Health inspection·June 26, 2023

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some buttocks. Heel discoloration: right and left foot. Comments: admission skin assessment: Red dry blisters left upper back & lower back. Open blister left lower back, blisters on left hip, waist, left thigh, & left buttock. Open wound to left buttock. Record review daily skilled note dated 6/12/23 indicated Resident #1 had pressure wound to buttocks, left and right foot. Bruises: right and left arms, right and left hands. Blisters: upper and lower back and right hip. Heel discoloration: right and left foot. Record review daily skilled note dated 6/13/23 indicated Resident #1 had rashes to lower back, right and left hip and peri area. Wound: buttocks, right and left foot. Bruises/discolored: face, right and left arm, and right and left legs. Blister: upper and lower back. Heel discoloration: right and left foot. The wound note from the hospital dated 6/14/23 detailed Resident #1 had the following pressure injuries: *unstageable pressure wound to the left heel measuring 3.5 cm in length, 4 cm in width. The depth of the wound could not be assessed due to the Eschar (collection of dry, dead tissue within a wound). *unstageable pressure wound to the right heel measuring 5 cm in length, and 5 cm in width. The depth of the wound could not be assessed due to the Eschar (collection of dry, dead tissue within a wound). *unstageable pressure wound to the Lumbar Spine 4 cm in length and 3.5 cm in width and 0.3 cm in depth. *unstageable pressure wound Left ischium 6 cm in length. The width and depth was not documented . The 5-day MDS dated [DATE] and completed on 6/15/23 for Resident #1 in section M indicated Resident #1 had no pressure ulcers/injuries. The Significant Change MDS dated [DATE] and completed on 6/15/23 for Resident #1 in section M indicated Resident #1 had no pressure ulcers/injuries. The discharge MDS dated [DATE] and completed on 6/19/23 for Resident #1 in section M indicated Resident #1 had no pressure ulcers/injuries. During an interview on 6/26/23 at 4:23 p.m., MDS Coordinator F said she was the one who completed the MDSs for Resident #1. She said when completing the MDS she did not physically see the residents, she would gather the information from doing record reviews. MDS Coordinator F said for Section M she gathered the information from the facility's wound reports which are completed by the treatment nurse and MARS/TARS. She said she did not gather information from the resident's skin assessments because the assessments are not always accurate. MDS Coordinator F said she did not physically see Resident #1 when completing her MDSs, so she was not aware Resident #1 had any pressure sores. She said now that she is aware Resident #1 had pressure sores, then the MDS are not considered inaccurate. During an interview via email on 6/26/23 at 5:38 p.m., DON said she expects for the MDS Coordinator to gather information using resident charts, hospital records, and resident/staff interviews for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 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 676184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2023 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 0641 completing the MDS. Level of Harm - Minimal harm or potential for actual harm During an interview via email on 6/26/23 at 11:57 a.m., Administrator said they refer to RAI Manual when completing MDS. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 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 676184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2023 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent new pressure injuries from developing was provided for 1 of 3 residents reviewed for pressure injuries (Resident #1). Residents Affected - Some The facility did not perform a complete skin assessment for Resident #1 upon her readmission to the facility on 6/9/23. The facility did not perform accurate skin assessments for Resident #1 on 6/10/23 and 6/11/23. The facility did not ensure treatment orders were put in place for Resident #1's DTIs (deep tissue injuries) upon her readmission on [DATE]. The facility did not provide wound care treatment to Resident #1's DTIs for 3 days. This failure could place residents at risk for new development or worsening of existing pressure injuries, pain, and decreased quality of life. Findings included: Record review of Resident #1's face sheet dated 6/16/23 indicated she was [AGE] years old re-admitted to the facility on [DATE] and discharged from the facility on 6/13/23. Resident #1's admitting diagnoses included unspecified fracture of the left pubis (either of a pair of bones forming the two sides of the pelvis), End stage renal disease, Type II diabetes, muscle weakness, and lack of coordination. Record review of the MDS dated [DATE] indicated Resident #1 understood others and made herself understood. The MDS indicated she had mild cognitive impairment (BIMS of 11). The MDS indicated she had no behavior of rejecting care. The MDS indicated Resident #1 was totally dependent on staff for locomotion in her wheelchair. The MDS indicated she required extensive assistance with bed mobility and dressing. The MDS indicated transfers, and personal hygiene had only occurred once or twice during the 7days look back period. The MDS indicated Resident #1 required limited assistance with eating. The MDS indicated she required supervision only with toilet use. The MDs indicated Resident #1 was always incontinent of urine and was occasionally incontinent of bowel. The MDS indicated Resident #1 was at risk for developing pressure injuries. The MDS indicated Resident #1 had no unhealed pressure injuries. Record review of the Care plan dated 6/10/23 indicated Resident #1 was at risk for or had Skin Breakdown as evidence by, Moderate risk for pressure injury (6/10/23), Rash (6/11/23) the presence of a wound (6/11/23[the wound type nor location was not specified]), the presence of blister(6/11/23 [the location was not specified]), the presence of heel discoloration (6/11/23), and the presence of an open lesion (6/11/23 [the location and size of the lesion was not specified]). The care plan interventions included, Inspect skin weekly head to toe every week and document results; Inspect skin daily with care and bathing; and administer treatments and dressings as ordered by the physician. The hospital note dated 6/4/23 indicated Resident #1 had excoriation to her L heel excoriation and redness to her buttocks. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 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 676184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2023 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 0686 Level of Harm - Minimal harm or potential for actual harm The hospital note dated 6/6/23 indicated Resident #1 had redness to her buttocks and excoriation to her right and left heels. The hospital Discharge summary dated [DATE] indicated Resident #1 was admitted to the hospital on [DATE] and discharged on 6/9/23. Residents Affected - Some The nursing note dated 6/9/23 indicated Resident #1 stated readmitted patient via facility van. This section of the note was electronically signed by LVN G on 6/9/23 at 5:49 p.m. The second section of the note stated Resident readmitted with bad smelling odou [odor]. Peri area dirty, looks like resident has not been cleaned throughout her time in the hospital. Completed skin assessment. Patient noted with blisters allover her body. left upper back, lower back. Open wound left lower back, blisters on left hip, waist, left thigh, & left buttock. Open wound to left buttock. Open wounds to left & right heels Will notify wound care nurse. This section of the nursing note was marked addendum and electronically signed by LVN G on 6/11/23 at 6:10 p.m. Record review of the nurses notes from 6/10/23 to 6/13/23 did not document any skin or wound assessments. Record review of the skin section daily skilled note for Resident #1 dated 6/10/23 stated Status- Skin color normal; Rash/Redness- No; Wound (pressure, diabetic or stasis)- No; Open lesions- No; Surgical woundNo; Bruises/discolored- No; Skin tear/Laceration- No; Abrasions- No; Burn- No; Blister- No; Cyanotic extremities- No; Heel discoloration- No; Skin Breakdown Interventions- Pressure Relief Mattress , Pressure Relief Chair Cushion , - Floating Heels , - Frequent repositioning , - Low Air Loss Mattress; Changes in skin- No change. This note was completed by LVN H Record review of the skin section daily skilled note for Resident #1 dated 6/11/23 stated Status- Skin color normal; Rash/Redness- No; Wound (pressure, diabetic or stasis)- No; Open lesions- No; Surgical woundNo; Bruises/discolored- No; Skin tear/Laceration- No; Abrasions- No; Burn- No; Blister- No; Cyanotic extremities- No; Heel discoloration- No; Skin Breakdown Interventions- Pressure Relief Mattress , Pressure Relief Chair Cushion , - Floating Heels , - Frequent repositioning , - Low Air Loss Mattress; Changes in skin- No change. This note was completed by LVN I. Record review of the physician order for Resident #1 dated 6/11/23 stated Treatment 1 time per day cleanse left lower back wound with normal saline, pat dry, apply drsg (dressing) of choice. This order was discontinued on 6/17/23 Record review of the physician order for Resident #1 dated 6/11/23 stated Treatment 1 time per day cleanse left buttock wound with normal saline, pat dry, apply drsg (dressing) of choice. This order was discontinued on 6/17/23. Record review of the physician order for Resident #1 dated 6/11/23 stated Treatment 1 time per day cleanse left heel wound with normal saline, pat dry, apply drsg (dressing) of choice. This order was discontinued on 6/17/23. Record review of the physician order for Resident #1 dated 6/11/23 stated Treatment 1 time per day cleanse right heel wound with normal saline, pat dry, apply drsg (dressing) of choice. This order was discontinued on 6/17/23. Record review of the TAR for Resident #1 for June 2023 indicated she received treatment as ordered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 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 676184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2023 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 0686 Level of Harm - Minimal harm or potential for actual harm to the left lower back wound, left buttock wound, left heel wound, and right heel wound on 6/12/23. The TAR indicated Resident #1 had not received any wound care for her wounds from 6/9/23 to 6/11/23. Record review of the physician orders for Resident #1 from 6/9/23 to 6/13/23 indicated Resident #1 had no wound treatment orders prior to 6/11/23 for the 6/9/23 to 6/13/23 admission. Residents Affected - Some The nursing note dated 6/13/23 indicated Resident #1 was sent to the hospital due to a syncope (temporary loss of consciousness )episode. The wound note from the hospital dated 6/14/23 detailed Resident #1 had the following pressure injuries: *unstageable pressure wound to the left heel measuring 3.5 cm in length, 4 cm in width. The depth of the wound could not be assessed due to the Eschar (collection of dry, dead tissue within a wound). *unstageable pressure wound to the right heel measuring 5 cm in length, and 5 cm in width. The depth of the wound could not be assessed due to the Eschar (collection of dry, dead tissue within a wound). *unstageable pressure wound to the Lumbar Spine 4 cm in length and 3.5 cm in width and 0.3 cm in depth. *unstageable pressure wound Left ischium 6 cm in length. The width and depth was not documented . During an interview with LVN G on 6/24/23 at 4:09 p.m., LVN G said she completed the assessment of Resident #1 on 6/9/23 at the end of her shift. LVN G sad she had not documented the assessment on 6/9/23 so she made an addendum to her note when she returned to the facility on 6/11/23. She clarified she did not work on 6/10/23. During an interview on 6/24/23 at 4:10 p.m., the Wound Care Nurse said she had not seen Resident #1 during her 6/9/23 to 6/13/23 stay. The Wound care nurse said she was in the facility the morning but was gone for the day prior to her admission that evening. The Wound care nurse said she was on vacation from 6/10/23 to 6/15/23. The Wound Care Nurse said LVN H and LVN J performed wound care during her absence. During an interview on 6/25/23 at 2:00 p.m., LVN H said he performed wound care from 6/12/23 to 6/15/23. He said he did not perform wound care on the 10th and the 11th but did take care of Resident#1. He said he could not remember if she had any wounds or DTIs. He said if he had had he would have charted it. LVN H said he could not remember any drastic skin issues with Resident #1. During an interview on 6/25/23 at 2:05 p.m., LVN I said she no longer worked at the facility. LVN I said she could not recall Resident #1 or if she had any wounds or DTIs. LVN I said if she had noted any wounds or DTIs on Resident #1 she would have documented them. An interview with LVN J was attempted by phone on 6/25/23 but was not obtained. During an interview with LVN G on 6/25/23 at 2:30 p.m., LVN G said she completed the assessment on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 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 676184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2023 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 6/11/23 because she had not completed the assessment on 6/9/23. LVN G said she had not completed the assessment on 6/9/23 because the resident was re-admitted at the end of her shift and she had an appointment to attend. LVN G said she completed an assessment on 6/11/23 and documented it on the 6/9/23 note. When LVN G was asked why she said in the previous interview (6/24/23) why she said she had completed the assessment on 6/9/23. She replied I didn't assess her on the 9th I assessed her on the 11th. LVN G said she gave report to LVN I on 6/9/23 and LVN I should have done the initial skin assessment. During an interview on 6/25/23 at 3:15 p.m. the ADON said she expected nurses to complete a skin assessment promptly on admission. The ADON said the nurses had 24 hours to complete the skin assessment but said the skin assessment should be completed as soon as possible. The ADON said it was not ok that Resident #1 was admitted with DTIs and did not receive treatment until 6/12/23. The ADON said if a Resident is admitted after hours (when the wound care nurse would be in the facility) or on the weekend, and found with wounds, the M.D. should be notified, and the nurse should enter the standing wound care orders until more specific orders were provided. The ADON said she felt the nurses that documented skin assessments on 6/10-6/11 on the daily skilled notes had not assessed/documented accurately. The ADON said any wounds should be described in detail and measurements obtained. During an interview on 6/26/23 at 2:30 p.m., the DON said when a resident admits over the weekend or after hours, It was the facilities' expectation that skin assessments were completed within 24 hours from admission and that the nurse that identifies the wounds notify physician and obtain wound care orders. The DON said the process in place to monitor new admission and ensure they received appropriate wound treatment was the daily (Monday -Friday)clinical meetings. The DON said Resident #1 was discussed in the clinical morning meeting on Monday (6/12/23). The DON said in the meeting she was aware that the nurse noted wounds, notified the physician, and obtained orders. The DON said the facility had recently hired an RN weekend supervisor, currently still in training, who will monitor wounds on the weekends. During an interview on 6/26/23 at 2:35 p.m., the Administrator said it was the facilities' expectation that the skin assessment is done within 24 hours of admission. The Administrator said the process in place to monitor new admissions and ensure they received appropriate wound treatment was the daily clinical meetings. Record review of the facility policy and procedure titled Prevention of Pressure Ulcers/Injuries dated July 2018, stated .Assessment and Treatment of Pressure Ulcers/Injuries It is important that each existing PU/PI (Pressure Ulcer/Pressure Injury)be identified, whether present on admission or developed after admission, and that factors that influenced it's development, the potential for development of additional PU/PIs or the deterioration of the PU/PI be recognized, assessed and addressed . When assessing the PU/PI itself it is important that documentation address: The type of injury (pressure related versus non-pressure related) .The PU/PI's stage: A description of the PU/PI's characteristics; The progress toward healing and identification of potential complications; if infection is present; the presence of pain , what was done to address it, and the effectiveness of the intervention; and a description of dressings and treatments Record review of the facility policy and procedure titled, Skin Data Collection; Licensed Nurses, revised July 2018 stated . Any significant abnormal findings are reported to the patient's/resident's physician and resident or responsible party. The website (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 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 676184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2023 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf accessed on 6/29/23 stated, Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue . Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. Event ID: Facility ID: 676184 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 676184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2023 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies, and skills set to carry out the functions of the food and nutrition service for 1 of 1 (DM) reviewed for qualified dietary staff. The facility failed to ensure the facility's DM met the requirements for a certified dietary manager. This failure could place residents at risk of not having their nutritional needs met and placed them at risk for food born illnesses. Findings included: During an interview via email on 6/19/23 at 6:00 p.m., the Administrator said DM was promoted to her new position on 5/23/23, was currently working on CDM, and he was waiting to hear back on the testing date. During an interview on 6/23/23 at 10:51 a.m., the DM stated she had a Food Handlers certificate but did not have a dietary manager's certificate. She explained she was enrolled in a certification program on 5/23/23 and had completed two of five tests but she currently has not yet finished. Record review of Food Safety Manager Principles Training and Texas Food Safety Manager Exam receipt with order date 6/26/23 addressed to DM indicated the DM had just enrolled into the CDM courses at 7:46 a.m. During an interview via email on 6/26/23 at 3:56 p.m., the Administrator said Texas no longer has CDM requirements if facility had a full-time dietitian. State Investigator requested to review the Dietician's contract, and it was not provided. During an interview via email on 6/26/23 at 5:02 p.m. the Administrator said they have a Regional Dietitian Consultant who visited biweekly and as needed on the following dates: 5/2/23, 5/16/23, 5/30/23, 6/6/23 and on 6/20/23. During a telephone interview on 6/30/23 at 11:24 a.m. The Regional Dietitian said she was the full time Dietitian for all four of her company's facilities. She said she had two local facilities and two facilities out of town, and she visits each facility at least three times a month. State Investigator requested to see a copy of the Dietitian's contract and she said she would send a copy to the Administrator for him to provide. State Investigator never received contract to review. Record review of undated Nutrition Services Manager Job Description revealed Job Purpose: The Nutrition Services Manager is responsible for the general operations of the Nutrition Services Department. Essential Functions: .Regulatory compliance with all local, state and federal guidelines. Qualifications: -Successful completion of an approved state food service supervisor course required. - Certified Dietary Manager (CDM) certification required. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 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 676184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation and safety. -The facility failed to ensure food items in the dry storage, refrigerator, and freezer were dated, labeled and sealed appropriately. -Dietary aides B, and C failed to use a beard restraint. -Cook D failed to use a beard restraint. These failures could affect the residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination. Findings included: During an observation of the kitchen on 6/16/23 at 4:04 p.m. to 5:24 p.m. revealed the following: -Cook D was not wearing a beard restraint while working in the kitchen, he had his beard gathered into a ponytail with an orange or red colored rubberband. -at 4:13 p.m., Dietary aide B entered the kitchen from a back door entrance, he did not wash hands nor wore a hairnet. He went straight to the dishwasher getting cups to fill with ice. [NAME] D handed Dietary aide B with a hairnet to wear. -at 4:25 p.m., unknown staff wearing pink scrubs entered the kitchen from the backdoor entrance walked through the kitchen, got ice and exited into the facility she did not wash her hands, nor wore a hairnet. -at 4:38 p.m., Dietary aide B and C assisted on tray service line, no beard restraint worn. During an interview on 6/16/23 at 5:22 p.m., [NAME] D, Dietary aides B and C said they had been working at facility for three weeks or less and the DM had never required for them to wear beard restraints. [NAME] D said there was no beard restraints available in kitchen, and that was why he wore his beard in a ponytail. During an observation on 6/23/23 at 10:51 a.m., Dietary aide E was not wearing a beard restraint while working in the kitchen. During an interview on 6/23/23 at 10:55 a.m., DM said she was new in her position and was not aware beard restraints was a requirement. During an observation of the kitchen's dry storage, refrigerator, and freezer on 6/25/23 starting at 11:27 a.m., revealed the following: Walk-in refrigerator (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 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 676184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2023 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 0812 -One plastic bag of sausage links, not labeled, and not dated Level of Harm - Minimal harm or potential for actual harm -One gallon size Ziplock bag of shredded carrots not labeled, and not dated -One open plastic bag of shredded carrots not labeled, and not dated Residents Affected - Some -Large bundle of what looked like purple cabbage wrapped in several layer of clear plastic wrap, not labeled, and not dated. Walk-in freezer -one open plastic bag not dated stored in a box that had a product sticker labeled peanut butter frozen cookie dough. -on the back shelf a glass dessert bowl with brown pudding like food covered with a plastic wrap, not labeled, and not dated. -on the back shelf was a plastic bag of unidentified meat, not labeled, and not dated. -on back shelf, bottom rack was a brown box with an open brown bag of unknown amount of frozen regular cut fries, not dated. -on the right shelf was a white box, with an open clear bag of unknown amount of frozen beef patties, not dated. Dry storage -on the left shelf one Ziplock bag of unknown white grain like food item not labeled, and not dated. -on left shelf one open plastic bag of unknown white grain like food item not labeled, and not dated. -on back shelf one open plastic bag of nilla wafers, not labeled, and not dated. Refrigerator -open 5-pound pack of sliced pasteurized process Swiss and American cheese, not dated. -open Ziplock bag of sliced pasteurized process Swiss and American cheese dated 6/18/23, not labeled. -Large plastic container with mixed fruits covered with a plastic wrap, not labeled, and not dated. During an interview on 6/25/23 at 11:50 a.m., DM said the current staff trained the new hires. She said she expected for all food items in the freezer and refrigerator to be dated and labeled. In addition, items in the dry storage area should be sealed or in containers, dated, and labeled. Record review of revised nutrition services infection control policy dated 5/28/20 indicated All (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 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 676184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some local, state and federal standards and regulations are followed to ensure a safe and sanitary Nutrition Services Department Procedure: . 5. Anyone who enters the kitchen will have all hair restrained using bouffant caps, mesh or net, beard guard and clothing which covers body hair. Record review of nutrition services food storage policy dated 8/1/18 indicated Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored, prepared, and transported at an appropriate temperature and by methods designed to prevent contamination. Procedure: 1.Storeroom: -Air-tight containers or bags are used for all opened packages of food. All containers are accurately labeled with the item and date opened. 2.Refrigerator: -All foods are covered, labeled and dated. Defrosting meat, eggs and milk shakes are labeled with date pulled for thawing. 3.Freezer: -Foods are covered, labeled and dated. Any item out of the original case must be properly secured and labeled. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 12 of 12