Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Providence Park Rehabilitation And Skilled Nursing during CMS and state inspections, most recent first.
A resident with a history of severe respiratory conditions did not receive continuous oxygen therapy as ordered during a Hoyer lift transfer when two CNAs removed the nasal cannula, leaving the resident without supplemental oxygen for several minutes. Despite the resident's repeated requests for oxygen and visible signs of distress, the oxygen was not restored until after the transfer was completed. The incident resulted in the resident becoming unresponsive and later being pronounced dead at the hospital. Facility staff and policy confirmed that only licensed nurses should manage oxygen devices and that CNAs were not authorized or trained to remove oxygen during transfers.
Staff failed to follow infection control protocols by not performing hand hygiene during medication administration for two residents with severe cognitive impairment and by not using required PPE, including N95 respirators, gowns, and gloves, when entering the rooms of residents on COVID-19 isolation precautions. Both the medication aide and other staff acknowledged awareness of the protocols but did not adhere to them as required by facility policy.
A medication aide failed to secure multiple blister-pack cards of medications for two residents with severe cognitive impairment, leaving them unattended on top of a locked medication cart during administration. The aide dispensed required doses but did not return the remaining medications to the locked cart before entering residents' rooms, contrary to facility policy and staff expectations.
A resident with chronic myeloid leukemia and mobility issues was not properly secured in a wheelchair during transport, leading to a fall and injuries. The transport staff lacked training and awareness of emergency procedures, and the facility did not have a transportation policy, contributing to the incident.
The facility failed to provide adequate housekeeping and maintenance services, resulting in a shortage of clean linens for several residents. Observations and interviews revealed that residents frequently experienced unmade beds and had to wait for clean sheets, impacting their comfort and ability to use their beds. A hand count confirmed the facility had significantly fewer linens than required.
A resident with a history of paraplegia did not receive scheduled showers and had inaccurately documented bed baths. Interviews with staff confirmed discrepancies in documentation and failure to provide necessary hygiene care, with the resident receiving only one shower since admission.
The facility failed to provide adequate meals for two residents undergoing dialysis, leading to them being hungry before and after their sessions. Staff interviews and observations revealed a lack of clear procedures and communication regarding the preparation and distribution of sack lunches for these residents.
A resident with chronic respiratory conditions was observed receiving oxygen therapy without a corresponding physician order. Staff confirmed the continuous use of oxygen since admission, but no formal order was found in the resident's records, contrary to the facility's policy.
The facility failed to maintain a medication error rate below 5 percent, resulting in a 7 percent error rate. A resident did not receive a scheduled dose of Vitamin B12, and another resident received a multivitamin instead of a prescribed multivitamin with minerals due to unavailability on the medication cart.
A resident's call light was found to be inoperative, failing to light and sound at the centralized call light panel. The issue was confirmed through observation and interviews, and it was only resolved after the ADON replaced the call light cord. The facility's policy did not address the functionality of call lights, contributing to the oversight.
The facility failed to post daily Nursing Staffing Data for three consecutive days in May 2024 and did not maintain the required staffing data for February, March, April, and May 2024. The ADON, who took over the responsibility in February 2024, admitted to not posting the data due to being busy with other duties.
The facility failed to secure a treatment medication cart, leaving it unlocked and unattended near the nurse station, making medications easily accessible to residents and unauthorized personnel.
Failure to Provide Continuous Oxygen Therapy During Transfer
Penalty
Summary
A deficiency occurred when a resident with a history of chronic respiratory conditions, including COPD, congestive heart failure, and acute and chronic respiratory failure with hypoxia, did not receive continuous oxygen therapy as ordered by his physician. The resident required oxygen at 3LPM via nasal cannula and had documented needs for continuous oxygen to maintain adequate oxygen saturation. During a transfer from wheelchair to bed using a Hoyer lift, two CNAs removed the resident's nasal cannula, leaving him without supplemental oxygen for several minutes. The CNAs struggled with the transfer, and during this time, the resident repeatedly requested oxygen and showed signs of respiratory distress, including turning blue and gasping for air. The CNAs did not immediately restore the oxygen, and only after the transfer was completed was the nasal cannula reattached and oxygen flow resumed. Video evidence and interviews confirmed that the resident was without oxygen for an extended period during the transfer, despite his repeated verbal requests and visible signs of distress. The CNAs involved stated they removed the oxygen because they believed the tubing would not reach or might get tangled during the transfer, and both acknowledged they were not trained or authorized to remove or adjust oxygen devices. Other CNAs and nursing staff interviewed confirmed that only licensed nurses should handle oxygen administration and that it was not standard practice to remove oxygen during transfers for residents with respiratory needs. The facility's policies also indicated that oxygen delivery devices should be managed according to standard practice guidelines and that CNAs should notify a licensed nurse if oxygen needed to be removed. Following the transfer, the resident became unresponsive and required emergency intervention. Nursing staff assessed the resident, found him to be breathing with a faint pulse, and provided high-flow oxygen while awaiting emergency services. Despite these interventions, the resident was later pronounced dead at the hospital. The incident was identified as an Immediate Jeopardy situation due to the failure to provide care consistent with professional standards for respiratory therapy, specifically the failure to ensure continuous oxygen therapy as ordered.
Failure to Follow Infection Control Protocols During Medication Administration and Isolation Precautions
Penalty
Summary
Facility staff failed to adhere to established infection prevention and control protocols during medication administration and when caring for residents on isolation precautions. Specifically, a medication aide did not perform hand hygiene before, between, or after contact with two residents during the medication administration process. The aide handled multiple medication blister packs and administered medications to both residents without washing or sanitizing hands at any point, despite facility policy requiring hand hygiene before and after resident contact and medication administration. The aide acknowledged awareness of the hand hygiene requirements but stated she forgot to perform them. Both residents involved had severe cognitive impairment, were incontinent, and dependent on staff for most activities of daily living. Their medical histories included conditions such as stroke, dementia, diabetes, hypertension, and chronic kidney disease. Observations confirmed that the medication aide did not follow hand hygiene protocols as outlined in the facility's policies, which emphasize hand hygiene as the most important step in preventing infection spread. Additionally, the Assistant Director of Nursing and a Certified Nursing Assistant entered the rooms of two residents on droplet precautions for COVID-19 without donning the required personal protective equipment (PPE), including N95 respirators, gowns, and gloves. Both staff members acknowledged after the fact that they were aware of the PPE requirements but did not follow them during the incident. Facility policy and posted signage clearly indicated the need for full PPE when entering rooms of COVID-19 positive residents.
Unsecured Medications Left Unattended During Administration
Penalty
Summary
Medication Aide MA-B failed to properly secure medications for two residents during medication administration. For one resident, MA-B removed five blister-pack cards of medications from the medication cart, placed them on top of the cart, and after dispensing the required doses, left the remaining cards unsecured on the cart while entering the resident's room to administer the medications. The medications left unattended included Atorvastatin, Ropinirole, Levetiracetam, Prazosin, and Famotidine. The resident had a history of stroke, dementia, seizures, diabetes, hypertension, and hyperlipidemia, and was noted to have severely impaired cognition. A similar incident occurred with another resident, where MA-B removed four blister-pack cards of medications, placed them on top of the cart, and left them unsecured while administering medications in the resident's room. The medications included Amlodipine, Lisinopril, Metoprolol tartrate, and Potassium chloride. This resident also had a history of dementia, stroke, heart failure, hypertension, and chronic kidney disease, with severely impaired cognition. In both cases, MA-B locked the medication cart but failed to return the unused medication cards to the secured cart before leaving the area, resulting in the medications being left unattended and accessible. Interviews with MA-B, another medication aide, and the DON confirmed that medications should not be left unsecured and that only authorized personnel should have access to medications, as outlined in the facility's medication storage policy.
Failure to Secure Resident During Transport
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident during transport. The resident, who had a history of chronic myeloid leukemia, lack of coordination, unsteadiness on feet, muscle weakness, and abnormal posture, was not properly secured in a wheelchair during transport from the hospital back to the facility. The transport staff did not use the shoulder harness, and the resident slid out of the wheelchair, resulting in injuries including a bruise and bump on the forehead, bruises and scratches on the right foot, puncture wounds, redness to the knee, and pain. The transport staff were not aware of emergency precautions during a fall, such as not lifting the resident and calling 911. Instead, the transport aide picked the resident up and placed him back in the wheelchair without proper assessment. The facility did not have a policy for transportation, and the transport drivers lacked pre-employment training or a competency check-off list for driving the van. This lack of training and policy contributed to the incident, as the transport driver was not instructed to use the seatbelt and shoulder harness, and did not know to call 911 in the event of a fall. Interviews with staff and family members revealed that the facility's administration did not communicate effectively with the resident or family about the incident. The family member reported that the facility tried to minimize the incident and did not apologize, which could have alleviated some of the family's concerns. The facility's lack of a transportation policy and inadequate training for transport staff were significant factors in the deficiency, placing residents at risk of falls and potential injury during transport.
Facility Fails to Provide Adequate Linens for Residents
Penalty
Summary
The facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment, specifically in providing clean and adequate linens for four residents. Observations and interviews revealed that residents frequently experienced a shortage of clean linens, leading to unmade beds and residents having to wait for clean sheets. For instance, Resident #5 mentioned that they often ran out of linens, and Resident #58 was observed without any sheets on their bed, having to wait for laundry to be done to have clean linens available. Similar situations were observed with Residents #42 and #44, who also reported frequent shortages of clean sheets, impacting their comfort and ability to use their beds. Interviews with Certified Nursing Assistants (CNAs) confirmed the frequent shortage of linens, with reports of running out of clean sheets 2-3 times a week. CNA F and CNA G both noted that they were unable to make residents' beds due to the lack of clean linens, corroborating the residents' accounts. Observations of the linen closets on different halls further confirmed the shortage, with no fitted or flat sheets available at the time of inspection. A hand count conducted by the Laundry Supervisor revealed that the facility had a total of 170 flat sheets and 133 fitted sheets, significantly below the required 300 of each to ensure adequate supply. The Laundry Supervisor and the Administrator both acknowledged the shortage and the need to order more linens. The facility's Statement of Resident Rights emphasizes the residents' right to safe, decent, and clean conditions, which was not upheld in this instance due to the linen shortage.
Failure to Provide Scheduled Showers and Accurate Documentation
Penalty
Summary
The facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene. Specifically, Resident #62 did not receive scheduled showers or baths and had inaccurately documented bed baths. The resident, who had a history of paraplegia and required partial to moderate assistance with showers or baths, did not receive 9 scheduled showers since her admission. Additionally, bed baths were documented on dates when the resident was not present in the facility, indicating inaccurate record-keeping by the staff, including agency staff who were not paying attention to the resident's actual presence in the facility. Interviews with the CNA, ADON, and DON confirmed the discrepancies in the documentation and the failure to provide the necessary hygiene care. The CNA admitted to signing off on bed baths for dates when the resident was not in the facility. The ADON and DON both acknowledged that the resident could not have received baths on those dates and confirmed that the resident had only received one shower since her admission. The facility's policy on bathing, revised in January 2023, was not adhered to, leading to this deficiency.
Failure to Provide Adequate Meals for Dialysis Residents
Penalty
Summary
The facility failed to provide at least three meals daily at regular times or in accordance with resident needs for two residents undergoing dialysis. Resident #7, a [AGE] year-old female with multiple diagnoses including respiratory failure, congestive heart failure, and diabetes, did not receive a sack lunch on her dialysis days. Despite being cognitively intact and having specific dietary orders, she reported not receiving any sack lunches since her admission, leading to her being very hungry upon returning from dialysis sessions. The facility staff, including the ADON and transportation personnel, confirmed that no sack lunches were provided on the specified dates, and there was a lack of communication and responsibility among staff regarding the preparation and delivery of these meals. Resident #97, a [AGE] year-old male with conditions such as hemiplegia, diastolic heart failure, and chronic obstructive pulmonary disease, also did not receive a sack lunch or breakfast before his dialysis sessions. He reported consistently leaving for dialysis hungry and returning to the facility still hungry. Interviews with various staff members, including the MA, receptionist, and dietary aides, revealed a lack of clear procedures and communication regarding the preparation and distribution of sack lunches for dialysis patients. The dietary staff were unaware of the need for these meals, and there was no permanent dietary manager to oversee the process. Observations in the kitchen showed a list indicating the need for dialysis lunches, but it lacked specific times and clear instructions. The RD confirmed the need for sack lunches for dialysis patients but noted that the responsibility for picking up these meals was unclear among the staff. The DON acknowledged that sack lunches were not being sent with dialysis residents and presented an external email from the dialysis care unit recommending against eating while on the dialysis machine. This lack of coordination and communication among the facility staff led to the deficiency in providing adequate nutrition to the residents undergoing dialysis.
Failure to Ensure Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that Resident #73, who required respiratory care, had physician orders for oxygen therapy. Resident #73, an elderly female with chronic obstructive pulmonary disease, acute and chronic respiratory failures, shortness of breath, pneumonia, and cognitive deficit, was observed receiving oxygen therapy at 2 LPM via nasal cannula on multiple occasions. However, a review of her physician orders dated 05/07/2024 did not indicate any orders for oxygen therapy. Interviews with the resident and staff confirmed that she had been receiving oxygen continuously since her admission, but no formal order was found in her records. The care plan for Resident #73 indicated a need for respiratory treatments and oxygen as ordered, but this was not reflected in the physician's orders. Staff members, including an LVN and the ADON, acknowledged the absence of an oxygen therapy order and emphasized the importance of having such an order to prevent potential respiratory issues. The facility's policy on applying an oxygen delivery device also required validation of physician's orders, which was not adhered to in this case.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure the medication error rate was not 5 percent or greater, resulting in a 7 percent error rate for two residents. For Resident #104, a scheduled dose of Vitamin B12 1000 mcg SL was not administered because the medication was not available on the cart or in the facility. Similarly, Resident #53 did not receive a physician-ordered multivitamin with minerals because it was not available on the medication cart. The medication aide later administered a multivitamin instead of the prescribed multivitamin with minerals, which did not meet the physician's order. During interviews, the medication aide acknowledged the unavailability of the medications and the subsequent failure to administer them as prescribed. The Director of Nursing (DON) confirmed that the expectation was for medication aides to inform the charge nurse if a medication was not available, and the facility would then obtain the necessary medications from a local pharmacy or retailer. The facility's policy on medication administration emphasized that medications should be administered and documented as ordered by the physician and in accordance with state regulations.
Inoperative Call Light System for Resident
Penalty
Summary
The facility failed to ensure that a working call system was available in each resident's bathroom and bathing area, specifically for one resident. Resident #09's call light was found to be inoperative, failing to light and sound at the centralized call light panel located at the nurse station near hall 400. This deficiency was identified through observation, interview, and record review. Resident #09, who has multiple diagnoses including muscle weakness, dysphagia, cognitive communication deficit, and chronic kidney disease, reported that her call light had not been answered for 3-4 days. Upon testing, it was confirmed that the call light did not illuminate or sound at the nurse station, indicating a malfunction in the system. The issue was only resolved after the Assistant Director of Nursing (ADON) replaced the call light cord, which then restored its functionality. During the investigation, a Certified Nursing Assistant (CNA) and a Licensed Vocational Nurse (LVN) both confirmed that the call light was not working. The facility's policy on call light answering, revised in January 2023, did not address the functionality of call lights, which contributed to the oversight. The failure to maintain an operative call light system could delay the response to residents' needs, as evidenced by Resident #09's experience. The deficiency highlights a critical lapse in ensuring that residents can effectively communicate their need for assistance to the staff.
Failure to Post and Maintain Daily Nursing Staffing Data
Penalty
Summary
The facility failed to post Nursing Staffing Data information daily as required for three consecutive days in May 2024. Observations on 05/06/24, 05/07/24, and 05/08/24 revealed that the daily nursing staffing data was not posted at various times throughout the day. Additionally, the facility did not maintain the posted daily nurse staffing data for a minimum of 18 months, as required by State law, for the months of February 2024, March 2024, April 2024, and May 2024. This failure was confirmed during an interview with the Assistant Director of Nursing (ADON), who stated that she had taken over the responsibility of posting the daily staffing sheets after the staffing coordinator left in February 2024 but had not posted any since then due to being busy with other duties. The facility's undated Staffing Coordinator Job Description indicated that the role of the staffing coordinator includes ensuring adequate and appropriate staffing of the facility nursing department to meet the needs of the residents and posting work sheets and time schedules. The ADON admitted that she had not had the time to post the daily staffing sheets because she was occupied with working shifts as a charge nurse and managing her responsibilities as the ADON. This lapse in posting and maintaining the required staffing information could lead to residents, families, and visitors being unaware of the facility's daily staffing levels.
Unsecured Medication Cart
Penalty
Summary
The facility failed to ensure medications were secured on one of the two treatment medication carts reviewed for pharmacy services. On the evening of March 11, 2024, the treatment medication cart for the 500/600 Hall was observed to be left unlocked, unsecured, and unattended near the nurse station. This cart, which contained medications and treatments, was easily accessible to anyone passing by, including a resident who was seen walking out of the nourishment room located behind the nurse station. The incident was noted to have occurred for an unknown amount of time. During interviews, the charge nurse for the 500 Hall, who worked the 6 pm to 6 am shift, stated she was unaware that the treatment cart was unlocked and confirmed that treatment and medication carts should never be left unlocked. The Assistant Director of Nursing (ADON) also confirmed that the carts should remain locked and secured when not attended. The facility's medication storage policy, dated September 2018, was reviewed and it stated that only authorized personnel should have access to medication carts and that these should remain locked when not in use or attended.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Tyler
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meadow Lake Health Center | 1.1 mi | ★★★★★ | 0 | 0 |
| The Waterton Healthcare & Rehabilitation | 1.6 mi | ★★★★★ | 5 | 0 |
| Reunion Plaza Healthcare & Rehabilitation | 1.8 mi | ★★★★★ | 0 | 0 |
| The Center At Grande | 2.1 mi | ★★★★★ | 1 | 0 |
| Avir At Azalea Heights | 2.2 mi | ★★★★★ | 11 | 1 |
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