Health inspection·June 18, 2025

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few face down to the right of the not yet dispensed cards of medications. MA-B then locked her cart and turned her back to the medication cart without placing the 5 blister-pack cards of medicine inside the secured medication cart. The 5 blister-pack cards left lying unsecured on top of the cart contained the following: 30 tablets Atorvastatin 80mg, 24 tablets Ropinirole 0.5mg, 40 tablets Levetiracetam 250mg, 7 capsules Prazosin 5mg, and 2 tablets Famotidine 20mg. MA-B entered Resident #19's room with her back to the cart, walked to the far side of the room where Resident #19 was sitting, and administered the medications to Resident #19 without ever looking back at the medication cart and the 5 medications lying unsecured on top of the cart. After administering the medications to Resident #19, MA-B then turned toward the door of the room and walked back to her cart. She started to push the cart away from the doorway and stopped after noting the cards of medication were lying on top of the cart. MA-B then unlocked the medication cart and placed the 5 blister-pack cards of medication inside the drawer, shut the drawer, and locked the cart. During an observation on 06/17/2025 at 08:19 AM, MA-B was observed to unlock her medication cart and remove 4 (four) blister-pack cards of medications belonging to Resident #45 from the cart drawer and laid them, stacked on top of each other, on the top of the medication cart. After dispensing the required dose of medication to be administered from each card, MA-B laid the no longer needed card face down to the right of the not yet dispensed cards of medications. MA-B then locked her cart and turned her back to the medication cart without placing the 4 blister-pack cards of medicine inside the secured medication cart. The 4 blister-pack cards left lying unsecured on top of the cart contained the following: 2 tablets Amlodipine 5mg, 17 tablets Lisinopril 20mg, 8 tablets Metoprolol tartrate 100mg and 14 tablets Potassium chloride 10mEq. MA-B entered Resident #45's room with her back to the cart, walked to the far side of the room where Resident #45 was lying in bed and administered the medications to Resident #45 without ever looking back at the medication cart and the 4 medications lying unsecured on top of the cart. After administering the medications to Resident #45, MA-B then turned toward the door of the room and walked back to her cart. She noted the 4 cards of medication lying on top of the cart. MA-B unlocked the medication cart and placed the 4 blister-pack cards of medication inside the drawer, shut the drawer, and locked the cart. During an interview on 06/17/2025 at 08:30 AM, MA-B said she forgot to put the cards of medications back into the medication cart drawer before walking away and leaving the medications unsecured. She said a resident could have taken one or more of the medications from the cart. She said leaving medications out and unsecured could result in a resident having an adverse reaction. During an interview on 06/17/2025 at 08:50 AM, MA-C said medications could not be left on top of the medication carts unattended by staff. She said unattended medications could be taken by a resident and cause serious problems. During an interview on 06/17/2025 at 11:00 AM, the DON said she expected the medication aides to follow the rules of medication administration including keeping medications secure in locked medication carts. A review of the facility's policy dated 01/2024 and titled Medication Storage indicated the following; Medications and biologicals are stored properly, .to keep their integrity and support safe, effective drug administration. The medication supply shall be accessible only to licensed medical personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 2 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 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 0761 Procedures: Level of Harm - Minimal harm or potential for actual harm 3. In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides are allowed access to medication carts. Medication rooms, cabinets, and medication supplies should remain locked when not in use or attended to by persons with authorized access. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 3 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Park Rehabilitation and Skilled Nursing 5505 New Copeland Rd Tyler, TX 75703 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 7 residents (Residents #19 and #45) reviewed for infection control practices. Residents Affected - Some 1. The facility failed to ensure MA-B performed hand hygiene prior to, between, and after contact with Resident #19 and Resident #45 during the medication administration process. 2. ADON -D and CNA-C failed to ensure followed isolation protocols and used appropriate PPE for COVID-positive residents. These failures could place residents under her care at risk for the transmission of communicable diseases and infections. Findings included: 1. Record review of Resident #19's face sheet dated 06/18/2025 indicated she was a [AGE] year-old female who admitted to the facility on [DATE]. She had diagnoses which included stroke (damage to brain due to interruption of blood supply), dementia (group of conditions characterized by impairment of at least two brain functions such as memory loss and judgement), seizures, diabetes mellitus (group of diseases that affect how the body uses blood sugar), hypertension (elevated blood pressure), and hyperlipidemia (high levels of fat particles in the blood stream). Record review of a quarterly MDS dated [DATE] revealed Resident #19 had a BIMS score of 3 (three) indicating her cognition was severely impaired. The MDS also indicated she was incontinent and dependent on staff for most activities of daily which included including bathing and mobility. Record review of resident #45's face sheet dated 06/18/2025 indicated she was a [AGE] year-old female who admitted to the facility on [DATE]. She had diagnoses which included dementia, stroke, heart failure, hypertension, and chronic kidney disease. Record review of a quarterly MDS dated [DATE] noted Resident #45 had a BIMS score of 3 (three) indicating her cognition was severely impaired. The MDS also indicated she was incontinent and dependent on staff for most activities of daily which included including bathing and mobility. During an observation on 06/17/2025 at 08:11 AM, revealed MA-B was noted to push a medication cart to the doorway of Resident #19's room. MA-B proceeded to remove 5 blister packs (cards with medications in individual clear, plastic blisters) from the cart. MA-B did not perform any hand hygiene prior to beginning the medication preparation process. She then proceeded to use her hands to punch out the prescribed dose from each of the 5 different medication cards into a small, paper medicine cup. MA-B took the medicine cup and a glass of water into Resident #19's room and handed them to Resident #19 who swallowed the medications and drank the water. MA-B took the empty containers from Resident #19 and threw them in the trash. MA-B returned to the medication cart and pushed it down the hall to Resident #45's room. MA-B did not perform any hand hygiene after she left Resident #19's room. During an observation and interview on 06/17/2025 at 08:19 AM, revealed MA-B was noted to push a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 4 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Park Rehabilitation and Skilled Nursing 5505 New Copeland Rd Tyler, TX 75703 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some medication cart to the doorway of Resident #45's room. MA-B proceeded to remove 4 blister packs from the cart. MA-B did not perform any hand hygiene prior to beginning the medication preparation process. She then proceeded to use her hands to punch out the prescribed dose from each of the 4 different medication cards into a small, paper medicine cup. MA-B took the medicine cup and a glass of water into Resident #45's room and handed them to Resident #45 who swallowed the medications and drank the water. MA-B took the empty containers from Resident #45 and threw them in the trash. MA-B returned to the medication cart. MA-B did not perform any hand sanitation after leaving Resident #45's room. During an interview on 06/17/2025 at 08:25 PM, MA-B said she did not perform any hand hygiene during any part of the observed medication administration process for Resident #19 and Resident #45. She said she should have either washed her hands with soap and water or used the hand sanitizer on the top of the medication cart. She said she should have sanitized her hands before she removed Resident #19's medications from the cart and when she returned to the cart after administering Resident #19's medications. She said she should then have sanitized her hands before she removed Resident #45's medications from the cart and when she returned to the cart after administering Resident #45's medications. MA-B said hand hygiene was important to prevent the spread of infection. She said she forgot to wash her hands. During an interview with the DON on 06/17/2025 at 11:00 AM, she said she expected the staff to follow infection control and prevention protocols. She said hand hygiene was important and was the first and most basic step for preventing the spread of infection. Record review of the facility's policy titled Hand Hygiene for Staff and Residents (Effective: July 2018, Revised: February 2025) indicated the following: Purpose: To reduce the spread of infection with proper hand hygiene. Policy: Proper hand hygiene technique is completed whenever hand hygiene is indicated. NOTE: Hand Hygiene is the most important component for preventing the spread of infection Procedure; 1. Hand hygiene is done: Before: A. Resident contact .G. taking part in a medical or surgical procedure .After: A. contact with soiled or contaminated article, B. resident contact . Record review of the facility's policy titled Medication Administration indicated the following. 11 .Hands are washed with soap and water after administration and with any resident contact. Antimicrobial sanitizer may be used in place of soap and water as allowed. 2. During an observation 06/16/2025 at 12:45 PM observed ADON D and CNA C entering the room of Residents #20 and #18 who were on droplet precautions for COVID-19, both residents tested positive for covid 6/11/2025, there was signage on the door for droplet precautions, both were observed entering without donning a gown, or N95 respirator. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 5 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Park Rehabilitation and Skilled Nursing 5505 New Copeland Rd Tyler, TX 75703 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 6/17/2025 at 10:00 AM, CNA C said she had on a surgical mask and not a N95, it was an emergency. She stated didn't think of a N95 mask, just taking care of resident and after she entered the room, she knew she should have had on a N95 mask, gown and gloves. During an interview on 6/17/2025 at 10:15 AM, the ADON said she knew she should have had a N95, gown and gloves on after she entered the room when she was called to assist with the resident. During an observation on 6/16/2025 at 10:00 AM, on hall 500 revealed there were 5 residents with signage for droplet precautions The signage indicated: droplet precaution, clean hands cover eyes, nose and mouth before entering. During an observation and interview on 6/17/2025 3:00 PM with ADON D, she said she expected the staff to follow infection control and prevention protocols. She stated she was in the process of making sure all staff were currently educated on COVID 19 protocols. She said that the signs on the COVID-19 rooms should follow the policy for COVID -19 which their policy required PPE for COVID-19 positive resident or residents suspected of having COVID-19, staff should wear an N95, face shield or goggles, gown, and gloves. Record review of the facility's policy titled CORONAVIRUS 2-2019 (Effective: March 2023, Revised: May 2023) indicated the following: Purpose: The facility staff will deliver care to the resident with Coronavirus 2-2019; according to the guidelines set forth by the state of Texas, Centers for Medicare and Medicaid Services, Centers for Disease Control and Prevention, Occupational Safety and Health Administration. H/2 - COVID19-PPE a. The required PPE for COVID-19 positive resident or residents suspected of having COVID-19, staff should wear an N95, face shield or goggles, gown, and gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 6 of 6