Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Greenbrier Nursing & Rehabilitation Center Of Tyle during CMS and state inspections, most recent first.
Incomplete Neurological Checks After Resident Falls: The facility failed to complete ordered neuro checks after falls for three residents. One resident with Alzheimer’s disease had an unwitnessed fall and no neuro checks were started. A second resident with intact cognition sustained a fall with head injury, but the record showed only limited neuro checks documented. A third resident with dementia had an unwitnessed fall, and the LPN initiated neuro checks but did not complete the required follow-up checks or documentation.
Insufficient CNA staffing led to a secured unit being left without staff present at times, with CNAs floating off the unit to cover other areas because only 3 aides were working on some day shifts instead of the facility’s expected staffing level. A grievance also reported staff could not be found over the weekend, and interviews with the CNA, LVN, ADON, DON, Administrator, and Treatment Nurse confirmed that short staffing caused delays in care, missed tasks such as showers and toileting, and difficulty supervising residents.
Expired pneumococcal vaccine and bisacodyl suppositories were found in the East Wing med room refrigerator during observation. Staff gave conflicting accounts of who was responsible for checking med rooms and refrigerators for expired meds, and the Pharmacy Consultant said she visited every other month and would remove expired items if found. The facility policy stated outdated meds are to be immediately removed from stock and disposed of per medication destruction procedures.
Failure to notify family after a resident fall. A resident with dementia, severely impaired cognition, and fall risk status fell, and the fall event note showed the family was not notified. The LVN said she assessed the resident and notified the MD but did not call the family, while the DON and Administrator stated that the MD and family should be notified as soon as the resident was safe and that families should be kept informed of changes.
Quarterly MDS assessment not completed on time for a resident with COPD and moderately impaired cognition. The MDS nurse said the assessment was missed and should have been done every 3 months; the DON and Administrator stated untimely MDSs can affect care plans and staff awareness of resident needs. Facility policy required review of the MDS at least once every 3 months.
Care Plan Conferences Not Held or Properly Notified: A resident with Alzheimer's disease, severe cognitive impairment, and total ADL dependence did not have an interdisciplinary care plan process that included the resident or his RP. Records showed missed quarterly care plan conferences and documentation that the resident did not attend because he did not understand the meeting, while the RP reported she was not invited by phone, letter, or in person. The SW said she was responsible for coordinating meetings and notifying family, but notifications were not documented and letters were not being sent.
Failure to provide timely incontinent care: A resident with severe cognitive impairment and bowel/bladder incontinence was supposed to be checked every 2 hours and assisted with toileting as needed, but was found with urine-soaked clothing while sitting in the lobby. The Treatment Nurse said she checked the resident before lunch but did not return afterward because she was covering multiple areas, and the DON acknowledged the resident had been left wet for an undetermined amount of time.
Medication error rate exceeded the required threshold when an LPN gave a resident an incorrect insulin dose and failed to administer a scheduled dose during a med pass. The resident had dementia and DM, with orders for Novolin R daily and Novolog per sliding scale. During observation, the LPN checked the resident's BG, stated the resident would receive both insulins, but used the Novolog pen to give 29 units instead of giving the ordered Novolin R and separate Novolog doses. The LPN said she did not check the MAR or compare the orders before administering the insulin.
An LVN administered the wrong insulin dose to a resident with dementia, Parkinson's disease, diabetes, and bipolar disorder during a med pass. The resident had orders for Novolin R 25 units daily and Novolog sliding scale coverage, but after a blood sugar of 255, the LVN gave 29 units of Novolog from one pen instead of separating the ordered Novolin R and Novolog doses. The LVN later acknowledged she did not check the MAR first or compare the orders before giving the insulin.
An East Wing medication cart contained an unopened insulin pen for a resident instead of storing it in the refrigerator as required by the label and facility policy. Staff interviews showed inconsistent responsibility for checking carts and medication rooms for expired medications, and the pharmacy consultant and administrator confirmed unopened insulin should be refrigerated and outdated medications removed from stock.
Dietary Aide G prepared food, drinks, desserts, and trays without a valid Food Handler's License. The aide said the license had expired and had not been renewed, and the DM said she hired the aide knowing the license was not current. The DM and Administrator stated they did not believe there was any risk to residents or staff, and a kitchen staffing policy was requested but not provided.
Expired coleslaw was found in a facility refrigerator during a kitchen observation, showing food was not stored under sanitary conditions. Kitchen leadership said all kitchen staff were responsible for checking refrigerators for expired items, but there was no set schedule or assignment for those checks. The DM said the item was not expired, only misdated, and the Administrator said the DM supervised kitchen staff and believed refrigerators were checked each morning.
Hand hygiene was not performed appropriately during incontinent care for a resident with dementia, severe cognitive impairment, and bowel incontinence. A CNA placed gloves on without washing or sanitizing her hands, changed gloves inconsistently while cleaning the resident’s perineal area, and applied a brief without gloves before washing her hands after care was completed. The DON and Administrator stated staff should perform hand hygiene before, during, and after care and between glove changes.
A shower handrail in the East Unit shower room was observed loose and pulled away from the wall. CNAs reported the issue had been present for about a week, with one CNA stating she submitted a maintenance request through the electronic form and another saying she was unaware of the problem. The ADM said she did not know about the loose rail until the prior day and noted the facility had no maintenance director at the time.
Cigarette butts were found in a trash can in the smoking area instead of in the designated locked red butt can. CNA K, the HSK Supervisor, and the Administrator all stated that ashtrays were supposed to be emptied into the red smoking can after each smoke break, and the facility's smoking policy required ashtrays to be emptied into a metal container with a self-closing cover device.
The facility did not honor a resident's right to voice grievances without discrimination or reprisal and failed to establish a grievance policy or make prompt efforts to resolve complaints.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet care needs.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The facility failed to accurately assess seven residents' mental health conditions in their MDS assessments, leading to incorrect PASRR coding. The MDS Coordinator misunderstood the coding requirements, believing that residents not qualifying for specialized services should be coded as not having a mental illness. This misunderstanding, shared by the Regional Reimbursement Consultant, was due to perceived ambiguities in the RAI manual.
A resident with multiple diagnoses was at risk due to improper medication administration via a gastrostomy tube. The LVN failed to check tube placement before administering medications, mixed multiple medications, and attempted to force them through a clogged tube, contrary to facility policy. The DON acknowledged the oversight in ensuring the LVN was aware of the correct procedures.
A resident with multiple health conditions received improperly mixed medications via a gastrostomy tube by an LVN, who was not oriented to the facility's policy on medication administration. The LVN mixed several medications together, contrary to the policy requiring individual administration with water flushes between each medication.
A facility failed to maintain a safe environment for a resident due to persistent water leaks and discoloration marks on the ceiling. Water was observed dripping from the privacy curtain track into a trash can, with water extending onto the floor, creating a safety hazard. Staff interviews revealed the issue had been ongoing for months, with attempts to patch the roof proving ineffective. The Administrator was unaware of the specific leak but acknowledged broader issues affecting multiple rooms.
A resident with multiple health conditions reported verbal abuse by a CNA, who told him to "shut up" during an interaction. The incident was investigated, and the CNA admitted to the behavior, leading to the substantiation of the allegation. The facility's abuse policy emphasizes the protection of residents' rights, and the CNA was terminated following the investigation.
A CNA was caught on camera stealing snacks from a resident's personal refrigerator, leading to a substantiated case of misappropriation of property. The resident, who had severe cognitive impairment and multiple health issues, was unaware of the incident. The CNA admitted to taking the snacks for another resident but was terminated following the facility's investigation.
A facility failed to document a resident's skin condition, including a pressure ulcer, in her care plan. The resident, with multiple diagnoses including Alzheimer's and dementia, had a wound on her left ankle documented on several occasions. However, the care plan lacked any mention of this condition. The DON admitted responsibility for the oversight, acknowledging that both she and the treatment nurse were responsible for updating care plans.
The facility failed to accurately transcribe medication orders for two residents, leading to incorrect dosages and potential risks for medication errors. The errors were discovered during a review, and the facility's policies on medication reconciliation and order entry were not adequately followed.
Incomplete Neurological Checks After Resident Falls
Penalty
Summary
The facility failed to ensure neurological checks were completed after falls for three residents. Resident #11, a female with Alzheimer’s disease and severely impaired cognition with a BIMS score of 00, had an unwitnessed fall on 2/08/2026. Her fall event note indicated the nurse did not initiate or complete any neurological checks after the fall. During interview, the ADON stated she was the charge nurse at the time, assessed the resident after she was found on the floor, and forgot to start neurological checks. Resident #15, a male admitted with sepsis and intact cognition with a BIMS score of 14, sustained a fall in his room on 3/12/2026 that resulted in head injuries. The incident report did not document a neurological check. The electronic record showed neurological checks at 6:20 pm on 3/12/2026, 7:25 pm on 3/13/2026, and 2:27 am on 3/14/2026, with no other neurological checks documented. When observed later, he had multiple scabbed areas to his forehead and above his right eye and a dark purple bruise to his right eye, and he stated he had fallen in his bathroom and hit his head. Resident #43, a female with dementia and severely impaired cognition with a BIMS score of 01, had an unwitnessed fall on 3/23/2026 at 7:50 am. The nurse initiated a neurological assessment at the time of the fall but did not complete another neurological check until 2:45 pm that day. The LVN stated she assessed the resident after the fall, initiated neurological checks, but got behind with other tasks and did not complete the remaining checks or enter the documentation. The DON and Administrator stated that neurological checks were to be initiated and completed according to the facility’s fall protocol and that missed checks could compromise resident safety.
Insufficient CNA Staffing and Unsupervised Secured Unit
Penalty
Summary
The facility failed to provide sufficient nursing staff on a 24-hour basis to meet resident needs and to follow its facility assessment staffing levels. Record review showed that on March 8, 12, 13, 14, 17, 20, and 23, 2026, the day shift was staffed with fewer CNAs than expected, with entries showing 2 to 3 CNAs and 0 to 1 medication aide for census levels of 57 to 60 residents. The facility assessment stated that day shift staffing for CNAs should be 5 and medication aide 1, but the Administrator stated the facility did not follow those staffing numbers and instead calculated staffing based on census. A grievance dated 3/09/2026 stated a family member could not find clinical staff over the weekend, and the facility summary of findings noted a CNA position was unfilled and a CNA from the other side of the facility had to float to provide care. The direct care postings and sign-in sheets showed that although some schedules listed 4 CNAs and a medication aide, the facility actually had only 3 CNAs and 1 medication aide on the day shift on the reviewed dates. The PBJ Staffing Data Report for FY Quarter 1 2026 showed the facility had a 1-star staffing rating. On 3/23/2026, observations on the secured unit showed CNA A away from the unit charting outside the glass doors and later off the unit assisting on the other side, with no staff present on the secured unit for a period of time. During interviews, CNA A said she was assigned to the secured unit and also had residents on the other side because only 3 aides were working, and she said shortages affected supervision and care. The LVN, ADON, DON, Administrator, CNA E, and the Treatment Nurse all described short staffing, staff leaving the secured unit, and delays or missed care such as showers and toileting when the facility was short on nurse aides.
Expired Medications Left in Medication Room Refrigerator
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications for the East Wing medication storage room. During an observation on 3/24/2026 at 11:39 am, the refrigerator in the East Wing medication room contained (2) vials of pneumococcal vaccine that had expired, a box of bisacodyl 10 mg suppositories dispensed on 9/27/2024 with instructions not to use after 9/27/2025, and (1) box of bisacodyl 10 mg that expired in 4/2025. During interviews, LVN B stated the Transport CNA was responsible for checking medication carts and medication rooms for expired medications monthly, and said medications would not be as effective if given past their expiration dates. The Transport CNA stated he was responsible for checking the medication carts and medication rooms but not the refrigerators, and said it had been more than a month or longer since he last checked them because he had been on transport taking residents to appointments. The Pharmacy Consultant stated she visited the facility every other month, checked medication carts and rooms, and would remove anything expired if found. The Administrator stated the Transport Aide had previously been responsible for central supply and was not aware he was checking the medication rooms or carts. The facility policy stated outdated medications are to be immediately removed from stock and disposed of according to medication destruction procedures.
Failure to Notify Family After Resident Fall
Penalty
Summary
The facility failed to immediately inform the resident, consult with the resident's physician, and notify the resident representative when Resident #43 had a fall and a significant change in condition. Resident #43 was a female resident with dementia, a BIMS score of 01 indicating severely impaired cognition, and she required minimal assistance with ADLs. Her care plan identified her as a fall risk, and a grievance note dated 3/19/2026 showed the family had already raised concerns about interventions for recent falls and the results of recent tests. On 3/23/2026, the fall event note documented that Resident #43's family was not notified of the fall. During interview, the family member stated the nurse had not called about the fall that morning and said this had happened before with falls or changes in condition. The LVN assigned as charge nurse stated CNA A told her about the fall at 7:50 am, she assessed the resident, and she notified the doctor but did not call the family. The DON and Administrator stated that the doctor and family should be notified as soon as the resident was safe and that families should always be kept informed of changes.
Quarterly MDS Assessment Not Completed on Time
Penalty
Summary
The facility failed to complete a quarterly MDS assessment for Resident #14 within three months of the previous assessment. Record review showed the resident was a [AGE]-year-old male admitted with a diagnosis of chronic obstructive pulmonary disease, and a quarterly MDS assessment had an Assessment Reference Date of 11/21/25. The quarterly assessment was due on 2/21/26, but it was not entered into the system until 3/20/26 and remained in progress, making it 27 days overdue. During interviews, the MDS nurse said she was unsure how the assessment was missed and stated that assessments should be completed every 3 months and that this resident should have had one in February. She also stated that if assessments are not completed appropriately, they may be inaccurate and care plans may not be updated accordingly. The DON and Administrator both stated that incomplete or untimely MDS assessments could affect care plans and staff awareness of resident care needs. The facility policy stated that each resident would be examined and the MDS reviewed no less than once every three months.
Care Plan Conferences Not Held or Properly Notified
Penalty
Summary
The facility failed to ensure a comprehensive care plan was prepared by an interdisciplinary team that included the resident and the resident representative for Resident #7, a male resident with Alzheimer's disease who had a BIMS score of 00, was dependent on staff for all ADLs, and was always incontinent of bowel and bladder. The resident's face sheet identified his daughter as the resident representative, and the comprehensive MDS indicated that the resident and his representative were active in participating in assessment and goal setting. Record review showed a care plan conference on 1/14/25 in which neither the resident nor his representative attended, with the form indicating both were unable to attend. The record also showed no documentation of a quarterly care plan conference in April 2025 or until 09/09/25, and no documentation of a quarterly care plan conference in December 2025. The 9/9/25 and 1/6/26 care plan conference records indicated the resident did not attend because he did not understand the purpose of the meeting, and his representative did not attend due to prior commitments or was unable to attend. During interviews, the Social Worker said she was responsible for coordinating care plan meetings and notifying family members, but she had not documented notifications and had not sent letters because families were not receiving them. The resident's representative stated she had not been invited by phone, letter, or in person to attend a care plan meeting within the last year.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to ensure a resident who was unable to perform activities of daily living received timely incontinent care. Resident #2 was admitted with diagnoses including dementia, GERD, and anxiety disorder. A significant change MDS assessment indicated severe cognitive impairment with a BIMS score of 0, substantial/maximal assistance needed for toileting hygiene, and bowel incontinence. The care plan identified bladder and bowel incontinence with interventions to check the resident every two hours and assist with toileting as needed. On 3/23/2026, Resident #2 was observed eating lunch, later sitting in a wheelchair in the lobby, and then standing by her wheelchair with staff present when the back of her pants was found soaked with urine. Staff then took her to her room to change her. The Treatment Nurse stated she had checked the resident before lunch but did not return after lunch because she was moving between halls and the secure unit and unit staff needed relief. The DON stated incontinent care should be provided every 2 hours and acknowledged the resident had been left wet for an undetermined amount of time. The Administrator stated care should be provided as needed and frequent checks were usually every 2 hours, and said she was not aware the resident had not been checked and was wet.
Medication error rate exceeded threshold during insulin administration
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5 percent. Surveyors identified 2 medication errors out of 30 opportunities, resulting in a 6.67 percent medication error rate involving one resident reviewed for pharmacy services. The errors occurred during a medication pass when an LVN administered an incorrect dose of Novolog insulin and failed to administer a dose of Novolin R insulin to the resident. Resident #32 had diagnoses of dementia and diabetes mellitus. Record review showed he had insulin orders for Novolin R 25 units subcutaneously daily and Novolog per sliding scale, with 4 units ordered when blood sugar was 250-299. During observation, the LVN checked the resident's blood sugar at 255 and stated the resident would receive 25 units of Novolin R and 4 units of Novolog for a total of 29 units. The LVN then took the Novolog pen, dialed it to 29 units, and administered 29 units of Novolog insulin to the resident. During interview, the LVN stated she used one pen when administering the insulin and said the 4 units of Novolog should have been given from the Novolog pen instead of all being given from the Novolin R pen. She stated she should have checked the MAR and compared the orders before administering the medication and was not sure why she gave 29 units of Novolog. The medication cart contained separate pens for Novolog, Novolin R, and Lantus for the resident. The DON and Administrator stated staff should verify the correct medication and dosage before administration, and the facility policy required medication discrepancies and adverse medication reactions to be documented and reported.
Wrong insulin dose administered during medication pass
Penalty
Summary
The facility failed to ensure a resident was free from a significant medication error when an LVN administered the wrong insulin dose during a medication pass. The resident had diagnoses including dementia, Parkinson's disease, diabetes mellitus, and bipolar disorder. Active physician orders showed Novolin R 25 units subcutaneously once daily and Novolog by sliding scale, with 4 units ordered for a blood sugar of 250-299. During observation, the LVN checked the resident's blood sugar and obtained a result of 255. After obtaining the blood sugar result, the LVN stated the resident would receive 25 units of Novolin R and 4 units of Novolog for a total of 29 units. The LVN removed the Novolog flex pen from the medication cart, dialed it to 29 units, and administered 29 units of Novolog insulin to the resident. When questioned, the LVN said she used one pen for both insulins and later acknowledged that the 4 units of Novolog should have come from the Novolog pen instead of all being given from the Novolin pen. She also stated she should have checked the MAR first and compared the orders before administering the medication. Record review showed the resident had insulin orders for both Novolin R and Novolog, and the medication cart contained separate pens for Novolog, Novolin R, and Lantus. The DON stated staff should verify the correct medicine, dosage, right resident, and the order before administering medication, and acknowledged the incident involved the resident receiving the wrong dose of insulin. The pharmacy consultant stated the resident's insulin regimen included two short-acting insulins with similar onset and peak actions, and the administrator stated staff should verify the correct medicine and dosage before giving any medication.
Improper Storage of Unopened Insulin in Medication Cart
Penalty
Summary
The facility failed to store drugs and biologicals in accordance with accepted professional principles for 1 of 2 medication storage rooms and 1 of 4 medication carts reviewed. During an observation of the East Wing nurse medication cart, an unopened insulin degludec pen for Resident #18 was found in the cart rather than in the refrigerator. The box indicated it should be kept in a cold place until first use and stored at 36 to 46 degrees. The resident’s insulin order was to inject 20 units daily, and the prescription had been filled at a local pharmacy on 12/16/2025. During interviews, staff stated unopened insulin should be refrigerated and that medications could lose efficacy if stored at the wrong temperature or used past expiration. The LVN said the Transport CNA was responsible for checking medication carts and medication rooms for expired medications monthly, but also said she only checked the cart about once a week. The Transport CNA said he was responsible for checking the carts and medication rooms but not the refrigerators, and said it had been more than a month since he last checked them because he had been on transports. The Pharmacy Consultant and Administrator both stated unopened insulin should be stored in the refrigerator, and the facility policy required medications needing refrigeration to be kept between 36 and 46 degrees and outdated medications to be removed from stock.
Dietary Aide Worked Without a Valid Food Handler License
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out food and nutrition services because Dietary Aide G was preparing food without a valid Food Handler's License. During interview, Dietary Aide G said she had worked at the facility since August 2025 and was responsible for preparing drinks and desserts, refilling the coffee/drink bar in the lobby, and preparing trays. She stated that she did not have a valid food handler's license and could not recall when it expired. The DM stated she hired Dietary Aide G knowing the aide did not have a valid food handler's license and did not get the license renewed. The DM and Administrator both stated they did not feel there was any risk to residents or staff from the aide working in the kitchen without a valid license. Review of food handler's licenses showed Dietary Aide G completed a Food Handler Certificate Program on 3/25/26. A kitchen staffing policy was requested but not provided.
Expired Coleslaw Left in Refrigerator
Penalty
Summary
Food was not stored, prepared, distributed, and served under sanitary conditions in 1 of 1 facility kitchens when surveyors observed a bag of coleslaw in a facility refrigerator with a use-by date of 3/20/26 during an observation on 3/23/26 at 9:50 a.m. The coleslaw remained in the refrigerator past the listed date at the time of the survey observation. During interviews, kitchen leadership and administration stated that all kitchen staff were responsible for checking refrigerators for expired food and removing items that were no longer usable. [NAME] H said there was no set schedule or assignment for who should check for expired food items and when. The DM stated the food was improperly dated when stored and did not believe it was expired, while the Administrator said the DM was responsible for supervising kitchen staff and believed refrigerators were checked every morning for expired items. Review of the facility policy titled Food Storage and Supplies stated that perishable refrigerated items are dated once opened and used within 7 days if they do not have an expiration date.
Hand Hygiene Not Performed During Incontinent Care
Penalty
Summary
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 1 of 4 staff reviewed for infection control. The deficiency involved CNA C during incontinent care provided to Resident #2, who had diagnoses of dementia, GERD, and anxiety disorder, severe cognitive impairment with a BIMS score of 0, substantial to maximal assistance needs for toileting hygiene, and bowel incontinence. During an observation, CNA C took Resident #2 to the bathroom for incontinent care and placed gloves on without washing or sanitizing her hands. After the resident urinated, CNA C cleaned the resident’s perineal area, changed gloves in an inconsistent manner, and at one point removed her gloves and applied a glove only to her left hand before wiping the resident again. CNA C then removed her gloves, placed a brief on the resident without wearing gloves, and washed her hands only after the care was completed. In interview, CNA C stated she should have washed her hands before care started and between glove changes, and said she had forgotten to do so. The DON stated hand hygiene should be performed before, during, and after care and between glove changes, and the Administrator stated staff should perform hand hygiene before and after care.
Loose Shower Handrail in East Unit
Penalty
Summary
A shower room handrail in the East Unit was not firmly affixed to the wall and was observed pulled away from the wall during surveyor observation. The issue was identified in 1 of 2 shower rooms reviewed for handrails. An anonymous interview reported concern that a resident attempted to hold the rail and it pulled away from the wall. During interviews, CNA C stated she was unaware of the loose shower handrail and explained that staff normally submitted repair requests through a QR code system, but the facility had no maintenance man on staff for about 1 week. CNA F stated she knew the shower rail was broken, had reported it through the electronic maintenance form, and said no repairs were made because there was no maintenance man. The ADM stated she was unaware of the loose shower rail until the previous day, repaired it herself because the facility had no maintenance director, and said she had no access to the electronic reporting system.
Cigarette Butts Placed in Trash Can in Smoking Area
Penalty
Summary
The facility failed to follow its smoking policy for 1 of 1 smoking areas when cigarette butts were found in a trash can designated for trash. During an observation and interview on 3/24/2026 at 9:01 am, the smoking area had a trash can with a plastic liner containing cigarette butts and trash, while a separate red smoking can with a lock was present and identified for cigarette butts. Five residents were outside smoking with CNA K, who stated that when residents finished smoking she would empty the ash trays into the red smoking can and that staff were supposed to empty the ash trays after each break. CNA K said cigarette butts should not be in the trash and noted there was a risk of residents going into the trash and getting them or a risk of fire. During interviews on 3/25/2026, the HSK Supervisor said Maintenance was normally responsible for emptying the ashtrays into the red smoking cans, but the Maintenance Supervisor had been terminated the prior week. She said she had started checking the red cans that week and had a key to it, and that cigarette butts should never be placed in the trash because of fire risk. The Administrator stated there was a resident who liked to empty the ashtrays into the trash and said the person supervising smokers during breaks should empty them into the red smoking can. Record review of the facility's Smoking Policy stated that ashtrays of noncombustible materials and safe design would be provided in all areas where smoking is permitted and that ashtrays would be a metal container with a self-closing cover device into which ashtrays may be emptied.
Failure to Honor Resident Grievance Rights
Penalty
Summary
The facility failed to honor the resident's right to voice grievances without discrimination or reprisal. Additionally, the facility did not establish a grievance policy or make prompt efforts to resolve grievances as required. This deficiency was identified based on observations and findings that the facility did not have appropriate procedures in place to address and resolve resident complaints in a timely and non-retaliatory manner.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to residents who were unable to perform activities of daily living (ADLs) independently. The report notes that residents requiring help with ADLs did not receive the necessary support from staff, resulting in unmet care needs for those individuals. No additional details about the specific residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Inaccurate PASRR Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate assessments for seven residents regarding the Preadmission Screening and Resident Review (PASRR) process. These residents were identified as having mental illnesses but were not accurately coded in their Minimum Data Set (MDS) assessments. The MDS assessments incorrectly indicated that these residents were not considered by the state Level II PASRR process to have serious mental illness, intellectual disability, or a related condition, despite their diagnoses of various psychiatric and mood disorders. The MDS Coordinator, during an interview, revealed a misunderstanding of the PASRR coding requirements. She believed that if residents did not qualify for specialized services under PASRR, they should be coded as not having a mental illness in Section A1500 of the MDS. This misunderstanding led to the inaccurate coding of residents' mental health statuses, as the coordinator did not realize that Section I Active Diagnoses should align with Section A PASRR screening documentation. The Regional Reimbursement Consultant also expressed confusion regarding the PASRR process, indicating that the local authority's determination was misunderstood as an indication that residents no longer had a mental illness. This confusion was attributed to the lack of clarity in the Resident Assessment Instrument (RAI) manual, which was used to guide the completion of MDS assessments. As a result, the facility's failure to accurately assess and code the residents' mental health conditions could potentially impact the care and services provided to them.
Improper Management of Enteral Feeding Tube
Penalty
Summary
The facility failed to ensure proper management of enteral feeding for a resident, leading to a deficiency in care. The resident, who was admitted with multiple diagnoses including gastro-esophageal reflux, major depression, hemiplegia, hemiparesis following cerebrovascular disease, hypertension, and dementia, was at risk due to improper medication administration via a gastrostomy tube. The facility did not follow its policy for administering medications through the tube, as observed during a medication administration session. The Licensed Vocational Nurse (LVN) did not check the placement of the gastrostomy tube by auscultation before administering medications, which is a critical step to prevent complications. During the medication administration, the LVN attempted to push medications through a clogged tube without checking for proper placement or following the facility's policy of administering one medication at a time with appropriate water flushes. The LVN mixed multiple medications and attempted to force them through the tube, which was against the facility's policy. The Director of Nursing (DON) acknowledged the oversight in ensuring the LVN was aware of the correct procedures, assuming the LVN's training covered these aspects. This oversight placed the resident at risk for not receiving the correct medication dosage and potential damage to the gastrostomy tube.
Improper Medication Administration via Gastrostomy Tube
Penalty
Summary
The facility failed to ensure proper pharmaceutical services for a resident who required medication administration via a gastrostomy tube. The resident, who had a history of gastro-esophageal reflux, major depression, hemiplegia, hemiparesis following cerebrovascular disease, hypertension, and dementia, was administered multiple medications mixed together by LVN A. This occurred during a medication administration observation, where LVN A used a 60 cc syringe to mix and administer Celecoxib, gabapentin, Tylenol with codeine, doxycycline Hyclate, baclofen, and buspirone HCL with a small amount of water. LVN A, during an interview, stated a belief that mixing all medications for gastric tube administration was permissible. The Director of Nursing (DON) acknowledged that LVN A was oriented as a Treatment Nurse and not as a floor nurse, and admitted it was an oversight that LVN A was not informed of the facility's policy on gastric tube medication administration. The facility's policy requires medications to be administered one at a time with specific water flushes between each medication, which was not followed in this instance.
Facility Fails to Address Persistent Ceiling Leak
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for a resident, as evidenced by water leaks and discoloration marks on the ceiling in the resident's room. Observations revealed water dripping from the privacy curtain track into a trash can, with water extending onto the floor, creating a potential safety hazard. The brownish discoloration on the ceiling indicated a persistent issue that had not been adequately addressed. Interviews with staff revealed that the ceiling leak had been ongoing for several months. A CNA reported the issue to the Maintenance Supervisor, who was aware of the problem and had informed the Administrator and Area Maintenance Supervisor. Despite attempts to patch the roof, the leaks persisted. The Administrator was unaware of the specific leak in the resident's room but acknowledged the broader issue of water leaks affecting multiple rooms, which rendered some rooms unusable. The presence of water on the floor was recognized as a safety hazard, necessitating the relocation of the resident to another room.
Verbal Abuse Incident by CNA
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse by staff. On November 25, 2023, a Certified Nursing Assistant (CNA) identified as CNA B told a resident to "shut up" during an interaction in the resident's room. The resident, who has a history of quadriplegia, anxiety disorder, post-laminectomy syndrome, respiratory failure, hypertension, mild intellectual disability, and autism, reported the incident to the facility's social worker (SW) on November 27, 2023. The resident described the staff member as using feminine pronouns and stated that the incident occurred in the presence of his roommate. The resident did not report any physical harm and mentioned that the incident happened only once. The facility's investigation revealed that CNA B was the only female employee working on the day of the incident who was not present the following day. When interviewed, CNA B admitted to telling the resident to "shut up" but denied getting in the resident's face. The facility substantiated the allegation based on CNA B's admission. The resident's psychosocial well-being was assessed, and it was noted that he did not show signs of increased anxiety or sadness following the incident. The facility's abuse policy, revised on September 9, 2024, emphasizes the residents' right to be free from abuse by anyone, including facility staff. The policy mandates the recognition, reporting, and prompt investigation of any actual or alleged abuse. The facility's administrator, who serves as the abuse coordinator, confirmed that CNA B was terminated due to the incident. The administrator also stated that criminal history checks are conducted upon hire, and staff are regularly in-serviced on abuse policies.
Misappropriation of Resident Property by CNA
Penalty
Summary
The facility failed to protect a resident from the misappropriation of property, specifically when a Certified Nursing Assistant (CNA) was caught on camera stealing snacks from the resident's personal refrigerator. The incident involved a resident with severe cognitive impairment, as indicated by a BIMS score of 2, and multiple diagnoses including senile degeneration of the brain, hypertension, anxiety disorder, vascular dementia, and protein calorie malnutrition. The resident required limited assistance with daily activities and was frequently incontinent of bladder and occasionally incontinent of bowel. The incident was reported by the resident's responsible party, who observed the CNA taking snacks from the resident's refrigerator through a camera. The responsible party witnessed the CNA enter the resident's room, assist the resident to the bathroom, and then proceed to take items from the refrigerator. The facility's camera footage corroborated the responsible party's account, showing the CNA entering and exiting the resident's room multiple times and placing drinks on the floor next to an overbed table. The CNA admitted to taking the snacks but claimed it was for another resident who was hungry. However, the facility's investigation substantiated the theft, and the CNA was terminated. The resident was asleep during the incident and did not recall it occurring. A social service interview indicated no decline or distress in the resident's psychosocial well-being following the event, and the resident expressed no concerns with the staff.
Failure to Document Skin Condition in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and time frames to meet the resident's mental and psychosocial needs. This deficiency was identified for one of nine residents reviewed for care plans. Specifically, the facility did not document the resident's skin condition, including a pressure ulcer/injury, on her comprehensive care plan. The resident, an elderly female, was admitted with multiple diagnoses, including Alzheimer's disease, hypertension, anxiety disorder, protein calorie malnutrition, dementia with behavioral disturbance, and cognitive communication deficit. The resident's discharge MDS indicated the presence of an unhealed pressure ulcer/injury that was not present upon admission. The facility's records showed that the resident had a wound on her left ankle, as documented in wound evaluation and management summaries on several dates. However, the revised care plan did not include any documentation about the resident's skin condition or pressure ulcer/injury. During an interview, the DON acknowledged that both she and the treatment nurse were responsible for adding treatments and skin conditions to care plans. The DON admitted she was unaware of the omission and accepted responsibility for the oversight. The facility's comprehensive care planning policy mandates the development and implementation of a care plan that includes measurable objectives and timeframes to address the resident's needs identified in the comprehensive assessment.
Medication Transcription Errors
Penalty
Summary
The facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for two residents reviewed for pharmacy services. For Resident #1, the facility inaccurately transcribed a morphine order, resulting in the resident receiving an incorrect dosage of the medication. The hospice nurse discovered the error when the resident was actively dying, and the order was corrected after the Director of Nursing (DON) was notified. The incorrect dosage did not cause the resident's death, as confirmed by multiple medical professionals, but the error highlighted a significant lapse in medication administration procedures. For Resident #2, the facility failed to accurately transcribe medication orders for lorazepam, tramadol, and oxycodone. The orders were entered separately for sublingual and oral administration, which could have led to the resident receiving too much medication if administered by different nurses before the ordered frequency time had elapsed. Although the resident did not receive any of the as-needed medications during the review period, the incorrect order entry posed a significant risk for medication errors. The deficiencies were primarily due to errors in transcribing medication orders by LVN C, who entered the orders incorrectly into the Electronic Medical Record (EMR) system. The DON and ADON acknowledged the errors and indicated that there was no current plan in place to address order entry and reconciliation when the ADON was working as a staff nurse. The facility's policies on medication reconciliation and order entry were not adequately followed, leading to these significant lapses in medication administration for both residents.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 162 citations issued within 25 miles in the last 12 months — including the 11 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Tyler
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Briarcliff Health Center | 3 mi | ★★★★★ | 0 | 0 |
| Avir At Azalea Heights | 3.1 mi | ★★★★★ | 11 | 1 |
| Avir At Petal Hill | 3.3 mi | ★★★★★ | 8 | 2 |
| Avir At Rose Trail | 3.3 mi | ★★★★★ | 23 | 3 |
| Park Place Nursing & Rehabilitation Center | 4.3 mi | ★★★★★ | 11 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.