusion to assess catheter function and prevent complications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 6 of 17 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 676184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Park Rehabilitation and Skilled Nursing 5505 New Copeland Rd Tyler, TX 75703 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview with the DON on 04/05/2025 at 04:30 PM, she said she could not locate any documentation of training nor skill check-offs for general medication guidelines, G-Tube medication administration, nor IV medication administration. During an interview with DON and Corporate RN on 04/05/23 05:10 PM, both agreed that the facility has no evidence of training or nursing in-services regarding medication administration practices. Event ID: Facility ID: 676184 If continuation sheet Page 7 of 17 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 676184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Park Rehabilitation and Skilled Nursing 5505 New Copeland Rd Tyler, TX 75703 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure 1 (one) resident (Resident # 42) of 1 resident reviewed for positioning and mobility received treatment to prevent further reduction of range of motion (ROM). LVN A, LVN B, and RN C failed to follow the physician's orders for daily placement of braces on Resident #42. This failure could place the resident at risk for increased contractures and complications associated with contractures such as skin breakdown. Findings included: Resident #42, a [AGE] year-old female, was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including stroke, diabetes, depression, difficulty speaking and swallowing, and gastrostomy tube placement. a stroke and muscle weakness. A review of Resident #42's physician's orders dated 01/24/2023 indicated a black ankle brace was to be applied at 07:00 AM and removed at 07:00 PM daily. During the initial tour of the facility on 04/03/2023 at 10:45 AM, Resident #42 was noted lying on her back with the head of the bed elevated and a bolster pillow under her knees. Her legs were bent at the knees over the pillow and crossed at the ankles. Her feet were drawn close to the pillow's edge. A sign was posted on the wall over the bed with instructions to place black ankle braces on the resident daily and to place a Bolster pillow under the knees. Resident #42 did not have any braces on. Resident #42 was observed again 04/03/2023 at 12:15 PM, 02:30 PM, and 03:20 PM and no braces were noted to her lower extremities. Resident #42 was observed for braces on 04/04/2023 at 8:01 AM, 09:20 AM, 12;10 PM, and 03:00 PM with none being noted. Resident #42 was observed again on 04/05/2023 at 09:00AM and no braces were noted on her legs. A review of Resident #42's April, 2023 electronic Medication Administration Record indicated RN E documented the braces had been applied on 04/03/2023. LVN A documented the braces were applied on 04/04/2023. LVN C documented the braces were applied on 04/05/2023. RN E was not available for interview. Attempts to contact LVN A by phone on 04/05/2023 at 11:00 AM were unsuccessful. During an interview on 04/05/2023 at 10:47 AM, LVN C said the braces were not on the resident. When asked about the documentation of the braces being applied, LVN C said it was an oversight. During an interview with the Rehab Director on 04/05/2023 at 10:40 AM, she said it was nursing's job to apply and remove the braces for Resident #42. She said Therapy had placed the sign over the bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 8 of 17 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 676184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Park Rehabilitation and Skilled Nursing 5505 New Copeland Rd Tyler, TX 75703 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview with the Rehab Director on 04/05/2023 at approximately 3:45 PM, she said therapy would look Resident #42. During an interview with the Rehab Director and the Regional Rehab Consultant on 04/05/2023 at approximately 04:45 PM, they both agreed that Resident #42 had not had any decline in range of motion. The Rehab director said the resident's muscle tone was tight but normal for that resident. Event ID: Facility ID: 676184 If continuation sheet Page 9 of 17 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 676184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Park Rehabilitation and Skilled Nursing 5505 New Copeland Rd Tyler, TX 75703 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure 1 resident (Resident #42) of 3 residents reviewed for gastrostomy tubes received proper tube care during administration of medications. LVN A failed to check for obstruction and position of the gastrostomy tube prior to administering medications via the gastrostomy tube route. This failure could place the resident at risk for aspiration and infection. Findings included: A review of Resident #42's face sheet dated 04/05/2023 indicated the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses including a stroke, difficulty swallowing, and gastrostomy tube (feeding tube). A review of the April, 2023 physician's orders and medication records indicated the gastrostomy tube was to be used for providing nutrition and medications. During observation of medication administration on 04/04/2023 at 08:01 AM, LVN A was observed to administer 3 (three) medications to Resident #42 via the gastrostomy tube (G-Tube) route. LVN A did not wash or sanitize her hands prior to donning gloves in preparation for administering medications via the G-Tube nor after completion of giving the medications and removing the gloves. LVN A did not wash or sanitize her hands before administering medications to the next resident. LVN A did not check the G-Tube for position nor obstruction prior to flushing the tube with water and administering medications. LVN A was observed to disconnect the G-Tube from the feeding pump, flush the tube with water, administer medications, flushing with water between each medication, and flush the tube with water after administering the medications. She did not auscultate (use a stethoscope to listen to the stomach for sounds of air being flushed through the tube) the stomach nor aspiration of stomach contents to check for possible obstruction of the tube (patency)patency and position prior to performing medication administration. During an interview with LVN A on 04/04/2023 at 1:45 PM, LVN A was made aware of this failure to check the tube for obstruction and placement/position. LVN A made no comment except to say she was not feeling well and should not have come to work. The DON was present during this interview. During an interview with the DON on 04/05/2025 at 05:00 PM, she said she could not locate any documentation of training nor skill check-offs for G-Tube medication administration. A review of the facility's policy titled Medication Administration: General Guidelines provided the following instructions: 11. Hands are washed with soap and water and gloves applied before administration of topical, ophthalmic, otic, parenteral, enteral, rectal, and vaginal medications. Hands are washed with soap and water again after administration and with any resident contact. Antimicrobial sanitizer may be used in place of soap and water as allowed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 10 of 17 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 676184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Park Rehabilitation and Skilled Nursing 5505 New Copeland Rd Tyler, TX 75703 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the facility's policy titled Hand Hygiene indicated hand hygiene was to be completed before and after resident contact. A review of the facility's procedure titled FEEDING TUBES: MEDICATION ADMINISTRATION CHECK-OFF noted the steps to be taken during administration of medications via feeding tubes. The first step reads as follows: 1. Washes hands/puts on gloves 10. Checks residual volume 11. Flushes tube with 5cc water first, if unable to flush, notifies MD of blockage FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 11 of 17 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 676184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Park Rehabilitation and Skilled Nursing 5505 New Copeland Rd Tyler, TX 75703 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 0759 Ensure medication error rates are not 5 percent or greater. 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 ensure its medication error rate was less than 5%. 1 of 14 residents (Resident #42) reviewed for medication administration. Residents Affected - Few LVNA administered the wrong type of vitamin D and administered instead of withholding a cardiac medication that did not comply with the parameters specified by the physician. This failure could place the resident at risk for not receiving the intended therapeutic response and increasing the risk of adverse effects. Findings included: A review of Resident # 42's face sheet dated 04/05/2023 indicated resident was admitted on [DATE] and readmitted on [DATE] with diagnoses including stroke, difficulty speaking, heart failure, and Vitamin D deficiency. A review of a Resident #42's physician's order dated 02/07/2022 indicated an order for Vitamin D3 5000 units one time a day. A review of a Resident #42's physician's order dated 12/12/2021 indicated an order for carvedilol 3.125 mg to be given two times a day. Hold if systolic blood pressure is less than 100 or if diastolic blood pressure is less than 60 or if pulse is less than 60. During observation of medication administration on 04/04/2023 at 08:01 AM, LVN A took Resident #42's blood pressure and verbalized the blood pressure was 115/56 and the pulse was 58. Surveyor verified the numbers by repeating the numbers back to the nurse. LVN A confirmed the blood pressure and pulse readings were 115/56 and 58, respectively. Then, LVN A was observed to administer 1 capsule of Vitamin D 5000 units and 1 tablet of carvedilol 3.125 mg (milligrams) to Resident #42 via the gastrostomy tube route. During a review of the electronic Medication Administration Record for Resident #42 dated 04/04/2023, LVN A documented a blood pressure reading of 136/76 and a pulse of 67 instead of the verbalized readings of blood pressure 115/56 and pulse 58. During further review of the medication Administration Record for Resident #42 dated 04/04/2023, LVN D recorded a blood pressure 111/67 and a pulse of 67 later that same day. No adverse effects of receiving the carvedilol medication were noted. Attempts to contact LVN A by phone on 04/05/2023 at 11:00 AM to discuss the discrepancies between the verbalized vital sign readings and the documented readings were unsuccessful. A review of the facility's policy titled Medication Administration: General Guidelines provided the following directions under the section of Medication Administration: 1. Medications are to be administered in accordance with written orders of the prescriber. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 12 of 17 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 676184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Park Rehabilitation and Skilled Nursing 5505 New Copeland Rd Tyler, TX 75703 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 0760 Ensure that residents are free from significant medication errors. 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 ensure 1 (Resident #42) of 14 residents reviewed for medication administration was free of significant medication errors. Residents Affected - Some The nurse failed to follow the physician's instructions for administration of a cardiac medication. This failure could place the resident at risk for a lower than desired blood pressure and/or pulse. Findings included: A review of Resident # 42's face sheet dated 04/05/2023 indicated resident was admitted on [DATE] and readmitted on [DATE] with diagnoses including heart failure. A review of a Resident #42's physician's order dated 12/12/2021 indicated an order for carvedilol 3.125 mg to be given two times a day. The order included instructions to Hold if systolic blood pressure is less than 100 or if diastolic blood pressure is less than 60 or if pulse is less than 60. During observation of medication administration on 04/04/2023 at 08:01, LVN A assessed Resident #42's blood pressure and pulse. She said the blood pressure was 115/56 and the pulse was 58. Surveyor repeated the vital sign numbers back to the nurse. LVN A confirmed the blood pressure and pulse readings. LVN A was then observed to administer 1 tablet of carvedilol 3.125 mg (milligrams) to Resident #42 via the gastrostomy tube route. During a review of the electronic Medication Administration Record for Resident #42 on 04/05/2023, it was noted that on 04/04/2023, LVN A had documented a blood pressure reading of 136/76 and a pulse of 67 instead of the verbalized readings of blood pressure 115/56 and pulse 58. During further review of the medication Administration Record for Resident #42 dated 04/04/2023, LVN D recorded a blood pressure 111/67 and a pulse of 67 later that same day. No adverse effects of receiving the carvedilol medication were noted. Attempts to contact LVN A by phone on 04/05/2023 at 11:00 AM to discuss the discrepancies between the verbalized vital sign readings and the documented readings were unsuccessful. A review of the facility's policy titled Medication Administration: General Guidelines provided the following directions under section Medication Administration: 1. Medications are to be administered in accordance with written orders of the prescriber. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 13 of 17 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 676184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Park Rehabilitation and Skilled Nursing 5505 New Copeland Rd Tyler, TX 75703 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 ensure the use of appropriate infection prevention and control practices for 5 of 14 residents observed during medication administration Residents Affected - Some LVN A failed to demonstrate appropriate hand hygiene practices when administering medications to Residents #'s 6, 41, 42, 43, and 61. This failure could increase the risk for and spread of infection among residents. Findings included: Resident #6, a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including diabetes and congestive heart failure. During observation of medication administration on 04/04/2023 at 07:30 AM, LVN A was observed to obtain a Novalog insulin pen, a Basaglar insulin pen, and 1 tablet of furosemide 20mg (milligram) from the nurses' cart. LVN A then put on a pair of medical gloves and took the medications into the room of Resident #6. She gave him his pill and then pulled his shirt up to expose his abdomen. LVN A injected the 2 insulins into the residents right upper abdominal quadrant, pulled his shirt down, and left the room. When she returned to the cart, she removed the gloves from her hands and discarded them. She completed her documentation and proceeded to prepare for the next medication task. LVN A did not wash her hands nor use hand sanitizer before applying gloves and before beginning medication administration nor after completion of the medication administration. LVNA was observed to touch the arm of the resident's chair, the resident's clothes, the resident's abdomen, the nurses' cart, opened and shut drawers on the cart, prepared medications for administration, and administered medications without performing any hand hygiene measures. Resident #42, an 81year-old male, was admitted to the facility on [DATE] with diagnoses including congestive heart failure. During observation of medication administration on 04/04/2023 at 07:45 AM, LVN A obtained 1 tablet of furosemide 20mg from the cart without performing any hand hygiene prior to obtaining the medication. She entered Resident #41's room, gave him his medication, and left the room. She returned to the cart. LVN A failed to wash her hands or use hand sanitizer to cleanse hands prior to nor after performing the medication administration task. Resident #61, an [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including congestive heart failure, irregular heart rate, and shortness of breath. During observation of medication administration on 04/04/2023 at 07:52 AM, LVN A obtained 2 oral medications (Eliquis 5 mg tablet and Bumex 5 mg tablet) and 1 inhaler (fluticasone furoate nasal spray) from the nurses' cart. She then put on a pair of medical gloves without cleansing her hands before doing so. She did not perform hand hygiene after contact with the previous resident nor prior to obtaining the medications from her cart. She entered Resident #61's room, assisted the resident to take a drink of water by holding the cup to his lips/mouth. She then assisted him to take his medications by holding the medicine cup to his mouth. LVN A returned to the cart, removed the gloves from her hands and discarded them into the trash bin on the side of the cart. She did not perform hand (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 14 of 17 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 676184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Park Rehabilitation and Skilled Nursing 5505 New Copeland Rd Tyler, TX 75703 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 hygiene afterwards. Level of Harm - Minimal harm or potential for actual harm Resident # 42, a [AGE] year-old female, was admitted on [DATE] with diagnoses including stroke, muscle weakness, diabetes, congestive heart failure, gastrostomy tube placement, and vitamin D deficiency. Residents Affected - Some During observation of medication administration on 04/04/2023 at 08:01, LVN A was observed to administer 3 (three) medications to Resident #42 via the gastrostomy tube (G-Tube) route. During this process, LVN A was observed to use the resident's right forearm to obtain the resident's blood pressure and pulse, then she proceeded to pull the bed linens covering the resident down and raise the resident's gown to expose the gastrostomy tube. The nurse then disconnected the G-Tube from the formula tubing and administered the medications. LVN A did not wash or sanitize her hands prior to donning (putting on) gloves in preparation for administering medications via the G-Tube route nor after completion of giving the medications and removing the gloves. LVN A was observed to touch the feeding pump and the pole it was on, the nightstand beside the bed, the resident's clothes and bed linen, and the gastrostomy tube, without ever performing hand hygiene measures. Resident #43, a [AGE] year-old male, was admitted on [DATE] with diagnoses including left hip fracture, diabetes, left hip ulcer, right hip wound, sacral pressure ulcer, malnutrition, urinary obstruction, and sepsis (a life threatening complication of infection). Resident was hospitalized recently and re-admitted on [DATE] with orders for intravenous antibiotic therapy. During observation of medication administration on 04/04/2023 at 09:00, LVN A obtained a syringe with a normal saline solution in it and a small bag containing an antibiotic solution from the cart. She did not have the tubing needed to administer the antibiotic via the intravenous (IV) route. After looking throughout the cart, LVN A went to the medication room and looked for the appropriate tubing, using her hands to open cabinets and drawers. After obtaining tubing from the DON, LVN A, she donned (put on) medical gloves without performing any hand hygiene measures and went into Resident #43's room. LVN A removed the cap from the Resident #43's peripherally inserted central catheter (PICC) line, cleansed the port with an alcohol swab, flushed the line with the normal saline solution, and connected the bag containing the antibiotic to the central line's port. LVN A returned to the cart, removed the gloves and discarded them into the trash bin attached to the cart. LVN A did not wash nor sanitize her hands before, during, or after the process of administering the intravenous antibiotic. LVN A was observed to administer medications to the 5 (five) above residents (#6, #41, #61, #42, #43) without performing any handwashing nor sanitizing measures at any time. Upon completion of the observations, LVN A was asked if, in retrospect, could she think of anything that she would or should have done differently and she said she that she did not think so. A review of the facility's policy titled Medication Administration: General Guidelines provided the following instructions: 11. Hands are washed with soap and water and gloves applied before administration of topical, ophthalmic, otic, parenteral, enteral, rectal, and vaginal medications. Hands are washed with soap and water again after administration and with any resident contact. Antimicrobial sanitizer may be used in place of soap and water as allowed. A review of the facility's policy titled Hand Hygiene indicated hand hygiene was to be completed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 15 of 17 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 676184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Park Rehabilitation and Skilled Nursing 5505 New Copeland Rd Tyler, TX 75703 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 Before: Level of Harm - Minimal harm or potential for actual harm B. resident contact . D. taking part in a medical or surgical procedure Residents Affected - Some After: D. contact with soiled or contaminated articles, such as articles that are contaminated with body fluids E. resident contact F. contact with a contaminated object or source where there is a concentration of microorganisms . K. removal of medical/surgical gloves L. Contact with resident's intact skin (e.g taking a pulse or blood pressure) M. Contact with environmental surfaces in the immediate vicinity of resident. A review of the facility's procedure titled FEEDING TUBES: MEDICATION ADMINISTRATION CHECK-OFF noted the steps to be taken during administration of medications via feeding tubes. The first step reads as follows: 1. Washes hands/puts on gloves. During an interview with LVN A on 04/04/2023 at 1:45 PM, LVN A was made aware of these observations to which she replied, I'm sick. I should not have come in today. The DON was present during this interview. During an interview with the DON on 04/05/2025 at 04:30 PM, she said she could not locate any documentation of training nor skill check-offs for general medication guidelines, G-Tube medication administration, nor IV medication administration. During an interview with DON and Corporate RN on 04/05/23 05:10 PM, both agreed that the facility has no evidence of training or nursing in-services regarding medication administration practices. A review of the facility's policy titled Medication Administration: General Guidelines revealed the following: POLICY Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices . PROCEDURES Medication Preparation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 16 of 17 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 676184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Park Rehabilitation and Skilled Nursing 5505 New Copeland Rd Tyler, TX 75703 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 3. Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record. Compare the medication and dosage schedule on the resident's MAR with the medication label. Medication Administration Residents Affected - Some 9. Verify medication is correct three (3) times before administering the medication. A review of the facility's policy titled Medication Administration: General Guidelines provided the following instructions: 11. Hands are washed with soap and water and gloves applied before administration of topical, ophthalmic, otic, parenteral, enteral, rectal, and vaginal medications. Hands are washed with soap and water again after administration and with any resident contact. Antimicrobial sanitizer may be used in place of soap and water as allowed. A review of the facility's policy titled Medication Administration: General Guidelines provided the following directions under the section of Medication Administration: 1. Medications are to be administered in accordance with written orders of the prescriber. A review of the facility's policy titled Hand Hygiene indicated hand hygiene was to be completed before and after resident contact. A review of the facility's procedure titled FEEDING TUBES: MEDICATION ADMINISTRATION CHECK-OFF noted the steps to be taken during administration of medications via feeding tubes. The first step reads as follows: 1. Washes hands/puts on gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 17 of 17