Cycle 1
Health 2025-06-18 · Fire 2025-06-18
3 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Tyler, TX
Providence Park Rehabilitation and Skilled Nursing
3-star overall rating with 2-star inspections with $265,674 in total fines with 3 recent health deficiencies
5505 New Copeland Rd, Tyler, TX
(903) 939-2443
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
125
Certified beds
Average residents
97
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Stonegate Senior Living
Operator or chain grouping
Approved since
2008-07-24
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
24 facilities
Chain averages 2 overall / 2 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.48
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.97
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.99
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.45
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.46
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.04
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.29
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.49
CMS adjusted RN staffing hours
Adjusted total hours
3.52
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,889
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.43
Composite VBP score used to determine payment impact.
Payment multiplier
0.9865
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.56
Baseline 26.83% · Performance 21.88% · Measure score 4.56 · Achievement 0 · Improvement 4.56
Healthcare-associated infections
5.60
Baseline 10.46% · Performance 7.13% · Measure score 5.60 · Achievement 2.37 · Improvement 5.60
Total nurse turnover
0.74
Baseline 68.48% · Performance 63.06% · Measure score 0.74 · Achievement 0 · Improvement 0.74
Adjusted total nurse staffing
1.68
Baseline 3.67 hours · Performance 3.56 hours · Measure score 1.68 · Achievement 1.68 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.76% |
10.72%
2 pts worse
|
No Different than the National Rate · Eligible stays 146 · Observed rate 16.44% · Lower 95% interval 9.17% |
| Discharge to community | 57.59% |
50.57%
7 pts better
|
No Different than the National Rate · Eligible stays 127 · Observed rate 51.97% · Lower 95% interval 50.37% |
| Medicare spending per beneficiary | 1.1 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 99.12% |
95.27%
3.9 pts better
|
Numerator 112 · Denominator 113 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 113 |
| Discharge self-care score | 77.5% |
53.69%
23.8 pts better
|
Numerator 31 · Denominator 40 |
| Discharge mobility score | 65% |
50.94%
14.1 pts better
|
Numerator 26 · Denominator 40 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 113 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.13% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 89 · Observed rate 6.74% · Lower 95% interval 3.81% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 222 |
| Staff flu vaccination coverage | 1.65% |
42%
40.4 pts worse
|
Numerator 3 · Denominator 182 |
| Discharge function score | 70% |
56.45%
13.5 pts better
|
Numerator 28 · Denominator 40 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 81 · Denominator 81 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 1.61% |
25.2%
23.6 pts worse
|
Numerator 1 · Denominator 62 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.4 |
2.1
1.3 pts worse
|
1.9
1.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.4 · Observed 3.9 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
2.1
0.6 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.6 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
3.3%
1.6 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 1.4% · Q4 4.1% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.7%
2.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 3.5% |
3.3%
0.2 pts worse
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.4% · Q3 3.9% · Q4 5.0% · 4Q avg 3.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.5% |
18.9%
8.4 pts better
|
19.6%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 10.2% · Q3 11.1% · Q4 10.0% · 4Q avg 10.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 1.0% |
10.8%
9.8 pts better
|
16.7%
15.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.0% · Q3 0.0% · Q4 2.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 5.3% |
15.4%
10.1 pts better
|
16.3%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 9.6% · Q3 0.0% · Q4 10.8% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.3% |
16.1%
11.8 pts better
|
14.9%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 7.0% · Q3 3.8% · Q4 3.4% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 4.1% |
15.0%
10.9 pts better
|
19.8%
15.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 1.5% · Q3 2.8% · Q4 6.0% · 4Q avg 4.1% |
| Percentage of long-stay residents with pressure ulcers | 1.8% |
4.2%
2.4 pts better
|
5.1%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.3% · Q3 3.5% · Q4 1.2% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.5% |
89.7%
2.8 pts better
|
81.7%
10.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.5% · Q2 92.2% · Q3 89.9% · Q4 95.5% · 4Q avg 92.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.4% |
12.0%
3.4 pts worse
|
12.0%
3.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.4% · Observed 17.0% · Expected 12.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.8% · Q3 0.8% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.4% |
88.0%
3.4 pts better
|
79.7%
11.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 39.1% |
25.9%
13.2 pts worse
|
23.9%
15.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 39.1% · Observed 38.0% · Expected 23.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-08 · Fire 2024-05-08
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-04-05 · Fire 2023-04-05
15 health deficiencies
Top issue: Nutrition and Dietary (6 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-04-05
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-06-16
Inspection history
Recent health citations
J · Immediate jeopardy
2025-11-24
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-11-25
E · Potential for more than minimal harm
2025-06-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-19
D · Potential for more than minimal harm
2025-06-18
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-06-19
J · Immediate jeopardy
2024-08-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-08-31
E · Potential for more than minimal harm
2024-05-08
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-05-09
E · Potential for more than minimal harm
2024-05-08
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-05-09
E · Potential for more than minimal harm
2024-05-08
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2024-05-09
D · Potential for more than minimal harm
2024-05-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-05-13
D · Potential for more than minimal harm
2024-05-08
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-05-20
D · Potential for more than minimal harm
2024-05-08
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-05-09
C · Minimal harm
2024-05-08
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-05-09
D · Potential for more than minimal harm
2024-03-29
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-04-05
F · Potential for more than minimal harm
2023-10-24
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-10-24
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-10-24
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-10-24
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2023-11-17
F · Potential for more than minimal harm
2023-08-18
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-08-19
E · Potential for more than minimal harm
2023-06-26
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-07-10
E · Potential for more than minimal harm
2023-06-26
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-11
E · Potential for more than minimal harm
2023-06-26
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2023-07-04
E · Potential for more than minimal harm
2023-06-26
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-06-28
E · Potential for more than minimal harm
2023-04-05
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-04-28
E · Potential for more than minimal harm
2023-04-05
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-04-28
E · Potential for more than minimal harm
2023-04-05
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-04-28
E · Potential for more than minimal harm
2023-04-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-04-05
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-04-05
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-04-28
Penalties and ownership
What sits behind the stars
$220,895
2025-11-24
Fine
Fine · fine $220,895
Fine
$44,779
2024-08-29
Fine
Fine · fine $44,779
Fine
Ownership
South Limestone Hospital District
5% Or Greater Direct Ownership Interest · Organization
Mckeehan, John
Operational/Managerial Control · Individual
Pf Broadmore SNF Ops, LLC
Operational/Managerial Control · Organization
Price, Larry
Corporate Officer · Individual
Stonegate Senior Living, LP
Operational/Managerial Control · Organization
Umb Bank Na
5% Or Greater Mortgage Interest · Organization
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#3
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