Above average — CMS composite of the measures below.
The next survey window likely opens around April 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 The Waterton Healthcare & Rehabilitation during CMS and state inspections, most recent first.
Unsanitary Shared Bathroom Conditions: Two residents with severe cognitive impairment and total dependence for toileting hygiene shared a bathroom that was observed with water on the floor, wet towels and blankets around the toilet and sink, and flying insects. Repeated observations over several days showed the same towels left on the wet floor and insects still present. Staff gave conflicting accounts about whether CNAs or housekeeping were responsible for removing the towels and cleaning up the water, and the DON and ADM acknowledged the leaking toilet and ongoing bathroom conditions.
Overdue PICC dressing change: A resident with a PICC line, IV meds, and active infection-related diagnoses had a dressing that remained dated with an old change date during repeated observations. Staff, including the charge nurse, ADON, and DON, confirmed the dressing was supposed to be changed every 7 days per MD order and facility policy, and one nurse later confirmed it was changed late.
Incomplete OOH DNR Documentation: Two residents with DNR status had OOH DNR forms in the chart that were signed but not dated by the resident, and the physician signatures were also undated. One resident had severe cognitive impairment with a BIMS of 5 and diagnoses including CVA, DM, and CAD; the other had a BIMS of 7 with diagnoses including myasthenia gravis, DM, CVA, PVD, memory deficit, and HTN. The SW stated the forms were not valid because the required dated signatures were missing.
Missing Hand Soap in Shared Resident Bathrooms: Antibacterial soap was not available in two shared resident bathrooms over multiple observations. Two residents with dementia and other medical conditions reported or were observed using other products or alternate locations for hand hygiene, while staff acknowledged the missing soap, broken dispensers, and communication gaps between housekeeping and maintenance. The facility’s infection control policy required ready availability of hand cleaning supplies at each sink.
A resident admitted for orthopedic aftercare with multiple surgical incisions did not receive care consistent with professional standards or the facility’s skin and wound policy. The care plan addressed pressure injury risk but omitted specific post‑surgical incision care. Nursing documentation showed that surgical wounds were either incompletely assessed or repeatedly marked as "not evaluated" over multiple days, and there were no wound treatments or monitoring documented on the MAR/TAR. An LVN applied betadine daily to the incisions without any documented MD order, while other staff recalled no treatment orders and that the sites were open to air. Attempts by leadership to contact the orthopedic clinic focused on scheduling follow‑up rather than obtaining wound care orders. The resident ultimately developed maceration and dehiscence of a left leg incision, was sent to the hospital for treatment of dehiscence and infection, and returned home with a wound vac.
The facility failed to accurately assess seven residents for the PASRR process, leading to incorrect MDS coding. Despite having mental health conditions, these residents were marked as not having serious mental illness or intellectual disability. The MDS Coordinator misunderstood the relationship between PASRR evaluations and MDS documentation, resulting in these inaccuracies.
A resident with a history of dementia and weight loss did not receive prescribed health shakes and desserts with meals, as observed over several days. The facility's dietary and nursing staff failed to ensure compliance with dietary orders, despite the resident's significant weight loss and nutritional needs. The dietary manager cited a recall of health shakes, but substitutes were also not provided.
Unsanitary Shared Bathroom Conditions
Penalty
Summary
The facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior in the shared bathroom used by two residents. Resident #55 was a female with diagnoses including unspecified dementia, diabetes, morbid obesity, muscle weakness, unspecified lack of coordination, and cognitive communication deficit; her most recent Quarterly MDS showed a BIMS of 5, indicating severe cognitive impairment. Resident #55 was dependent on staff for toileting hygiene and was always incontinent of bowel and bladder. Resident #62 was a female with diagnoses including unspecified dementia, age-related physical debility, other lack of coordination, muscle weakness, unsteadiness on feet, and weakness; her most recent Quarterly MDS also showed a BIMS of 5, indicating severe cognitive impairment. Resident #62 was dependent on staff for toileting hygiene, used a wheelchair for mobility, and was always incontinent of bowel and bladder. An observation of the shared bathroom showed water on the floor, wet towels and blankets surrounding the toilet and underneath the sink, and flying insects. Resident #55 stated she did not use the bathroom and was unaware of any issues. Resident #62 was unable to answer questions appropriately. Later observations showed housekeeping cleaning the bathroom, but the same towels remained on the wet floor and flying insects were still present. These same conditions were again observed later that day and on the following two days, with the towels still on the wet floor and flying insects still present in the bathroom. During interviews, the Life Safety Director stated a water line outside was being fixed and was causing water to come out from underneath the toilet in the shared bathroom. He said housekeeping should have been changing the towels and mopping up excess water and recognized the flying insects but did not know what they were. The Housekeeping Supervisor stated CNAs were responsible for picking up the wet towels before housekeeping could mop the excess water. CNA A and CNA B both stated they were aware of the towels on the floor and believed housekeeping was responsible for changing them regularly. The DON stated she was aware of the leaking toilet and said housekeeping was to clean the room more often, while also stating that if CNAs knew there were wet towels on the floor they should have removed them. The ADM stated the toilet was leaking due to construction of a pipe and was unsure how long this had occurred.
Overdue PICC Dressing Change
Penalty
Summary
The facility failed to ensure the PICC line dressing for Resident #69 was changed according to the physician’s order and facility policy. Resident #69 was an [AGE]-year-old female admitted with diagnoses including intraspinal abscess, streptococcal infection, depression, phlebitis and thrombophlebitis of the left moral vein, a non-pressure chronic ulcer of the back, muscle weakness, infection following a procedure, and cognitive communication deficit. Her MDS indicated a BIMS score of 15, showing she was cognitively intact, and she had IV access and IV medications ordered. The physician ordered PICC line care with dressing changes every 7 days and application of a Bio Patch with each dressing change. Observations showed the PICC line dressing remained intact and dated 4/23/2026 on 5/4/2026 at 9:30 AM and again on 5/5/2026 at 8:30 AM. Staff interviews confirmed the dressing change was overdue and that PICC line dressing changes were normally completed by the charge nurse or ADON. LVN A, LVN B, the ADON, LVN C, and the DON all stated the dressing should be changed every 7 days or sooner if compromised, and LVN C confirmed the dressing was changed late by the ADON on the afternoon of 5/5/2026. The facility’s PICC policy required transparent dressings to be changed every 7 days or sooner if loosened or soiled, and the PICC dressing change procedure required the dressing to be labeled and the procedure charted.
Incomplete OOH DNR Documentation
Penalty
Summary
The facility failed to ensure medical records were complete and accurately documented for two residents reviewed for record accuracy. Resident #3, a male admitted in 2020 with diagnoses including cerebral infarction, diabetes, and coronary heart disease, had a quarterly MDS showing a BIMS score of 5 and an EHR profile flagged with DNR status. His physician order reflected an OOH DNR order, and his care plan stated he had elected DNR status to honor his Advance Directive, but the OOH DNR form with witness signatures was signed by the resident without a date and the physician signature was also undated. Resident #6, a male admitted in 2016 with diagnoses including myasthenia gravis, diabetes, cerebral infarction, chronic venous ulcer, PVD, memory deficit, and hypertension, had an annual MDS showing a BIMS score of 7 and an EHR profile with DNR status. His physician order reflected DNR status and his care plan documented DNR status as initiated and revised, but the OOH DNR form with witness signatures was signed by the resident without a date and the physician signature was also undated. During interview, the SW stated she was responsible for ensuring OOH DNR forms were properly executed with dated signatures of both the person requesting DNR status and the physician, and that the two residents' most recent OOH DNRs were not valid because of the missing dates and should not have been placed into their charts.
Missing Hand Soap in Shared Resident Bathrooms
Penalty
Summary
The facility failed to maintain an infection prevention and control program by not ensuring antibacterial soap was available in the shared bathrooms of two resident rooms. Observations on multiple occasions showed no antibacterial soap in the bathrooms shared by two residents, and the absence of soap was confirmed again during later observations over several days. The facility’s infection control policy stated that the facility would provide areas, equipment, and supplies to implement its Infection Control Program, including ready availability of hand cleaning supplies and paper towels at each sink. Resident #36 was a female with diagnoses including acute kidney failure, COPD, and unspecified dementia. Her most recent Quarterly MDS showed a BIMS of 12 and indicated she was independent with toileting hygiene. During interview, she said she could not recall the last time there was soap in her bathroom and reported using shampoo to wash her hands after using the restroom. Resident #40 was a female with diagnoses including acute on chronic diastolic heart failure, ESRD, and type 2 diabetes. Her most recent Significant Change MDS showed a BIMS of 7, indicating severe cognitive impairment, and she required partial/moderate assistance with toileting hygiene. She reported there had been no soap in the bathroom for at least days and said she used bar soap to wash her hands after using the restroom. Resident #55 and Resident #62 also shared a bathroom without antibacterial soap present. Resident #55 had diagnoses including unspecified dementia, diabetes, morbid obesity, muscle weakness, lack of coordination, and cognitive communication deficit, and her MDS showed a BIMS of 5 with dependence on staff for toileting hygiene and incontinence of bowel and bladder. Resident #62 had diagnoses including unspecified dementia, age-related physical debility, lack of coordination, muscle weakness, unsteadiness on feet, and weakness, and her MDS also showed a BIMS of 5 with dependence on staff for toileting hygiene and incontinence of bowel and bladder. Observations showed housekeeping cleaning both shared bathrooms while no antibacterial soap was present, and later observations continued to show no soap in either bathroom. Interviews with housekeeping, CNA, LVN, DON, and the ADM showed staff awareness that soap was missing and that the issue involved broken dispensers and communication gaps. The Housekeeping Supervisor stated housekeeping was responsible for ensuring antibacterial soap was in resident bathrooms and said the dispensers needed to be replaced by maintenance. A Life Safety Director later repaired the soap dispenser for one bathroom and stated no maintenance request had been entered. A prior grievance also documented a complaint about a lack of hand soap in a bathroom dispenser.
Failure to Obtain Orders and Assess Post‑Surgical Incisions Leading to Dehiscence and Infection
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards, the resident’s care plan, and physician orders for a post‑surgical resident. The resident was admitted with recent orthopedic surgeries, including open reduction internal fixation of the left tibia/fibula and right femur, and had multiple surgical incisions documented by the hospital as approximated, moist, with scant serosanguineous drainage and edematous, ecchymotic surrounding skin. The hospital after‑visit summaries on admission and after an emergency room visit did not list any specific physician orders for surgical site care. On admission, the facility’s MDS documented that the resident had surgical wounds and was dependent on staff for most ADLs, with moderate cognitive impairment but able to make herself understood. The care plan dated several days after admission addressed risk for pressure injury and weekly head‑to‑toe skin assessments but did not address post‑surgical incision care or assessment. Facility documentation showed incomplete and inconsistent assessment of the resident’s surgical sites. An initial progress note shortly after admission described two skin issues: a right lateral thigh surgical wound and left shin incisions, with measurements for the right thigh and one left shin incision but no measurement for the second left shin incision. Subsequent daily skin issue notes on multiple dates documented that both skin issues had “not been evaluated,” including entries by several LVNs and an RN over a span of days. A later note described the right lateral thigh wound as approximated with staples and a healing ridge, and the left shin with two incision areas and multiple sutures, but did not provide further detailed assessment of the left leg incisions. From admission through the date the resident was sent to the hospital, there were no additional documented comprehensive assessments of the post‑surgical incision sites beyond these limited entries. The facility also failed to obtain and document physician orders for wound care to the resident’s post‑surgical incision sites and did not document any treatments on the MAR/TAR. Interviews revealed that one LVN reported applying betadine to each post‑operative surgical site when caring for the resident but could not recall who gave the order and could not find any documentation of provider communication or orders in the EMR or on her phone. A CNA corroborated that this LVN was putting betadine on the surgical sites daily. Other nursing staff, including an RN who worked nights, reported not recalling any treatment orders and stated the sites were open to air. The ADON reported she had not seen the resident until the day the family raised concern that the left outer leg incision appeared to be opening, and her earlier call to the orthopedic surgeon’s office had been only to schedule a follow‑up appointment, not to obtain treatment orders. Documentation of calls to the orthopedic surgeon’s clinic showed attempts to schedule follow‑up and later to report leg swelling, but no documented request for wound care orders. On the day of transfer, a progress note documented maceration of the left outer incision line, and the physician was notified and the resident sent to the hospital, where she was treated for dehiscence and infection of the left lateral incision and later discharged home with a wound vacuum. Throughout this period, the facility’s own skin and wound policy required admission and ongoing weekly assessments of all skin alterations, including surgical incisions, with measurement and description, and daily monitoring via MAR/TAR, which were not carried out for this resident’s post‑surgical wounds.
Inaccurate PASRR Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate assessments were completed for seven residents regarding the Preadmission Screening and Resident Review (PASRR) process. These residents were identified as having mental health conditions such as schizoaffective disorder, bipolar disorder, anxiety, depression, and other psychiatric disorders. Despite their diagnoses, the Minimum Data Set (MDS) assessments for these residents inaccurately indicated that they were not considered by the state Level II PASRR process to have serious mental illness or intellectual disability, which was contrary to their documented conditions. The inaccuracies in the MDS assessments were primarily due to a misunderstanding by the MDS Coordinator, who believed that if residents did not qualify for specialized services under PASRR, they should be marked as negative for mental illness or intellectual disability in Section A1500 of the MDS. This misunderstanding led to the incorrect coding of the residents' mental health status, despite their PASRR Level 1 screenings and evaluations indicating positive results for mental illness. The MDS Coordinator admitted during an interview that she was unaware that Section I Active Diagnoses was related to Section A PASRR screening documentation. This lack of awareness contributed to the incorrect coding, as she was under the impression that residents who did not meet the PASRR definition for specialized services should be marked as negative, even though they had documented mental health conditions. This failure to accurately assess and document the residents' conditions could potentially place them at risk for not receiving appropriate care and services.
Failure to Provide Prescribed Nutritional Supplements
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for a resident, identified as Resident #21, who was at risk for weight loss and malnutrition. The resident, a female with a history of dementia, major depressive disorder, iron and vitamin D deficiencies, muscle weakness, and abnormal weight loss, was prescribed a regular mechanical soft diet with health shakes and two desserts at lunch and dinner. However, the facility did not provide the prescribed health shakes and desserts on multiple occasions, specifically on 03/24/25, 03/25/25, and 03/26/25. Observations and interviews revealed that the dietary staff were responsible for placing health shakes on meal trays, and the nursing staff were supposed to check diet orders and tray cards to ensure compliance. Despite this, Resident #21 did not receive the prescribed health shakes or desserts with her meals. The dietary manager mentioned a recall of health shakes, leading to the substitution with Magic Cups, which were also not provided to the resident. Staff interviews indicated a lack of awareness and communication regarding the resident's dietary needs, contributing to the oversight. The resident's weight had been declining, with significant weight loss documented over several months. The facility's policy on Nutrition Status Management required dietary evaluation and recommendations for additional nutrition in cases of significant weight changes. Despite these guidelines, the facility did not adhere to the prescribed dietary orders, placing the resident at risk for further weight loss and malnutrition.
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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) |
|---|---|---|---|---|
| The Center At Grande | 1.3 mi | ★★★★★ | 1 | 0 |
| Providence Park Rehabilitation And Skilled Nursing | 1.6 mi | ★★★★★ | 1 | 1 |
| Park Place Nursing & Rehabilitation Center | 2.6 mi | ★★★★★ | 11 | 0 |
| Meadow Lake Health Center | 2.6 mi | ★★★★★ | 0 | 0 |
| Avir At Rose Trail | 3.2 mi | ★★★★★ | 23 | 3 |
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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.