Health inspection·November 24, 2025

F 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few needed. Record review of a physician order for Resident #1, dated [DATE], indicated 02 at 3LPM by NC Acute and chronic respiratory failure with hypoxia . Record review of hospital visit for Resident #1 dated [DATE] revealed that Resident #1 presented to the emergency room at 2:54 p.m. with cardiac arrest. 2:55 p.m. Bicarb was given.2:57 p.m. Pulse check. Cardiac standstill on US. Asystole (absence of ventricular contractions in the context of a lethal heart arrhythmia). CPR continued.2:59 p.m. [NAME] Check. Cardiac standstill. Asystole. (absence of ventricular contractions in the context of a lethal heart arrhythmia)2:59 p.m. Time of death called. During an interview on [DATE] at 9:29 a.m., with Resident #1's Family Member she said she had video from a camera that was in Resident #1's room. The video showed that on [DATE] at about 2:08 p.m. two aides, whom she did not know their names, had transferred Resident #1 from his wheelchair to his bed. She said the female CNA took off Resident #1's oxygen and started a hoyer transfer. She said that it took the female and male CNA several minutes to transfer him to his bed and the entire time he was without oxygen. She said that it was obvious that they did not know what they were doing as they struggled to get him into position over his bed. She said she heard Resident #1 saying, Hurry Hurry and I need oxygen Give me oxygen. She said she heard the female CNA say, We have to hurry he is turning blue. She said after they finally got him laid down to bed Resident #1 didn't say anything anymore. She said the female CNA said, Oh my God as she ran out of the room. She said the male CNA had placed the oxygen back on to Resident #1 by this point it was already too late they had already done the damage. She said the nurses entered the room, call 911, and are listening to his chest with a stethoscope. He was later pronounced dead at the hospital.Timeline of video provided by Family Member of Resident #1 on [DATE]. There are 9 separate videos. Video 1: 14:08:36 (2:08:36 PM) Video started with CNA's A and B with Resident #1 performing a Hoyer transfer. Resident #1 had an oxygen tank on the back of his wheelchair and was not wearing his nasal cannula. 14:10:22 (2:10:22 PM) Resident #1 began asking for oxygen. He had no supplemental oxygen on. CNA A had difficulty turning Resident #1 in the Hoyer lift. Resident #1 continued to say, oxygen turn oxygen on. CNA A maneuvered Resident #1 in the Hoyer lift towards his bed. 14:11:25 (2:11:25 PM) CNA A said, Where is his oxygen at? CNA B responded, It's over there. I had to turn it off because it like choked him.14:11:38 (2:11:38 PM) CNA A reached for Resident #1's oxygen concentrator and moved it. He did not give Resident #1 oxygen and turned around to finish lowering Resident #1 into his bed. 14:11:53 ( 2:11:53 PM) CNA A pointed to Resident #1's wheelchair oxygen tank and cannula and said, I gotta give him this one.14:12:02 (2:12:02 PM) CNA A inserted nasal cannula to Resident #1; CNA B checked his oxygen tank. CNA A said, Is it on? CNA B says, Yea I turned it on afterwards she manipulated the oxygen dial to his wheelchair oxygen tank.14:12:13 (2:12:13 PM) CNA B said, Oh my God I will be back. CNA B ran out of the room. CNA A continued to lower the Hoyer lift.14:13:08 (2:13:08 PM) LVN C entered the room and LVN D followed. CNA A said, Where is the thing here pointing at the oxygen concentrator. LVN C said, No I use the same one LVN C removed the nasal cannula connection from the tank and connected it to the oxygen concentrator. Video ended. Video 2:14:13:37 (2:13:37 PM) LVN C was spoke to Resident #1 and checked for vital signs. Resident #1 appeared to be breathing as his chest was moving up and down. Resident #1 was wearing nasal cannula attached to the oxygen concentrator. 14:14:35 (2:14:35 PM) LVN C said, I'm not getting a reading. Try one of those fingers. LVN C gave the pulse oximeter to LVN D. LVN C was also used his stethoscope to assess Resident #1. 14:15:11 (2:15:11 PM) LVN C said, I will send him out in which LVN D said, Yup. LVN C said, I will go call 911. LVN D continued to assess vitals. Resident #1 appeared to be breathing as there was an up and down movement in his chest. 14:16:48 (2:16:48 PM) End of video 2.Video 3:14:16:51 (2:16:51 PM) LVN D continued to assess Resident #1. Resident #1 chest was moving up and down. 14:17:20 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 2 of 8 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 11/24/2025 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 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few (2:17:20 PM) Video ended with LVN D assessing Resident #1's vitals. Video 4:14:17:21 (2:17:21 PM) LVN D continued to assess Resident #1. 14:17:34 (2:17:34 PM) LVN E entered the room with the crash cart. 14:17:55 (2:17:55 PM) LVN D said, He is still breathing. In response to LVN C who is talking on the phone. LVN D said, I am unable to obtain a pulse. Respirations are minute14:18:28 (2:18:28 PM) 911 Operator spoke on a speaker phone and asked, Have you started CPR yet? LVN D Responded, Not started yet at this point our respirations are present but weak. Call with 911 dispatcher ended. 14:18:53 (2:18:53 PM) LVN D said, I am getting a pulse it is just very faint. LVN C agreed with LVN D's assessment. Resident #1's chest was still moving up and down. 14:19:38 (2:19:38 PM) Video ended. Video 5:14:19:39 (2:19:39 PM) LVN D assessed Resident #1 and gave direction to the CNAs to get the AED. 14:20:23 (2:20:23 PM) LVN D said, He is still full code.14:21:34 (2:21:34 PM) LVN D with assistance from LVN E placed oxygen from the crash cart on Resident #1. 14:22:10 (2:22:10 PM) LVN E turned on the AED and pulled up Resident #1's shirt. Pads were not placed on Resident #1.14:23:51 (2:23:51 PM) Video ended with LVN E assessing Resident #1's vitals. Video 6: 14:23:54 (2:23:54 PM) LVN E assessed Resident #1's vitals. Resident #1's chest was seen moving up and down. 14:24:17 2:24:17 PM) LVN E said that she could still hear Resident #1's heart beating. Video endedVideo 7:14:24:25 (2:24:25 PM) LVN D and LVN E assessed Resident #1. Resident #1's chest was seen moving up and down. 14:25:01 (2:25:01 PM) Fire Department entered the room, received a report from LVN D, and placed AED pads on Resident #1. 14:26:18 (2:26:18 PM) Fire Department performed chest compressions. 14:27:34 (2:27:34 PM) LVN D said to LVN E, He initiated CPR because he could not get a pulse.14:29:27 (2:29:27 PM) Video ended with Fire Department providing chest compressions. Video 8:14:29:28 (2:29:28 PM) Fire Department continued chest compressions. LVN D and Fire Department spoke of his history.14:30:14 (2:30:14 PM) EMS entered the room. Fire Department discussed his history of being hospitalized the day before for altered mental status and they discuss how to transfer Resident #1.14:33:18 (2:33:18 PM) AED automated system said, No shock advised start CPR. Resident #1 is transferred to a stretcher. 14:34:26 (2:34:26 PM) Video ended.Video 9:14:34:28 (2:34:28 PM) EMS provided chest compressions as they secured Resident #1 to stretcher. 14:38:16 (2:38:16 PM) EMS transported Resident #1 out of his room. 14:38:41 (2:38:41 PM) Video ended.During an interview on [DATE] at 10:00 a.m., the DON said she had been the DON at this facility for 2 and a half years. She said on [DATE] Resident #1 passed away at the hospital. She said that he had a change in condition and became unresponsive in his room. She said nurses assessed him and went through the steps required when a resident had a change in condition such as this. She said they assessed Resident #1, called 911, and did not do chest compressions as he did have an active heart rate and respirations. She said that staff provided oxygen, got the crash cart just in case the AED was needed, called 911. She said that she believed her nursing staff responded appropriately for the situation. She said that at no point prior to the local Fire Department and EMS arriving did Resident #1 stop breathing or his heart stopped. She said Resident #1 did not expire at the facility. She said that Resident #1 did not have a DNR but he did not need to be resuscitated while he was in the facility because he never stopped breathing and he had a pulse per multiple LVN staff that assessed him.During an interview on [DATE] at 10:25 a.m., LVN D said she had worked at the facility for about 15 years. She said she was working on [DATE] when Resident #1 had a change in condition. She said she was working at the nurse's station when she heard other staff saying Resident #1 was unresponsive. She said she went in to assist and when she entered LVN C was already in the room. She said LVN C said Resident #1 was non-responsive as he left the room to call 911. LVN D said she then started her own assessment of Resident #1, and she directed one of the CNAs involved to get the crash cart which included a tank with a high rate of oxygen. She said she also directed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 3 of 8 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 11/24/2025 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 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few other CNA to get the AED. She said during her assessments of Resident #1 he was breathing and had a weak pulse. She said that when she assessed him, he had his nasal cannula on, and it was providing oxygen. She said that she switched Resident #1 out to the crash cart's non-rebreather at 15 LPM. She said that his respirations were poor, and he had labored accessory breathing. She said while she was waiting for EMS to arrive, she was constantly assessing him to ensure that he was both breathing and he had a pulse. She said the Fire Department entered, she gave a report, and they began CPR. She said that she was trained that if there was a pulse and the resident was breathing to not provide CPR. She said that when the Fire Department arrived Resident #1 had a pulse and was breathing. She said his pulse was faint and hard to find but it was there. She said that it was not standard procedure to take off a resident's oxygen or nasal cannula to complete a hoyer transfer. She said that a resident could continue to wear their cannula during a transfer. She said that she was not aware that Resident #1's nasal cannula had been taken off during his transfer. She said CNA A and CNA B did not tell her his cannula had been off for such a long period of time. She said it was only the responsibility of nurses to remove oxygen from a resident. She said that CNAs should not make adjustments to a resident's oxygen. She said that she could not say whether or not the act of the two CNAs removing Resident #1's oxygen led to his change of condition. She said that Resident #1 would desat (a common shorthand term for desaturation, a drop in oxygen saturation in the blood) q uickly without supplemental oxygen as he had an extensive history of respiratory distress.During an interview on [DATE] at 10:50 a.m., LVN C said he had worked at the facility for about one year and a half. He said he was finishing his shift when CNA B told him Resident #1 was not looking right. He said he went to investigate and found Resident #1 to be breathing, had a heartbeat, but was unresponsive. He said since he was breathing and had a pulse CPR was not needed. He said he could not get a pulse from the pulse oximeter because his fingers was too large as he was an obese man. He said that LVN D and LVN E entered the room, so he left to call 911. He said that CNAs said they had taken his oxygen off of him but his oxygen and cannula were working when he entered the room. He said he then took the oxygen connection from his wheelchair tank and moved it to the room oxygen concentrator. Resident #1's oxygen tank did have oxygen in it. He said it was not in the red but it wasn't full either. He said the reason there was no oxygen cannula on the oxygen concentrator is that when he gets in bed his cannula connection would be moved from the tank to his concentrator. He said that he would have performed CPR had there not been a heartbeat and he wasn't breathing but he was both breathing and had a heartbeat. He said to his knowledge Resident #1 was breathing and had a heartbeat when the Fire Department arrived. He said that Resident #1 was typically always on oxygen 24/7 as he had an order for continuous oxygen. He said that he believed that Resident #1 would go into respiratory distress if he went without oxygen for several minutes. He said that only a nurse should adjust or take off a resident's oxygen. He said that CNAs should not alter the flow of oxygen to a resident. He said he believes that when CNA A and CNA B removed Resident #1's oxygen it led to his change of condition and led to Resident #1 becoming non-responsive. He said that in the past few months Resident #1 had been hospitalized multiple times due to respiratory distress. He said that Resident #1 did not have any respiratory distress while wearing his oxygen. He said it was not standard procedure for a CNA to take a resident's oxygen off during a hoyer transfer. He said it was only the responsibility of a nurse to adjust a resident's oxygen.During an interview on [DATE] at 2:15 p.m. NP F said that she had worked with Resident #1 for many years as a patient. She said that he had been so fragile lately going in and out of the hospital for multiple reasons. She said he had been in the hospital more than in the facility lately due to respiratory distress. She said she did not know what his condition was like after (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 4 of 8 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 11/24/2025 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 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few he left the hospital from his last visit. She said that most people can go a few minutes without oxygen even when they are end stage or with COPD. She said that she cannot say if the CNAs not providing oxygen to Resident #1 was enough to cause him to go into respiratory distress because he had been so fragile lately. She said she will consult with her colleague and call back later. During an interview on [DATE] at 2:45 p.m. NP F said that not having assessed Resident #1 prior to the transfer she did not know exactly what was going on with Resident #1. She said that most patients can go a few minutes without oxygen. She said it will never be known for sure what caused this incident because he had so many co-morbidities. She said his position in the hoyer could have affected him. She said that she agreed that if the CNAs had kept the oxygen on Resident #1, he may still be alive but we would never know as there were so many variables. She said that she did not know if they had been taking Resident #1's oxygen off prior to hoyer transfers. She said that she would have to say yes that the CNAs removing Resident #1's oxygen during the hoyer transfer caused his respiratory distress.During an interview on [DATE] at 3:06 p.m., the DON said that the hoyer lift sling Resident #1 was an appropriately sized sling. She said he had his own sling that was just for him. She said that policy states to use the AED when, The patient is unconscious, absent of respiration, and has no pulse. She said all three need to be present before the AED is used. She said per the nurse's statements he had respirations and a pulse. She said that if you do CPR on a resident with a pulse you could do damage. She said that policy does not address whether a CNA can take off a resident's oxygen. She said that she believes that there was a combination of factors leading to Resident #1's respiratory distress including the compromising position from being in a Hoyer lift at his weight as he was bent over, his history of respiratory distress, CHF, COPD, and the fact that his oxygen was taken off during his transfer. I cannot say whether he would still be alive had the CNAs not taken off his oxygen cannula.During an interview on [DATE] at 8:40 a.m., LVN E said that she was working the day Resident #1 passed away. She said that CNA B came out of the room and said Resident #1 was blue in the face. She said that she went into the room with LVN C and D. She said that she felt a faint pulse on Resident #1 left side radial pulse. She said that Resident #1 was also breathing. She said that she was oscillating his heart rate with her stethoscope. She said that CPR was not started because Resident #1 was breathing and had a pulse. She said according to the American Heart Association training he did not need CPR. She said Resident #1 had a non-rebreather placed on him at its maximum volume of 15LPM. She said that facility policy also states that an AED was not to be used unless the resident was unconscious, not breathing, and did not have a pulse. She said that Resident #1 had a pulse and was breathing the entire time she was assessing Resident #1. She said that it was not appropriate for CNAs to transfer a resident after taking their oxygen off. She said that it isn't appropriate for a CNA to take off a resident's oxygen especially if they have a history of respiratory distress. She said that she could not say whether the CNAs taking off Resident #1's oxygen off is what caused his death. She said the CNAs should have asked for help if they were having trouble transferring with his oxygen still on. She said that she did not believe that an AED would have been useful had it been used during the incident. She said it is not the scope of practice for a CNA to alter a resident's oxygen. She said the CNAs should have never taken a resident's oxygen off. She said the CNAs should have immediately gotten help when the resident said he could not breathe or that he needed oxygen. She said Resident #1 should have been transferred only with oxygen because of his history of respiratory distress and his order for continuous oxygen.During an interview on [DATE] at 9:10 a.m., CNA A said that he had been a CNA since [DATE]th of 2025. He said that he had been working at the facility and it was his first job as a CNA. He said that he was working on [DATE] when Resident #1's incident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 5 of 8 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 11/24/2025 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 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few occurred. He said that he was one of the two CNAs that transferred Resident #1. He said he received training to complete Hoyer transfers. He said that oxygen administration was the duty and responsibility of nurses, and he had minimal classroom training regarding oxygen administration. He said only a nurse should turn a resident's oxygen off as well as removing a resident's nasal cannula. He said that before the Hoyer transfer himself and CNA B agreed to take off Resident #1's nasal cannula. He said CNA B said she did not want Resident #1's cannula to get tangled up during the Hoyer transfer. He said that during the transfer it was hard to hear Resident #1, and he thought Resident #1 did ask for oxygen, but he was focused on the Hoyer transfer. He said he had a hard time moving Resident #1 in the room because he was such a big guy. He said he thought Resident #1 asked for oxygen about 3 or 4 times. He said he did look for the oxygen concentrator, but he was told not to touch it by nursing staff, and it was missing the nasal cannula anyway. He said later he realized the cannula was on the oxygen tank and it needed to be moved. He said he got the nasal cannula attached to his oxygen tank, turned it on as high as it would go and placed the cannula on Resident #1. He said he could hear the oxygen coming out of the cannula. He said that Resident #1 was turning blue during the Hoyer transfer. He said that prior to his transfer Resident #1 was looking for his room so he could be put in bed. He said he was acting normal prior to his Hoyer transfer and there was no indication that there was something wrong with him.During an interview on [DATE] at 10:50 a.m., the ADM said he had been the ADM for two years. He said he was working the day of the incident but did not witness anything from the incident. He said that he had not watched the videos of the incident either. He said he had heard what happened, however. He said that he believed that a CNA can take off and place on a resident's oxygen. He said that he believed there could have been a safety issue regarding Resident #1's nasal cannula. He said it wasn't for him to judge the CNAs actions. He said he believed they had a call to make and what their call was, was their decision. He said that when Resident #1 was asking for oxygen he could not answer definitively what the CNAs should have done. He said perhaps the CNAs should have placed the oxygen back on Resident #1. He said that taking off Resident #1's oxygen off to transfer for a safety issue is not the driving factor as Resident #1 is a 400-pound man with a history of respiratory issues and non-compliant with his diet.During an observation and interview on [DATE] at 12:16 p.m., the DON showed the investigator a XXL Hoyer sling that had Resident #1's name written on it. The sling showed that it was rated for 450 pounds.During an interview on [DATE] at 2:40 p.m., CNA B said that she was working on [DATE] with CNA A. She said that she did help CNA A with a Hoyer transfer for Resident #1. She said when she got to work it was shift change and Resident #1 said he wanted to go to bed. She said she asked CNA A to help her get Resident #1 to bed. She said Resident #1 was joking and acting like he was having a good day prior to the transfer. She said that Resident #1 did not seem as if he was having any respiratory issues. She said Resident #1 and CNA A went back to his room to do the transfer. She said before his transfer her and CNA A decided to take his cannula off because they thought it would not be long enough to reach from his tank all the way to his bed. She said they took off Resident #1's cannula after they got his transfer setup. She said they had a difficult time transferring Resident #1 because when they set up the hoyer transfer they had him facing the wrong way and they had to maneuver him in the room to get him in the right direction and over towards his bed. She said she realized he was turning purple when they got him over the bed. She said he looked discolored and was gasping for air. She said they hurried up and lowered him onto his bed, CNA A got the oxygen and placed it back on Resident #1. She said that is when I said, Oh my God and ran out of the room to get a nurse. She said she was never trained to take a resident's oxygen off to perform a Hoyer transfer not here at the facility or in any of her past (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 6 of 8 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 11/24/2025 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 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few trainings. She said that CNAs are not certified to touch a resident's oxygen. She said that when Resident #1 was saying, I can't breathe and I need oxygen they should have given him his oxygen back right away. She said the TV was loud and she could not hear exactly what Resident #1 was saying during the transfer.During an interview on [DATE] at 2:52 p.m., CNA G said that she was trained to conduct Hoyer transfers. She said that if she transferred a resident that used oxygen she would never touch or remove that resident's oxygen. She said she would get a nurse to remove a resident's oxygen if it was impeding her ability to work.During an interview on [DATE] at 2:59 p.m., CNA H said that she had been trained to do Hoyer transfers. She said that she had transferred residents that was wearing oxygen in the past. She said that she is not qualified to change or alter a resident's oxygen so she would never take a resident's oxygen off to do any type of work. She said that only a nurse can remove a resident's oxygen.During an interview on [DATE] at 3:04 p.m., CNA I said that she had been trained to complete Hoyer transfers. She said that she had done Hoyer transfers in the past where a resident had supplemental oxygen. She said that she would never take a resident's oxygen off to do a Hoyer transfer. She said that if she needed a resident' s oxygen off she would get a nurse to do it.Record review of a facility policy titled, APPLYING AN OXYGEN DELIVERY DEVICE dated [DATE]. Policy shows that, Standard of Practice: Staff will apply oxygen delivery devices in accordance with standard practice guidelines: Identify the resident Validate physician orders Observe respiratory function and note behavioral changes and patency of airway as appropriate Validate peripheral capillary oxygen saturation (SpO2) through pulse oximetry if needed Perform hand hygiene Provide comfort for resident Attach oxygen delivery device as required Attach humidified oxygen source if required Nasal Cannula1. Place tips of cannula into the resident's nares2. Loop tubing over the resident's ears3. Adjust lanyard Mask device1. Apply mask over the resident's mouth and nose2. Bring straps over the head Maintain sufficient slack on oxygen tubing Observe for proper function of oxygen delivery device Verify setting on flowmeter and oxygen source and the prescribed flow rate Dispose of gloves properly Perform hand hygiene Record the procedure in the record Report abnormal findings to the nurse in charge or the health care providerRecord review of a facility policy titled, MECHANICAL LIFTS (HOYER/SIT-TO-STAND) dated February 12th 2020. Policy shows that: Residents will be assisted with their Activities of Daily Living, utilizing lifts according to manufacturer's guidelines.Procedure: 1. Mechanical Lift Pre-Operations Check a. Understand why Resident needs lift b. Demonstrate how to charge lift / locate batteries c. Demonstrate ability to lower resident if lift fails d. Locate emergency stop button and its purpose e. Check to ensure the sling is in good working condition with no torn or ripped areas, etc. f. Locate & read battery charge indicator 2. Mechanical Lift Operations a. Introduce self to Resident b. Verify correct patient using two identifiers c. Inform Resident of procedure d. Perform hand hygiene e. Gather necessary equipment and second person to assist f. Close blinds and close curtain or door to provide privacy g. Fold sling and place under patient in correct position h. Open feet of mechanical lift for wide stance i. Prepare location where Resident is going to go j. Do not lock wheels when lifting Resident k. Lift Resident slowly & safely, just until off bed l. Move Resident to other location and lower safely m. Remove gloves and perform hand hygiene n. Confirm Resident comfort and give call bell Report any change in condition to Charge Nurse .The Administrator was notified of the IJ on [DATE] at 12:08 p.m. and the IJ template was provided. The plan of removal was accepted on [DATE] at 8:15 a.m. and indicated the following:The facility's Plan of Removal:Date:?[DATE]? Resident #1 has been discharged from the facility. Education will be provided to clinical staff regarding the policy and procedure of administration of supplemental oxygen. Clinical staff will be educated by 11:59pm on [DATE]. Staff not receiving the education will not be allowed to work (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 7 of 8 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 11/24/2025 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 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete until education is completed. The education provided is the Policy and Procedure Titled Applying An O2 Delivery Device. The DON and ADONs will provide this education. Education was provided to the clinical staff that worked on [DATE] which included 1:1 Education to the staff directly involved in the incident. This education, provided by the DON and ADONs, included the same education provided to remaining clinical staff on [DATE]. Additionally, there was also education in the form of a Mock Code provided to the clinical staff on [DATE] as well as the staff directly involved in the incident. This education was provided by the DON and ADONs which included the following:Standard of Practice: Staff will apply O2 delivery devices in accordance with standard practice guidelines. If resident experiences respiratory distress staff is to notify charge nurse.S Procedure: Identify the resident Validate the physician orders Observe respiratory function and note the behavioral changes and patency of airway as appropriate Validate peripheral capillary o2 saturation through pulse oximetry if needed Perform hand hygiene Provide comfort for resident Attach 02 delivery device as required Attach humidified o2 source if required o Nasal cannula S Place tips of cannula into the resident's nares S Loop tubing over the residents' ears S Adjust lanyard o Mask device S Apply mask over the resident's mouth and nose S Bring straps over the head Maintain sufficient slack on o2 tubing Observe for proper function of o2 delivery device Verify setting on flowmeter and o2 source and the prescribed flow rate Dispose of gloves properly Perform hand hygiene Record the procedure in the record Report abnormal findings to the nurse in charge or the healthcare provider S Addendum to policy: CNA will notify Licensed Nurse to remove resident o2 device as needed while providing resident care.S Mock code steps include initial assessment of unresponsive and abnormal breathing, calling for help and starting high-quality CPR. Next steps are to attach the defibrillator, analyze the rhythm, deliver a shock if needed and resume compressions. Finally administer medications as indicated and continue rounds of CPR and rhythm checks.1. Assessment and Activation a. Assess the patient: check for unresponsiveness by shaking the person's shoulder and calling their name. b. Check breathing and pulse: look for abnormal breathing and check f[TRUNCATED] Event ID: Facility ID: 676184 If continuation sheet Page 8 of 8