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Inspection visit

Health inspection

Providence Park Rehabilitation and Skilled NursingCMS #6761844 citations on this visit
4 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs to meet the needs of each resident for 1 of 4 Residents reviewed for medications. (Resident #1) The facility failed to ensure Resident #1's medications were administered as ordered, this resulted in Resident #1 missing dosages of the following: Pantoprazole Tablet (for heartburn, acid reflux); Triamcinolone Topical cream (for Rash and other nonspecific skin eruption); Insulin Lispro (for Diabetes mellitus due to underlying condition without complications); Aspirin Tablet (for Chronic atrial fibrillation); Apixaban/Eliquis Tablet (for Chronic atrial fibrillation); and Levothyroxine tablets (for Hypothyroidism). Resident #1 was administered an incorrect dosage of acetaminophen (Acetaminophen 325 mg tablet) for 8 days. This failure could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications. Findings included: Record review of Resident #1's face sheet printed on 10/17/23 indicated Resident #1 was an [AGE] year-old female who admitted on [DATE] and discharged on 10/15/23 with diagnoses including chronic atrial fibrillation (an irregular and often very rapid heart rhythm), Atherosclerotic heart disease (This is an umbrella term that describes any disease of the heart and blood vessels caused by a common condition that develops when a sticky substance called plaque builds up inside your artery), hypertension (it means your blood pressure is always too high. This means your heart is working harder when pumping blood around your body), hypothyroidism (underactive thyroid, is a condition where the thyroid gland doesn't release enough thyroid hormone into the bloodstream), rheumatoid arthritis (a condition that can cause pain, swelling and stiffness in joints), and vitamin D deficiency (is essential for healthy bones, and a lack of it can lead to health problems, including cardiovascular disease). Record review of admission MDS assessment dated [DATE] indicated Resident #1 had clear speech and understood others. She had BIMS score of 12 out of 15 indicating she was moderately impaired cognitively. Resident #1's hearing and vision was adequate. Section GG indicated Resident #1 had no upper or lower extremity impairments. Required set up or clean -up assist with eating, oral hygiene and/or upper body dressing. Required moderate to substantial assist with toileting, showers, lower body dressing and with putting on shoes and socks. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 19 Event ID: 676184 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 10/24/2023 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 0755 Record review of Resident #1's care plan last reviewed/revised 10/05/23 indicated the following: Level of Harm - Minimal harm or potential for actual harm Problem: Pain; Evidence By: acetaminophen 325 mg tablet (ACETAMINOPHEN) 1 tablet by mouth every 6 hours As Needed PAIN/TEMP; Pain Scale every 2 shift. Goal: Residents will have pain assessed and managed for optimal comfort. Interventions: Administer pain medications as ordered; Give pain medications before pain becomes severe; Instruct family/resident about pain care and pain medications; Notify physician of any changes in level or frequency of pain, any increase in use of prn pain medications, and any noted side effects of pain medications; Observe resident for signs of pain with care and interactions; Obtain pain history onset, intensity, frequency etc. Problem: Diabetes Mellitus; Evidence By : insulin lispro (U-100) 100 unit/mL subcutaneous pen (INSULIN LISPRO) Units Per Sliding Scale Subcutaneous before meals and at bedtime. Goal: Resident blood sugars will be monitored and signs and/or symptoms of hyper or hypoglycemia will be treated according to physician orders on a daily basis over the next 90 days. Interventions: Administer insulin and/or oral hypoglycemics as ordered; Observe for S/S of Hyperglycemia such as blood sugar more than 180mg/dL, fatigue (weak, tired feeling), blurred vision, headaches, increased thirst, trouble concentrating, frequent urination, weight loss. Notify provider per order; FSBS via glucometer as ordered; Observe for S/S of Hypoglycemia such as shakiness, Nervousness or anxiety, Irritability or impatience, Confusion, Rapid heartbeat, Lightheadedness or dizziness, nausea, sleepiness, blurred vision, Tingling or numbness in lips or tongue, headaches, weakness or fatigue, lack of coordination, seizure, unconsciousness. Treat per hypoglycemic protocol. Residents Affected - Some Record review of after visit summary also known as the admitting orders dated 09/30/23 indicated Resident #1 was to have the following: -Acetaminophen 650 mg by mouth every 6 (six) hours as needed for Pain, takes 3 tablets daily -Apixaban 2.5 MG tablet Commonly known as: Eliquis; Take 1 tablet (2.5 mg total) by mouth 2 (two) times Daily -Aspirin 81 mg chewable tablet; Take 1 tablet Daily. -Insulin Lispro 100 UNIT/ML injection vial - Commonly known as: HumaLOG Inject 0.02-0.12 mLs (2-12 Units total) into the skin 3 (three) times daily with meals. -Levothyroxine 75 MCG tablet - Commonly known as: Synthroid; Take 1 tablet Daily. -Pantoprazole 40 MG enteric-coated tablet - Commonly known as: Protonix; Take 1 tablet (40 mg total) by mouth daily. -Triamcinolone 0.025 % cream - Commonly known as: Kenalog; Apply topically 2 (two) times daily. Record review of Resident #1's Facility's Order Summary Report from 09/30/23 to 10/19/23 revealed the following: -Levothyroxine 75 mcg tablet (LEVOTHYROXINE SODIUM) 1 tablet by mouth 1 time per day Dx : Hypothyroidism. Start Date: 09/30/23, End Date 10/19/23. -Pantoprazole 40 mg tablet, delayed release (PANTOPRAZOLE SODIUM) 1 tablet by mouth 1 time per day Dx : Essential (primary) hypertension. Start Date: 09/30/23, End Date: 10/02/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 2 of 19 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 10/24/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm -Insulin lispro (U-100) 100 unit/mL subcutaneous pen (INSULIN LISPRO) Units Per Sliding Scale Subcutaneous before meals and at bedtime Site Location 0 - 60 = 0 UNITS * MD Call 61 - 130 = 0 UNITS 131 - 180 = 2 UNITS 181 - 240 = 4 UNITS 241 - 300 = 6 UNITS 301 - 350 = 7 UNITS 351 - 400 = 10 UNITS 401 or greater then 12 UNITS * MD Call Residents Affected - Some Dx : Diabetes mellitus due to underlying condition without complications; Start Date: 10/02/23, End Date: 10/19/23. -Triamcinolone acetonide 0.025 % Topical Cream (TRIAMCINOLONE ACETONIDE) 1 Cream topically 2 times per day Dx : Rash and other nonspecific skin eruption; Start Date:09/30/23, End Date: 10/19/23. -Aspirin 81 mg tablet, delayed release (ASPIRIN) by mouth 1 time per day Dx : Chronic atrial fibrillation; Start Date: 09/30/23, End Date: 10/19/23. -Eliquis 2.5 mg tablet (APIXABAN) 1 tablet by mouth 2 times per day Dx : Chronic atrial fibrillation; Start Date: 09/30/23, End Date: 10/19/23. Record review of Resident #1's MED PRN MAR record dated 09/30/23 to 10/17/23 indicated the following: -Acetaminophen 325 mg tablet (ACETAMINOPHEN) 1 tablet by mouth every 6 hours As Needed PAIN/TEMP Dx: Pain, unspecified Start Date:09/30/2023: Was administer two times on 10/02/23; two times on 10/03/23; one time on 10/05/23; one time on 10/06/23; one time on 10/08/23; two times on 10/12/23; and two times on 10/13/23. Time: Was blank, no information entered. Record review of Resident #1's eMAR from 09/30/23 to 10/17/23 revealed the following: Pain Scale record dated 09/30/23 to 10/17/23 effective 10/02/23: On 10/02/23 - Day: No Pain; Night: No Pain; On 10/03/23 - Day: No Pain; Night: No Pain; On 10/04/23 - Day: No Pain; Night: No Pain; On 10/05/23 - Day: Generalized Pain 02:Intensity; Night: No Pain; On 10/06/23 - Day: No Pain; Night:05 (key did not identify pain level 5) On 10/07/23- Day: No Pain; Night: No Pain; On 10/08/23 - Day: No Pain; Night: No Pain; On 10/09/23- Day: No Pain; Night: No Pain; On 10/10/23- Day: Generalized Pain 04 (key did not identify pain level 4 ); Night: Headache 07 (key did not identify pain level 7) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 3 of 19 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 10/24/2023 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 0755 On 10/11/23- Day: Generalized Pain 03 (key did not identify pain level 3); Night: No Pain; Level of Harm - Minimal harm or potential for actual harm On 10/12/23- Day: No Pain; Night: Generalized Pain 03 (key did not identify pain level 3) On 10/13/23- Day: No Pain; Night: Headache Pain 04 (key did not identify pain level 4) Residents Affected - Some On 10/14/23- Day: Generalized Pain 04 (key did not identify pain level 4); Night: Blank -Eliquis 2.5 mg tablet (APIXABAN) 1 tablet by mouth 2 times per day Dx: Chronic atrial fibrillation, unspecified Start Date:09/30/2023. On 10/14/23 8:00pm dosage was marked X . Legend on the last page indicated X meant Medication had not been administered. - Insulin lispro (U-100) 100 unit/mL subcutaneous pen (INSULIN LISPRO) Units Per Sliding Scale Subcutaneous before meals and at bedtime Site Location 0 - 60 = 0 UNITS * MD Call 61 -130 = 0 UNITS; 131 - 180 = 2 UNITS; 181 - 240 = 4 UNITS; 241 - 300 = 6 UNITS; 301 - 350 = 7UNITS; 351 - 400 = 10 UNITS; 401 or greater then 12 UNITS * MD Call Dx: Diabetes mellitus due to underlying condition without complications Start Date:10/02/2023. Legend on the last page indicated X meant Medication had not been administered. On 10/4/23, 8:00pm Dosage was marked X. On 10/5/23, 8:00pm dosage was marked X. On 10/7/23, 7:00am dosage was marked X. On 10/9/23, 8:00pm dosage was marked X. On 10/14/23 4:00pm and 8:00pm dosage was marked X. - Triamcinolone acetonide 0.025 % Topical Cream (TRIAMCINOLONE ACETONIDE) 1 Cream topically 2 times per day Dx: Rash and other nonspecific skin eruption Start Date:09/30/2023. Legend on the last page indicated X meant Medication had not been administered. On 10/1/23, 8:00pm dosage was marked X. On 10/2/23, 9:00am dosage was marked X. On 10/14/23, 8:00pm dosage was marked X. Record review of Resident #1's MedAid MAR from 09/30/23 to 10/17/23 revealed the following: - Aspirin 81 mg tablet, delayed release (ASPIRIN) 1 tablet, by mouth 1 time per day Dx: Chronic atrial fibrillation; Start Date:09/30/2023. Legend on the last page indicated X meant Medication had not been administered. On 10/12/23, 9:00am dosage was marked X. On 10/13/23, 9:00am dosage was marked X. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 4 of 19 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 10/24/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some -Levothyroxine 75 mcg tablet (LEVOTHYROXINE SODIUM) 1 tablet by mouth 1 time per day; Dx: Hypothyroidism; Modification Date: 10/01/2023. Legend on the last page indicated X meant Medication had not been administered. On 10/14/23, 9:00pm dosage was marked X. - pantoprazole 40 mg tablet, delayed release (PANTOPRAZOLE SODIUM) 1 tablet, by mouth 1 time per day; Dx: Essential (primary) hypertension; Start Date:09/30/2023 End Date: 10/02/2023. Legend on the last page indicated X meant Medication had not been administered; Also, indicated * meant Medication was not active on that date. On 10/01/23, 9:00pm dosage was marked X. On 10/02/23, 9:00pm dosage was marked *. - omeprazole 20 mg capsule ,delayed release (OMEPRAZOLE) 1 capsule, by mouth 1 time per day; Dx: Gastro-esophageal reflux disease without esophagitis; Start Date:10/02/2023. Legend on the last page indicated * meant Medication was not active on that date. On 10/02/03, 9:00am dosage was marked *. Record review of facility's October sign in and out book located at the reception desk by front door, used by residents and/or family notifying resident was leaving the facility. No documentation Resident #1 was unavailable and/or left the building from 10/1/23 to 10/14/23. During an observation and interview on 10/16/23 at 6:07 p.m., Resident #1 was lying in bed at a local hospital with a family member at bedside. Resident #1 said she asked to go to the hospital because on 10/14/23 during the night her left foot felt numb, and then maybe an hour later the numbness traveled from her left foot to her left leg. Resident #1 said she had a stroke in the past and the s/s felt the same, so she wanted to be safe and go to the hospital to be evaluated. Resident #1 and family member at bedside said she was not receiving all her prescribed medications and did not want to return to the facility. Resident #1 could not recall exact medications missed because it but did remember one of the medications was her Eliquis. Resident #1 said she occasionally had bad sweats and would soak her clothes and bedsheets, she said she felt like she was having withdrawals possibly from missed medications. Family member said Resident #1 did not have the severe outbreak sweats prior to admission. During an interview 10/23/23 at 12:15 p.m., LVN M said whoever the charge nurse assigned to the admitting resident's hall was responsible for entering the list of medications into their system. She said she did not remember Resident #1 and did not admit Resident #1. LVN M reviewed Resident #1 closed clinical records and said according to the records she was Resident #1's admitting nurse. LVN M said she made a mistake according to Resident #1's admission orders because Resident #1 was to receive Acetaminophen 650mg, but she entered order for Resident #1 to receive Acetaminophen 325 mg tablet. She said she think she meant to put 2 tablets of 325mg to total the 650mg dosage, and she did not do that. LVN M said another staff or ADON should have double checked behind her to catch medication error, and she did not know why that step was not done. During an interview on 10/23/23 at 1:21 p.m., admission Coordinator said she handle all new admissions during the weekday, and for the weekend admissions she initiates the new admissions, and the weekend charge nurses completed the new admission paperwork and enter the medications according to the admitting hospitals after visit summary medication list. During an interview on 10/23/23 at 3:53 p.m. DON said facility preferred not to use pantoprazole (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 5 of 19 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 10/24/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some medication so that was not a medication they would have available in facility. She said that was a prescription the hospital typically used, but they preferred to use omeprazole instead, which would still have to be ordered. DON said according to Resident #1's MAR she started receiving omeprazole 20 mg capsule until 10/3/23, so it was possible Resident #1 missed 2 or 3 dosages. The DON said the admission Coordinator handle the new admissions; gives a copy of the After Visit Summary (admission Orders) to the charge nurse assigned to the hall and the charge nurse entered the orders. DON said the admitting nurse should have another nurse to double check for accuracy and the following morning the ADONs triple checked everything. She said during the morning meetings she verified the necessary admission forms were completed ( Example; skin assessment, baseline care plans, admission assessments etc , not necessarily checking the orders). During an interview on 10/23/23 at 4:35 p.m., DON and ADON F reviewed Resident #1's closed records to identify the staff names and looked for notes to why medications were not administered according to the MARS and provided the following information: -Eliquis 2.5 mg tablet (APIXABAN). On 10/14/23 8:00pm dosage was marked X by Agency Nurse O; Medication not administered due to Resident unavailable. - Insulin lispro (U-100) 100 unit/mL subcutaneous pen (INSULIN LISPRO). On 10/4/23, 8:00pm Dosage was marked X by LVN P; Medication not administered due to Special requirement parameters. On 10/5/23, 8:00pm dosage was marked X by LVN P; Medication not administered due to Special requirement parameters. On 10/7/23, 7:00am dosage was marked X by Agency LVN Q; Medication not administered due to Special requirement parameters. On 10/9/23, 8:00pm dosage was marked X by LVN P; Medication not administered due to Special requirement parameters. On 10/14/23 4:00pm and 8:00pm dosage was marked X Agency Nurse O; Medication not administered due to Resident unavailable. - Triamcinolone acetonide 0.025 % Topical Cream On 10/1/23, 8:00pm dosage was marked X by MA L; Medication on Hold On 10/2/23, 9:00am dosage was marked X by MA R; Medication on Hold On 10/14/23, 8:00pm dosage was marked X. by Agency Nurse O; Medication not administered due to Resident unavailable. - Aspirin 81 mg tablet. On 10/12/23, 9:00am dosage was marked X by MA L; Medication on Hold On 10/13/23, 9:00am dosage was marked X by MA L; Medication on Hold (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 6 of 19 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 10/24/2023 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 0755 -Levothyroxine 75 mcg tablet. On 10/14/23, 9:00pm dosage was marked X by CMA S; Medication not administered due to Resident unavailable. Level of Harm - Minimal harm or potential for actual harm - pantoprazole 40 mg tablet Residents Affected - Some On 10/01/23, 9:00pm dosage was marked X by MA L; Medication on Hold. On 10/02/23, 9:00pm dosage was marked *. - omeprazole 20 mg capsule. On 10/02/03, 9:00am dosage was marked *. Record review of Resident #1's clinical record from 09/30/23 to 10/17/23 reflected no documentation for why Resident #1 was marked unavailable, why medications were held, why medications were not administered due to parameters, and no blood sugar parameters were documented for the day and times Insulin medication was noted to be not given due to parameters. During an interview on 10/23/23 at 6:22 p.m., MA L verified her initials that was used on the MAR. She said she only marked medications on hold if facility was waiting on medication truck to deliver, or if medication was not available on her medication cart and/or medication room. MA L said Resident #1 had an order for a topical cream, and MAs were not allowed to administer any type of topical cream. She said Resident #1's Triamcinolone cream should not have been on her MAR, and she told a nurse but could not recall which nurse at that time; instead of falsifying records and marking that she gave it, she preferred to put on hold in the system because at least that way it would show that medication was not given. MA L said she marked on hold for Resident #1's Aspirin medication because there was none available in the building on 10/12 and 10/13. She said she marked on hold for Resident #1's pantoprazole medication which was not one they kept in the building so medication was not available to give at that time. MA L said there was nowhere for them to document other than by marking X on the MAR. During an interview via phone on 10/24/23 at 12:51 p.m., Resident #1's family member said Resident #1 was available in the facility the entire time from 9/30/23 to 10/15/23. She said Resident #1 was sent out to the hospital early Sunday morning 10/15/23 around 4:30 a.m. During attempted interviews via phone on 10/24/23 at multiple times for LVN P, Nurse O, MA S, MA R and LVN Q no answers, no return calls, left a voice message if available. During an interview on 10/24/23 at 3:09 p.m., ADON F said she was the ADON for 200/400 hall. She said for all new admissions admission Coordinator handles the admissions, and the charge nurse on the assigned hall entered the orders. The ADONs were responsible for reviewing the admission packets the following day to triple-check for medication errors. She said herself and the other nurse managers' must have missed Resident #1's acetaminophen 650 mg medication dosage error the next morning because she did not know until State Surveyor pointed it out to her. She said on the insulin medications she did not understand how the system allowed the staff to mark X on the MARS without entering a Blood sugar for insulin. ADON F explained the system they used was developed to make the staff enter vitals, or blood sugars before staff could proceed to the next step in the charting system. ADON F said they did not have computer issues during that time , and the only way to know how the staff was able to go around that step would be to ask the staff. State surveyor told ADON F multiple attempts had been made with each of the staff, but no return call at that time. ADON F looked in Resident #1's closed chart and could not find where blood sugars had been done for the dates on the MARS marked X (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 7 of 19 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 10/24/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some for medication not administered due to special requirement parameters and if no blood sugar documentation was charted, then it appeared as Resident #1's blood sugars had not been done and the only place to document blood sugars was on the nurse notes or on the MAR. ADON F said should a resident run out of an Aspirin medication before delivery, staff just needed to notify central supply and she would get the money from the Business Office and personally go pick up the medication from a local drug store. She said the only reason a staff should have marked Resident unavailable was if a resident was in therapy, or not in the building. ADON F said she did not know why but the system had a glitch, and for certain medications that are to be administered by a nurse only, after the order was entered the system glitch would automatically add for example Triamcinolone topical cream to the MedAide MAR and they would have to go back in and manually change it. She said they must had have missed that one. Record review of medication administration policy dated 9/2018 indicated Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Pg. 3 Medication Administration: 2) Obtain and record any vital signs as necessary prior to medication administration. 3) Medication administration timing parameter include the following: a. Medication to be given on an empty stomach or before meals are to be scheduled for administration 30 minutes to 2 hours prior to meals. B. Medications to be given with meals are to be scheduled for administration at the resident's mealtimes. C. Medications to be given after meals or with food are to be scheduled for administration immediately after and up to 2 hours after meals or with a snack (a single serving of a food item) as defined by the nursing center dietician. D. Medications to be given at bedtime are to be scheduled for administration up to 1 hour prior to the resident's scheduled bedtime. 14) Medications are administered withing 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center. Medications should not be given at mealtimes or in the dining room unless specifically ordered with meal. 19) For residents not in their rooms or otherwise unavailable to receive medication on the pass, the MAR is flagged. After completing the medication pass, the nurse returns to the missed resident to administer the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 8 of 19 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 10/24/2023 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 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to ensure the menu was followed for 1 of 1 meal reviewed for menus and nutritional adequacy. (Noon meal 10/22/23). Residents Affected - Some Residents on a pureed and mechanical soft diet were served Turkey Sausages at the noon meal instead of Baked Ham as indicated on the menu. The facility did not prepare and serve pureed bread at the noon meal on 10/22/23. The facility did not prepare and serve a dessert at the noon meal on 10/22/23. The facility did not serve green beans to five residents at the noon meal on 10/22/23. The facility did not prepare and serve the alternate meal: Salisbury steak and gravy, rice pilaf, and parsley carrots as indicated on the menu. These failures could affect residents who received food from the kitchens at risk for decreased meal satisfaction, potential weight loss due to poor meal intake, not having their nutritional needs met, and a decline in health status. Findings included: Record review of Week 2 week at a glance planned menu dated 10/22/23 for the noon meal reflected baked ham, three cheese potatoes, roasted green beans/onions, roll and Texas sheet cake. Also, planned alternate noon meal was Salisbury steak/gravy, rice pilaf, and parsley carrots. Record review of a resident's noon meal ticket dated 10/22/23 revealed: entrée - Salisbury steak/gravy; Starch - Three Cheese Potatoes; Vegetable - Parsley Carrots; Dessert - Texas Sheet cake. During an interview on 10/22/23 at 10:39 a.m., [NAME] K said she just finished serving breakfast meal, did not know if she was going to have time to prepare the noon meal listed on the menu and will prepare ham or turkey sandwiches instead of cooking the baked ham. During an interview on 10/16/23 at 3:08 p.m., The Ombudsman said meals were being served late and food complaints had been an ongoing problem. She said facility was looking for a new DM, because the last one hired quit. During an interview on 10/22/23 at 11:57 a.m., [NAME] K said they had been without a DM a few weeks, the kitchen staffing had not been consistent, and they really needed help because she was not a manager, [NAME] K said a manager from out of town would come and make the menus and did the scheduling. During an interview on 10/22/23 at 1:50 p.m., [NAME] K said she sent DA J to the grocery store to purchase butter (needed for the green beans and mashed potatoes) so she can go ahead and make the noon meal listed on the menu. She said she was not always able to make what was on the menu because they did not always have the ingredients or the food item available to make the menu item for the day; either she would have to leave and go to the store, send someone to the store or prepare whatever (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 9 of 19 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 10/24/2023 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some they had available that day. [NAME] K said they had the resident's complete meal tickets circling their preferences according to the menu, but if they did not have the circled items available then she will serve whatever she see they had available instead. [NAME] K said she used the meal tickets as a guide to go by when making plates on the serving line, such as diets and to make sure everyone had a plate. During an observation on 10/22/23 at 2:07 p.m., DA J returned from the grocery store with (3) three 2lbs container of butter, and (3) three 2lbs bag of shredded cheese. During an interview on 10/22/23 at 2:11 p.m., [NAME] K said she would make the 10/22/23 noon meal now that she had the cheese to make the three cheese mashed potatoes and butter to add to the food. Also, needed the cheese to make the Beef Enchiladas for the dinner meal that evening. During an observation and interview on 10/22/23 at 2:23 p.m., [NAME] K said she was going to use the Turkey Sausages that was left over from morning breakfast to make the noon meal's pureed meat and for the noon meal's mechanical chopped meat. She said at times whenever she had leftovers she would reuse the food items, because she preferred not to waste food. During an observation in kitchen on 10/22/23 at 3:11 p.m., noon meal on the serving line, [NAME] K prepared the following: Regular diet - Baked Ham, [NAME] Beans with onions, and mashed potatoes with shredded cheese. Pureed diet - Pureed turkey sausage, mashed potatoes, and carrots, Mechanical Meat - Chopped turkey sausage. Regular Diet Bread - Slice of bread Pureed Bread - None Pureed/Regular Dessert - None During an observation on 10/22/23 at 3:37 p.m., [NAME] K prepared and served 5 (Five) regular plates with no green beans ; instead, was served half piece of sliced ham, mashed potatoes and slice of bread. [NAME] K made the comment, should had made the whole can of green beans. During an observation and interview on 10/22/23 at 3:42 p.m., State surveyor asked [NAME] K about the noon meal dessert. [NAME] K said she had been there since 5:30 a.m., with no help, and barely was able to prepare the lunch meal so no she did not prepare or serve any dessert. [NAME] K asked State Surveyor since it was already so late could the noon meal also be the residents' dinner. [NAME] K assured State surveyor she would prepare the dinner meal, did not know what time she was going to serve dinner because she needed to wash dishes to cook, said she needed a break and left the kitchen into the dining room and sat at a table with residents who were eating lunch meal. During an interview on 10/23/23 at 1:35 p.m., ADON G said residents have complained about not getting what was on the menu, but if the food items were not available in the kitchen, then they could not serve something they did not have. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 10 of 19 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 10/24/2023 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 10/22/23 at 4:09 p.m., Resident #2 said the noon meal, did not have a dessert and she said that was the one food item she was wanting on the tray. Resident #2 said during the weekends it was not uncommon to not get what was on the menu. During an interview on 10/22/23 at 4:11 p.m., Resident #3 said Of Course I wanted the noon meal's dessert, she said they did not get dessert. During an interview on 10/23/23 at 12:45 p.m., Resident #5 said the meal tickets the kitchen used was a joke, because they did not get whatever food item they selected. Resident #5 said every weekend something was wrong or missing. She said on 10/22/23 there was on 1 (one) kitchen staff doing breakfast and that was why half of the breakfast items was left off. During an interview on 10/23/23 at 12:48 p.m., Resident #6 said she did not get what she ordered and would love to get what she ordered. She said her 10/22/23 dinner meal was small, but since it was so late, she did not ask for anything else. Record review of resident council meeting forms revealed the following: -On 6/27/23 Residents stated they were told whenever they asked about a food, the kitchen would be out of it. -Residents stated they were not getting what they ordered on their meal tickets. -On 8/31/23 - Residents stated they did not want to pick a meal of the month due to the inconsistency of the dietary staff, times of the meals, and they felt if they had picked something then they wouldn't get it. Also, residents stated that they are not getting what they ordered on their meal tickets, or they did not receive their meal at all. - Residents state they did not get the food they ordered. - Residents stated that the meals being served inconsistently and hardly served on time. -On 9/26/23 -Regarding Dietary Department the problems and concerns noted from the last Resident Council regarding Dietary continued to be an issue. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 11 of 19 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 10/24/2023 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that each resident received at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care for 7 of 7 resident reviewed for quality of life. (Resident #s 1, 2, 3,4, 5, 6 and 7) Facility failed to ensure Resident #s 1, 2, 3,4, 5, 6 and 7 received their meals timely. This failure could place residents at risk of not maintaining their highest practicable physical, mental, and psychosocial well-being and a decreased quality of life. Findings included: Record review of Resident #1's face sheet printed on 10/17/23 indicated Resident #1 was an [AGE] year-old female who admitted on [DATE] and discharged on 10/15/23 with diagnoses including chronic atrial fibrillation (an irregular and often very rapid heart rhythm), Atherosclerotic heart disease (This is an umbrella term that describes any disease of the heart and blood vessels caused by a common condition that develops when a sticky substance called plaque builds up inside your artery), hypertension (it means your blood pressure is always too high. This means your heart is working harder when pumping blood around your body), hypothyroidism (underactive thyroid, is a condition where the thyroid gland doesn't release enough thyroid hormone into the bloodstream), rheumatoid arthritis (a condition that can cause pain, swelling and stiffness in joints), and vitamin D deficiency (is essential for healthy bones, and a lack of it can lead to health problems, including cardiovascular disease). Record review of admission MDS assessment dated [DATE] indicated Resident #1 had clear speech and understood others. She had BIMS score of 12 out of 15 indicating she was moderately impaired cognitively. Resident #1's hearing and vision was adequate. Section GG indicated Resident #1 had no upper or lower extremity impairments. Required set up or clean -up assist with eating, oral hygiene and/or upper body dressing. Required moderate to substantial assist with toileting, showers, lower body dressing and with putting on shoes and socks. Record review of Resident #1 care plan dated 10/05/23 indicated: Problem- Altered Nutritional Status; Goal - Resident will be comfortable with food and fluids provided over the next 90 days; Interventions - Dietitian referral as indicated; Monitor oral intake of food and fluid; and Provide snacks between meals as preferred. During an interview on 10/16/23 at 6:07 p.m., Resident #1 and family member at bedside said dietary services was an issue at the facility. They said there was no designated mealtimes. During an interview on 10/16/23 at 3:08 p.m., The Ombudsman said meals were being served late and food complaints had been an ongoing problem. She said facility was looking for a new DM, because the last one hired quit. During an interview via phone on 10/30/23 at 6:59 p.m., Complainant for Intake #457876 indicated Resident #1 was alert and oriented. She said Resident #1 was at facility undergoing rehab. Complainant (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 12 of 19 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 10/24/2023 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some said Resident #1 and her nurse both told her that Resident #1 and the other residents were not receiving their regular meals and that the facility was understaffed and poorly managed. The Complainant said Resident #1's family member told her the facility had been delaying their meals. During an observation on 10/23/23 at 1:06 p.m., posted on the wall in a picture frame next to the kitchen door indicated Seated dining room hours were offered at: Breakfast 7:00am - 8:30am; Lunch 11:30am 1:00pm; Dinner 5:00pm - 6:30pm. During an observation on 10/22/23 at 10:33 a.m., 600 Hall Breakfast meal trays was still being prepared in the kitchen and needed to be served. During an observation on 10/22/23 at 2:56pm [NAME] K started making the first lunch/noon plate for 600 Hall. At 3:01 p.m., [NAME] K prepared the first lunch/noon plate that was going on the 200 Hall meal cart. At 3:11pm [NAME] K started working on 400 Hall meal trays. At 3:28pm [NAME] K started working on 500 Hall meal trays. At 3:41 p.m., [NAME] K served the last lunch/noon plate. During an observation and interview on 10/22/23 at 3:42 p.m., [NAME] K said she had been there since 5:30 a.m., with no help, and barely was able to prepare the lunch meal so no she did not prepare or serve any dessert. [NAME] K asked State Surveyor since it was already so late could the noon meal also be the residents' dinner. [NAME] K assured State surveyor she would prepare the dinner meal, did not know what time she was going to serve dinner because she needed to wash dishes to cook, said she needed a break and left the kitchen into the dining room and sat at a table with residents who were eating lunch meal. During an interview on 10/22/23 at 3:55 p.m., RN N said she was the charge nurse for 400 hall and the residents breakfast meals were delivered late from the kitchen around 10:45am. During an interview on 10/22/23 at 4:00 p.m., Resident #4's family member said the weekend mealtimes had been inconsistent, she said she started bringing sandwiches for Resident #4 and Resident #4's roommate because of the ongoing dietary issues. Resident #4's family member said for breakfast Resident #4 had a small bowl of grits that she complained did not taste good and one small piece of bacon. Resident #4 said since she did not eat much for breakfast, she was looking forward to the lunch meal, but was hungry because the lunch meal did not get served until after 3:00pm with no dessert. Resident #4's family member said both Resident #4 and her roommate ate the sandwich she brought because lunch was so late. During an interview on 10/22/23 at 4:09 p.m., Resident #2 said the breakfast and the lunch meals for that day were extremely late. She said she called a family member to bring her a lunch meal because it was after 3:00pm and she still had not received lunch. Resident #2 said during the weekends it was not uncommon for the meals to be late. During an interview on 10/23/23 at 11:43 a.m., Resident #2 said she received the 10/22/23 dinner meal late and it was around 7:00pm. She said every weekend they had dietary issues either the food was late, or never received. During an interview on 10/23/23 at 11:51 a.m., Resident #3 said she received the 10/22/23 dinner meal late. She said her dinner was so late that it kept her from going to bed until later that night. During an interview on 10/23/23 at 12:45 p.m., Resident #5 said the Sunday 10/22/23 meals was about (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 13 of 19 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 10/24/2023 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 0809 3 (three) hours late. She said it was 12:53pm and she still had not received lunch for the day. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/23/23 at 12:48 p.m., Resident #6 said the meals were always late, but worse on the weekends. She said her 10/22/23 dinner meal was small, but since it was so late, she did not ask for anything else. Residents Affected - Some During an interview on 10/23/23 at 12:54 p.m., Resident #7 said the mealtimes was inconsistent, could be 1 hour late, 2 hours, late or even 3 hours late. He said the way services and care had declined, the high staff turnovers, the previous administrator being walked out and all the dietary issues that someone would shut the facility down. Resident #7 said they have voiced their food complaints at Resident Council, but nothing had changed. During an observation and interview on 10/23/23 at 1:08 p.m., Resident #2 and Resident #3 were sitting at a table in the dining room waiting for lunch meal. The residents said for two days in a row the lunch meals had been late. The residents along with other resident in the dining room pointed to the private dining room where facility staff was having a potluck ; they said the worst part was the staff did not have to wait for their meals and was able to enjoy their food while they had to sit in the dining room waiting for their lunch meal to be served and watch them (the doors were propped open). Resident #2 said the sad part was they had to wait, because they had no other choice but to just sit and wait every day for the meals to come late. During an observation on 10/23/23 at 1:09 p.m., the first lunch cart was sent out the kitchen. During an interview on 10/23/23 at 6:09 p.m., LVN H was the on-call weekend supervisor, she said the 10/22/23 dinner meal was served late around 7:30pm. Record review of the facility's grievances/complaints revealed the following: -On 6/23/23 - A resident reported his concern was that he had to wait to for his breakfast, while his blood sugar was getting low. -On 7/17/23 -A family member complained a resident's meals had been coming out late. -On 7/18/23 - A resident stated on multiple times the kitchen did not bring her a tray, a CNA brought the resident a tuna fish sandwich, because she was not given a lunch or dinner tray. -On 8/14/23 - A resident reported that the food was always late. -On 8/14/23 - A resident stated none of his meals had ever came out right. -On 8/23/23 - A family member stated that the lunch did not arrive until almost 3pm. -On 8/23/23 - A family member stated that the food was not on time. Record review of resident council meeting forms revealed the following: -On 7/25/23 - Hot food is coming out cold, and mealtimes were not consistent. -On 8/31/23 - Residents stated that the meals being served inconsistently and hardly served on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 14 of 19 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 10/24/2023 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 0809 time. Level of Harm - Minimal harm or potential for actual harm -On 9/26/23 -Regarding Dietary Department the problems and concerns noted from the last Resident Council regarding Dietary continued to be an issue. Residents Affected - Some Record review of mealtime policy dated 8/1/23 indicated meals will be served in a timely manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 15 of 19 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 10/24/2023 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 - Many 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 refrigerator, and freezer were dated, labeled, and sealed appropriately. -Dietary aide J failed to use a beard restraint. Also, DA J grabbed the slice ham without washing hands or wearing gloves. -NA C failed to use a hairnet. -The facility failed to maintain proper dishwasher sanitation. -The facility failed to serve food at a proper serving temp. -The facility failed to ensure spoon was not left inside the jelly jar. -The facility failed to cover the turkey sausage stored on top of the oven. - The facility failed to store bottle of detergent away from food prep area. 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 10/22/23 at 10:33 a.m. to 3:45 p.m. revealed the following: -NA C was not wearing a hairnet. -at 11:50 a.m., NA C was washing dishes and jammed the garbage disposal, she was on her bare hands and knees attempting to unplug the dishwasher so she could stick her hand down the sink. -at 11:55 a.m., NA C was instructed by [NAME] K to cover the ham she was slicing, NA C did not wash hands, did not wear gloves, and touched the ham while trying to cover the food wax paper. -at 12:07pm DA J entered the kitchen from the back entrance, and walked straight to the dishwasher station, did not wash hands, nor did he wear a beard restraint. During an interview on 10/22/23 at 3:46 p.m., DA J said he did not normally work the serving line, and he forgot to wear a beard restraint. -at 12:19pm DA J performed sanitizer check to the Dishwasher; resulted in 200ppm and did not know the recommended number. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 16 of 19 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 10/24/2023 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 -The Dishwasher manufactured label indicated 50 -100 ppm was the required numbers. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/22/23 at 12:23 p.m., DA J said another staff normally did the sanitizer test, so he was not as familiar. He said they have not had steady management or structure in the kitchen, and they were just trying to make it and do what they could do. Residents Affected - Many -at 1:20 p.m., a bottle spray of detergent disinfectant was stored on the food prep table by the microwave. -at 1:21 p.m., an open 24-ounce bag of country style powder gravy was not sealed and spilt onto a serving cart, -at 1:23 p.m., 8-pound jar of grape jelly stored on the serving line by the cereal dispenser had a silver spoon left inside the food item. -at 1:42 p.m., DA J opened the oven, using his bare hands he reached into the oven and grabbed a slice of ham, then walked away. -at 1:55 p.m., [NAME] K said she was aware the kitchen floors were disgusting , but she did not have to clean or sweep the kitchen floors. -11:00am to 2:23 p.m., a tray of uncovered Turkey sausage was stored on top of the oven; later was used for the pureed and mechanical chopped noon meals. The serving line Temperatures -at 2:44p.m., Mechanical Chopped Turkey sausage meat was 113 degrees Fahrenheit -at 2:54 p.m., Pureed Turkey Sausage meat was 116 degrees Fahrenheit During an interview on 10/22/23 at 2:53 p.m., [NAME] K said she the food temperature was not at 165 Fahrenheit but since it was late, was just going to go ahead and served food items as it was . Walk-in refrigerator -One plastic bag of meat, not labeled, and not dated -One open 32-ounce carton of liquid eggs not dated -Two busted 12-ounce cans of biscuits with exposed dough -One plastic container of unknown brown liquid with blue rubber lid, not labeled, and not dated Walk-in freezer -on the right shelf seven glass dessert bowls with orange ice cream like food covered with individually plastic wrap, not labeled, and not dated. -on back shelf, was a white box with an open unsealed clear bag of unknown amount of frozen cut (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 17 of 19 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 10/24/2023 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 corn, not dated. Level of Harm - Minimal harm or potential for actual harm -on the left shelf was a brown box, with an open unsealed clear bag of unknown amount of frozen cookie dough patties, not dated. Residents Affected - Many -on the left shelf was two open unsealed clear bags of pie crust, not dated. Refrigerator -On the top shelf on the right side was two glass of chocolate milk like substance wrapped in plastic, not dated -On the top shelf on the right side was a one-gallon low fat milk, not dated. -On top shelf on the right side was a drink pitcher with thick brown liquid like substance, not labeled and not dated. - On the second row on the right side was a one-gallon low fat milk, not dated. -On the second row on the right side was an open 32 ounce of vanilla yogurt, not dated. -On the third row on the right side was a 10-liter plastic container of unknown food item covered with aluminum foil paper, not labeled, and not dated. -On the bottom row on the right side was 5 Liter plastic container of unknown food item with a blue plastic lid, not labeled, and not dated. -On the top row on the left side was a gallon size Ziplock bag of unknown amount of four stacks of sandwich cheese like food item, not labeled, and not dated. -On the bottom on the left side was one gallon container of Italian dressing, not dated; one gallon container of supreme thousand island dressing, not dated; one-gallon sweet pickle relish, not dated. Bread rack stored next to the walk-in refrigerator door had one open bag of hamburger buns, not dated. Also, four of four bags of buns dated 9/16/23 and were hard to the touch. During an interview on 10/22/23 at 11:05 a.m., [NAME] K said that items in the freezer and refrigerator should be dated and labeled . She said the food unlabeled container of food items in the refrigerator were cabbage and carrots dish and the other unlabeled food item was chicken soup. During an interview on 10/22/23 at 11:57 a.m., [NAME] K said they had been without a DM a few weeks, the kitchen staffing had not been consistent, and they really needed help because she was not a manager, staff whenever they did call in, they would call her and she said that was not her responsibility, she was hired to work as a cook not to be the manager. [NAME] K said a manager from out of town would come and make the menus and did the scheduling. Record review of nutrition services food storage policy dated 8/1/18 indicated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 18 of 19 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 10/24/2023 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 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: Residents Affected - Many 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. Record review of revised nutrition services infection control policy dated 5/28/20 indicated All 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 hot and cold food temperature policy and procedures dated 8/1/18 indicated The Temperatures of the food items will be managed to conserve maximum nutritive value and flavor and to be free of harmful organisms and substances. Procedure: 1) Cooking temperatures must be achieved and maintained according to recipes and regulations. 2) Hot food items held for serving will not fall below 135 degrees Fahrenheit after cooking. Prior to serving, deficient temperatures must be corrected. 4) Corrections will be made as needed to achieve and maintain appropriate temperatures. 5)All hot food items must be served to the resident at a palatable temperature. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 19 of 19

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Citations

4 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0755GeneralS&S Epotential for harm

    F755 - Pharmacy Services

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  • 0803GeneralS&S Epotential for harm

    F803 - Menus and nutritional adequacy

    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

  • 0809GeneralS&S Epotential for harm

    F809 - Frequency of Meals

    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

  • 0812GeneralS&S Fpotential for harm

    F812 - Food safety requirements

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

FAQ · About this visit

Common questions about this visit

What happened during the October 24, 2023 survey of Providence Park Rehabilitation and Skilled Nursing?

This was a inspection survey of Providence Park Rehabilitation and Skilled Nursing on October 24, 2023. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at Providence Park Rehabilitation and Skilled Nursing on October 24, 2023?

Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharm..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.