Health inspection·August 29, 2024

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few monitor for any change or decline in cognitive status. A problem of at risk for fall updated 8/26/24 indicated the resident had a fall on the van on 8/24/24. Some of the interventions were in-service/ education of transport driver on safety while on transport van, administer first aid, assess for contributing factors as related to the fall history. The care plan indicated a problem of impaired physical mobility, substantial to maximal assist with sitting to lying, lying to sitting, dependent with sitting to stand and dependent with chair to bed transfers. The intervention was to provide appropriate level of assistance to promote safety of the resident. Record review of Resident #1's computerized physician orders indicated an order dated 8/6/24 for acetaminophen 325 mg 2 tablets as needed every 6 hours for pain on hold. An order dated 8/26/24 indicated Tylenol 325 mg 1 capsule by mouth every 4 hours as needed for pain and temperature. An order dated 8/27/24 indicated treatment day shift to paint right food scabbing with betadine daily. Record review of Resident #1's nursing note dated 8/24/24 indicated it was electronically signed 8/25/24 at 1:38 p.m. It indicated the nurse was informed by transport that Resident #1 had a fall on the facility van while being transported from the hospital back to the facility. Upon assessment of the resident for injuries he was noted to have a small purple bruise on the right side of the forehead with a small bump, and 2 nickel size bruises on the right foot with small scratches on the 2nd and third toe of the right foot. When the nurse asked the resident if he hit his head he said no and later said he had. The family was at the bedside and were asked if they wanted the resident sent back to the hospital for evaluation. They said no and the resident was not complaining of pain at this time. Signed by LVN A. Record review of Resident #1' s incident report dated 8/24/24 at 4:30 p.m. indicated the incident happened off grounds, while the resident was a vehicle passenger. The description of the incident was informed by transport that Resident #1 had a fall on the facility van while being transported from the hospital back to the facility. Upon assessment of the resident for injuries he was noted to have a small purple bruise on the right side of the forehead with a small bump, and 2 nickel size bruises on the right foot with small scratches on the 2nd and third toe of the right foot. When the nurse asked the resident if he hit his head he said no and later said he had. The family was at the bedside and were asked if they wanted the resident sent back to the hospital for evaluation. They said no and the resident was not complaining of pain at this time. The comments were Resident #1 was oriented to time, place, and situation. He had impaired sitting balance, was extensive assist with transfers, was non- weight bearing, incontinent, and used a wheelchair for ambulation. Resident #1 was at risk for falls. Education /in service was done on safety while on the transport van. The incident was electronically signed by LVN A on 8/25/24 at 1:38 p.m. It was signed by the DON on 8/27/24 at 1:16 p.m. Record review of Resident #1's nursing note dated 8/26/24 at 11:38 a.m. indicated Tylenol 325 was given. This was the only indication the medication was given after the incident. Record review of Resident #1's nursing note dated 8/27/24 at 2:03 p.m. indicated Resident #1 had 3 scabbed areas to the right foot. The physician was notified, an order was received and applied, and no complaints of pain. Record review of Van Driver's B's employee file indicated a hire date of 3/25/24 and did not reveal any per employment training, or competency check off for driving the van. There was an employee job description which indicated part of the duties were to prepare accident and incident reports when necessary. The Essential duties included to assist passengers, including handicapped, in and out of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 2 of 11 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 08/29/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the vehicle, operate ramps, lifts and securement of devices as needed. Responds immediately to accidents or medical emergencies by notifying emergency response providers, and rendering first aid until emergency personnel arrive. Record review of Van Driver's C's employee file indicated a hire date of 5/7/24 and did not reveal any per employment training, or competency check off for driving the van. Records indicated he transferred from another facility. Record review of a Vehicle Log signed by Van Driver C and dated 8/26/24 through 8/27/24 indicated there were check offs before operating a vehicle such as making sure there was brake fluid, oil level, belts and hoses were appropriate, the general maintenance of the vehicle. Also, there were items to be with the vehicle and the driver such as emergency phone numbers, cell phones, trained in lift operation, and trained in securing resident. (This was the only log provided.) Record review of a training in-service form dated 8/26/24 indicated the Maintenance Director conducted an in service on securing of wheelchair and passengers and pre and post vehicle checks. Van Driver B and Van Driver C signed the in service. There was just that sheet of paper and nothing else attached. During an interview on 8/26/24 at 3:45 p.m. Resident #1's family member said on Saturday, 8/24/24 the van went to pick up Resident #1 from the hospital. She said as soon as she got to the facility Resident #1 said he was thrown out of the wheelchair to the floor. She said Resident #1 told the driver he was not strapped in and, the man ignored him. She said as soon as they left the front entrance of the hospital and turned Resident #1 was not belted in and slipped out of the chair. She said when Resident #1 stopped on the metal lift ramp and his knee and right foot were injured. She said he had four puncture wounds on his foot and contusions with tissue was inflamed. The family member said she had called the DON because no one seemed to know the resident had fallen. The family member said she got to the facility about 30 minutes to an hour after Resident #1 was delivered by the van driver. The family member said no one appeared to be aware Resident #1 had fallen, so they went to the front desk to look for Administrator. The family member said the person at the desk told them to call the DON. The family member said the DON was unsympathetic and upset that she was called. The family member said the DON must have contacted LVN A. The family member said LVN A came into the room to look at Resident #1. The family member said LVN A told them it was the hospital's fault Resident #1 had fallen. The family member said LVN A told them there were no belts on the facility van. The family member said Resident #1 told LVN A he was not secured in the chair by the transport driver. The family member said on Sunday, 8/25/24 he was grimacing, and had red marks on the outside of his left knee and was hurting. The family member said she asked LVN A for ice packs to place on his foot and knee. She said she was told by ADON/RN that they were doing an investigation into the fall, but no one had gotten back to the family or the Resident. The family member said the facility tried to minimize what happened. The family member said if the facility had just said they were sorry that the incident occurred it would have made the family and the resident feel better. During an interview on 8/27/24 at 12:09 p.m. the Maintenance Director said that he had worked at the facility for three months. He said that he was not aware of any accident that had occurred on the van. He said he had two staff that drove the van; Van Driver B and Van Driver C. During an interview on 8/27/24 at 12:15 p.m. Resident # 1 said on Saturday, 8/24/24 he was on the van and Van Driver B did not strap him into his wheelchair. He said he told him he was not strapped in, maybe he was in a hurry, but he ignored his comment. Resident #1 said they went around the corner (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 3 of 11 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 08/29/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few too fast, and he was thrown out of the wheelchair. Resident #1 described the driver as having a medium build with curly hair. Resident #1 said during the fall he had skinned his foot and his knee was twisted. Resident #1 said he landed on his left side and hit a pole or something. Resident #1 said the driver stopped in the middle of the road. He said Van Driver B picked him up and put him in his chair. Resident #1 said he had gone to an appointment this morning and Van Driver C had taken him. During an interview on 8/27/24 at 12:20 p.m. LVN D said the family member told her what happened on Saturday, 8/24/24 but she was not here. She said the family member was upset and said the resident had not been strapped in the wheelchair and slid out during transport. LVN D said she had not assessed Resident #1. She said LVN A did that on 8/24/24. She said she had not seen Resident #1's foot, knees, or any injury on him. She said that the resident had just gotten back from an appointment today. During a telephone interview on 8/27/24 at 12:30 p.m. ADON/ RN said she was aware Resident #1 had fallen on the van coming back from the hospital on 8/24/24. She said they did an x-ray and they in serviced the driver to make sure Van Driver B was doing all he was supposed to do to keep the residents safe. She said Resident #1 had some abrasions to his toes and the nurse said there was an area on his chest, but it was an old area. During an interview on 8/27/24 at 12:55 p.m. DON said she received a phone call from the facility on Saturday, 8/24/24 at 5:16 p.m. saying Resident #1's family member wanted to speak to her. It was an emergency. She said Resident #1's family member reported Resident #1 had fallen on the van during his transport from the hospital. The DON said she asked if the family member had notified the nurse so that he could be assessed. She said the family member wanted to know what they were going to do about the driver and the incident. The DON said she told the family member an investigation would occur. The DON said the family member seemed more concerned about the consequences to the driver than Resident #1 being assessed for his injuries. The DON had called LVN A and told her to complete a head to toe assessment of the resident and get vitals. She said she had called back and talked to LVN A later. She said LVN A said Resident #1 had some scratches and some bruises. She said the facility offered to send him back to the hospital, but the family refused. She said they did get x-rays and there was no injury. During a telephone interview with the DON present on 8/27/24 at 2:52 p.m. LVN A said Resident #1 had just gotten back from the hospital about 4:00 p.m. on 8/24/24. She said Van Driver B left paperwork at the desk. She said Van Driver B came back up to the desk and told her Resident #1 had fallen during transport. LVN A said she thought Resident #1 had fallen right outside. She said she thought that because the Van Driver said he picked Resident #1 up and put him back in the wheelchair. LVN A said she did not immediately go and assess the resident, she was trying to get some information on what, when, and where. She said Resident #1 should have been assessed before he was moved but the driver said he was fine. She said the DON called her and said Resident #1 had a fall and told her to go and assess him. She said when she went to do the assessment in Resident #1's room the Family member told her the incident happened right in front of the hospital. LVN A said Resident #1 told her that he told Van Driver B he was not secured, and when he made a left-hand turn, he fell out of his chair. LVN A said Resident #1 did not complain of pain. She said she offered him Tylenol, but he did not want it. She said he had some bruising on his right foot. She said she wrote a nursing note on 8/24/24 and wanted to make sure it was okay. She said the DON said was it was okay, so she signed off on the note on 8/25/24. LVN said the van driver did not say much to her and she did not ask questions. She thought he would have explained to administration and written a statement about what happened. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 4 of 11 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 08/29/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few During an observation and interview on 8/27/24 at 3:20 p.m. Van Driver B was observed getting a resident off the van. The resident's wheelchair's four wheels were locked and secured with restraints, and he had the seatbelt across the shoulder and lap of the resident . Van Driver B was observed to unlock the wheel restraint and then the seat belt and roll the resident onto the ramp. Van Driver said that on Saturday, 8/24/24 he had not used the shoulder/lap belt on Resident #1. He said he was never instructed to do so. He said when he was trained no one told him he needed to apply the seat belt. Van Driver B said what he usually did was ask the resident if they wanted the belt and if they said they did he would apply the belt. He said if they said they did not then he would not apply the belt. He said on 8/24/24 Resident #1 did not have on the shoulder/lap belt. He had hit a bump and Resident #1 fell out of the chair. He said normally he did not touch the residents and had been informed not to do so. However, he pulled over into the side lane, and put his flashers on. He said he asked the resident if he was hurt, and he said not really. He picked the resident up and put him back in his chair. He said Resident #1 had had a BM all over himself and there was some on the floor. He said he did not think of calling 911 or the facility. He just knew he could not leave him on the floor of the van. He said he arrived at the facility about 4:00 p.m. He said there were two aides at the nurse's station, he did not know their names, but they cleaned up the resident and also came to the van to clean the BM off the van floor. Van Driver B said if Resident #1 asked him to strap him into the seat, he did not hear him. He said after the incident he was in serviced on always using the shoulder restraint by the Maintenance Supervisor. During an interview on 8/27/24 at 3:35 p.m. the Maintenance Supervisor said he was just told to do an in-service. He said he was not aware anyone had fallen on the van., He said he was not provided that information. He said he had done the training with Van Driver B and Van Driver C. The Maintenance Supervisor said he conducted the in service on what he knew, to always strap the wheels down and put the shoulder/lap seat belt on. He said that he did not conduct the training on any policy or procedure, and as far as he knew they did not have one. He said he had worked at the facility for 3 months as the Maintenance Director and was trained by the admissions coordinator on the operation of the van. He said he was shown how to strap down the wheelchair and the residents. He said if a resident fell you called the facility or EMS. He said you did not move them until they were assessed. During an interview on 8/27/24 at 3:50 p.m. the Administrator said he did not have a policy for the operation of the van. He said the drivers had valid driver's licenses and that was all they needed. He said it was common sense to drive the transport van. He said there was no training prior to assuming the responsibility of the van. He said they did not have a checklist for the driver's competency prior to operating the van. He said the one vehicle log he provided was signed by Van Driver C and he had turned his in today. He did not have one for Van Driver B because his was still on the van. He said when Van Driver C was finished for today, he would turn his in as well. During an observation and interview on 8/27/24 at 4:00 p.m. Resident #1 and his family member said no one from administration had come and talked to them, not the DON, or any staff, or the Administrator. Resident #1 said no one from administration had talked to him about the incident that happened on Saturday 8/24/24. The family member said they had requested ice packs each time they came because he told her he was in pain. The family member said the wound care nurse came by today. Observation of the resident showed there was an ice pack on his right foot and his left knee. Observation of the foot showed it was purple around the toe areas on the top of the foot and swollen to the ankle. It had dark areas on the big toe and above the big toe. There were small areas on his second and third toe. During an interview on 8/27/24 at 5:00 p.m. the Administrator said they did not have a policy, but (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 5 of 11 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 08/29/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few they did have a person that came to the facility two times a year to do training on the van. He said he had not been to this facility this year. During an interview on 8/27/24 at 5:01 p.m. PRN Van Driver F said she was the admission coordinator. She said that she used to do transport. She said she had trained the Maintenance Director on the van but at that time they had a little minivan. She said they did not have the van that they have now. She said they did not have any checks at this facility During an interview on 8/28/24 at 11:34 a.m. Van Driver C said he worked for the company for 2 years but had transferred to this facility about 5 months ago. He said he was trained by the Maintenance Director at his old facility. He said he was trained to strap residents in with the shoulder/lap seatbelt. He said they strapped down all 4 wheelchair tires, tight. He said there was a seat belt from the side of the bus that you buckle around the resident in the wheelchair. He said he was supposed to strap and buckle the resident every time. He said his old Director taught him that was a necessity. He said you could not take chances with residents, had to buckle them in every time. He said Van Driver B was driving when Resident #1 fell. Van Driver C said he did not know if Van Driver B strapped Resident #1 in or not. He said he should have, that was the first thing transport should do. He said he had not had any in-services in the 5 months he had been here. He said if a resident fell out of the wheelchair when he was driving, he would stop at the next safe place and he would call 911 so that medical staff could assess the resident. He said he could hurt the resident if he tried to move them. During an interview on 8/28/24 at 12:16 p.m. the Administrator said based on the HHSC guidelines he did not need to call in Resident #1's incident from falling in the van. He said Resident #1 did not require ER intervention. He said the transport driver did not neglect Resident#1. The Administrator said based on the federal transit regulations there was no requirement for a seat belt if a resident was secured. He said transport was taught to properly secure the residents. The Administrator said if Resident #1 had been strapped it could have possibly prevented the fall but there were exceptions to all the rules. He said the in-service provided to transport this week was to use the straps when appropriate and the administrator said most of the time it was appropriate. The Administrator said they follow HHSC guidelines, follow the guidelines examples that was why they did not report. He said he did not think it was neglective because Van Driver B did not buckle Resident #1 in the wheelchair. He said there was not a requirement for a seat belt. During an interview on 8/28/24 at 1:19 p.m. Van Driver C said he did not understand what an in-service was. He said he had an in-service Monday 8/26/24 from the Maintenance Director and he was given a checklist they have to look at before transporting a resident. He said yesterday was the first time he had to fill one of those out. He said they had to strap a resident in 100% of the time. He said if he drove off with a resident in a wheelchair and did not strap them in and he turned a corner and the resident fell out it would be 100% the fault of him/the facility. He said the van was not new but new to the facility, they had the van about 1.5 months. During a telephone interview on 8/28/24 at 1:37 p.m. Van Driver B said he did talk to the DON and the administrator. He said he wrote a statement but did not do so until today. He said he was in serviced on Monday, 8/26/24 on using the shoulder/lap belt. He said he did not know that before, the incident no one had told him. He did not think about calling 911 he was not informed that was what he was supposed to do. He said Resident #1's fall scared him, and he was just trying to do what he thought best at the time. He said he would call 911 now that he had been made aware, after the in service. He said he was not supposed to move the resident, they were taught not to touch the residents and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 6 of 11 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 08/29/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few he could have caused further injury to a resident. He said nothing like that had ever happened before and he just got caught up in the moment. During a telephone interview on 8/29/24 at 8:05 a.m. CNA G said she assisted Resident #1 back to his room and bed on Saturday, 8/24/24. She said another CNA helped her. She said Resident #1 had a BM, so they cleaned him up. She said he had BM in the van also and they cleaned that up. She said Resident #1 had fallen in the van. She said Resident #1 told her he was not strapped in on the van, his wheelchair stayed in place, but he fell out of the wheelchair when the driver turned. She said she saw redness on the top of his right foot, and he told her it was sore. She said LVN A had assessed him. CNA G said she worked Sunday 8/25/24 and Resident #1's right foot was very swollen and a purple-ish/black color. She said his left foot was red and he had a scratch on his left side and maybe the g-tube scratched him when he fell in the van. She said the nurse (LVN A) gave him ice packs for the pain in his foot. She said all residents had to be secured in their wheelchair for traveling in the van. She said if you only secure the wheelchair then the resident could fall out of the wheelchair if not secured with a strap. She said Resident #1 should have been secured in his wheelchair. She said she was not sure what time Resident #1 got back to the facility but thought it was after 4:00 p.m. She said LVN A asked her what happened, but no one else asked her about the incident. CNA G said it was about 30 minutes after Resident #1 returned before LVN A assessed him. Record review of U.S Department of Transportation guideline provided by the Administrator on 8/28/24 at 12:33 p.m. indicated: What kinds of securement equipment must be provided in buses and vans- Section 39.23(d) of the Department of Transportation Americans with Disabilities Act( ADA) regulations required all ADA compliant buses and vans to have a two-part securement system, one to secure the wheelchair, and a seatbelt and shoulder harness for the wheelchair user. The guideline indicated: Does a wheelchair user have to use the seat belt and shoulder harness? Under the broad nondiscrimination provision Section 37.5 of DOT ADA regulations a transit operator is not permitted to mandate the use a seatbelt by wheelchair users. Unless the operator mandates the use of the devices by all passengers including sitting vehicle seats. Transit operators may establish a policy that required the seat belt and shoulder harness to be used by all riders, including those who use a wheelchair as well as vehicle seats. This was determined to be an Immediate Jeopardy (IJ) on 8/28/24 at 4:05 p.m. The facility Administrator, and DON were notified. The Administrator was provided with the IJ template on 8/28/24 at 4:05 p.m. and a POR was requested. Plan of Removal was accepted on 8/29/24 at 1:03 p.m. [Plan of Removal Transportation Policy and Procedure related to properly securing residents with seatbelts and emergency procedures was obtained and implemented on 8/28/2024. See attached policy: o Safety During Transport - Securing Chair o Procedure: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 7 of 11 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 08/29/2024 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 0689 1. Level of Harm - Immediate jeopardy to resident health or safety Check that you have all the equipment you need for the transport Residents Affected - Few Four (4) tie downs/securement straps per wheelchair a. b. One (1) Lap Belt/Seat Belt per wheelchair c. One (1) Shoulder Strap per wheelchair d. Ensure secure tracks are clean and free of debris and equipment is in good condition. 2. Roll resident to the appropriate set of brackets in the transport vehicle where resident is to be secured. Lock wheelchair brakes 3. Front Strap Securements: 2 straps required a. Anchor straps on the floor track 3 outside front wheels b. Ensure straps are at a 30-45 degree angle c. Secure close to the seat surface, to a welded junction. Ensure track fittings and straps are secure by pulling on them. 4. Rear Strap Securements: 2 straps required a. Anchor straps on the floor track so straps are in line with w/c frame. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 8 of 11 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 08/29/2024 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 0689 b. Level of Harm - Immediate jeopardy to resident health or safety Ensure straps are at a 30-45 degree angle. Residents Affected - Few Secure close to the seat surface, to a welded junction. Ensure track fittings and straps are secure by pulling on them. c. 5. Ensure all 3 track fittings are positioned in correct orientation with release facing away from the wheelchair. 6. Unlock w/chair brake. Check that w/chair does not move more than 2 in any direction. If needed, re-tighten straps and test again. Lock wheelchair brakes 7. Apply lap/seatbelt around resident with lap belt buckle on hip opposite shoulder strap to be used. Ensure belt is across lap and under wheelchair armrest to fit snuggly. 8. Apply the shoulder strap and secure it to the lap belt/seat belt. 9. FINAL CHECK a. Two (2) Front Straps 30-45 degree angles. Two (2) Rear Straps 30-45 degree angles b. All straps are not touching any other object in vehicle. c. All straps are not attached to any adjustable or removable parts of the wheelchair. No straps are attached to the footrests, armrests, or wheels. d. Lap belt/seat belt is on and secure. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 9 of 11 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 08/29/2024 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 0689 e. Level of Harm - Immediate jeopardy to resident health or safety Shoulder strap is on and secured to the lap belt/ seat belt. Residents Affected - Few Never transport residents in electric wheelchairs; the residents must be transferred to standard wheelchairs before being put on the lift. All wheelchairs must be secured in the vehicle. 10. o Emergency Procedures (including falling from a wheelchair) o Procedure: 1. If a resident fall occurs at any time during transport, call 911 for an ambulance to transport resident to the ER for evaluation. Do not move the resident or transport resident yourself. 2. Call the Director of Nursing, Assistant Director of Nursing, or Administrator. If they are not in facility, call cell phone numbers until you reach one of these individuals. 3. If the resident sustains a minor injury, i.e. skin tear or abrasion, clean and apply band-aid. Notify DON, ADON, or Administrator. If they are not in the facility, call cell phone numbers until you reach one of these individuals. 4. If the resident sustains minor injuries while being transported to a physician/clinic visit, then notify physician/clinic office personnel of the injury on arrival. 5. If the resident sustains any injury other than a small skin tear or abrasion without a fall, still call 911 for transport to ER. Do not transport yourself. 6. If the van is involved in an accident, immediately call 911. Notify DON, ADON, or Administrator after residents are out of danger. 7. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 10 of 11 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 08/29/2024 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 0689 The DON, ADON, or Administrator will notify resident's family or responsible party. Level of Harm - Immediate jeopardy to resident health or safety 8. Residents Affected - Few 9. The transport vehicle will be equipped at all times with a First Aid Kit for minor injuries. The transport driver will have a cell phone available at all times during transport. *If you call 911 and the ambulance refuses to transport the resident to the ER, notify the Administrator, DON, or ADON, for direction. o Use of Seatbelt o Procedure: 1. Transport driver and passengers must wear safety seat belts at all times during transport. 2. Locate clips at the bottom of seat belt. 3. Raise lever on one end of the clip upward and insert lever into slot on floor and place other end into track. 4. When clip is in slot, release lever and clip will pop into locked position. 5. Place seatbelt around resident's lap area and lock. Adjust tightness of seat belt as needed. (Be sure that you can comfortably place two (2) fingers under seat belt over resident's lap.) [TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 11 of 11