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 August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Watkins-logan-garrison Texas State Veteran's Home during CMS and state inspections, most recent first.
Failure to care plan aggressive behavior: A resident with Alzheimer’s disease, severe cognitive impairment, and recurrent behavioral symptoms had documented assaults on other residents and hospital transfers, but his comprehensive care plan did not include the potential for physical aggression until after the incidents. The record also showed psych med changes, including an increased Depakote dose and new Sertraline, while the DON, SW, MDS Coordinator, and Regional Director of Clinical Operations acknowledged the behavior should have been reflected in the care plan.
A resident with Alzheimer’s disease and severe cognitive impairment was placed on 1:1 supervision after an altercation with another resident, but the assigned CNA stepped away briefly while the resident was outdoors and another resident was struck again. Interviews showed the CNA understood 1:1 as staying within line of sight, while the DON stated staff were expected to keep the resident in view and intervene when needed; the RDCO stated there was no facility policy on 1:1 supervision.
The facility failed to ensure that residents were orally informed of their rights during their stay. Seven residents reported that their rights had not been reviewed or explained to them, and the facility's policy requiring oral communication of resident rights was not followed.
The facility failed to ensure timely mail delivery to residents on Saturdays, resulting in mail being held until Monday. This affected 11 residents, who reported that their mail was not distributed over the weekend. The weekend receptionist locked the mail in the administration building, and it was not provided to the resident responsible for mail delivery until Monday.
The facility failed to provide adequate supervision and assistance devices, resulting in significant injuries to two residents. One resident suffered a second-degree burn from spilling hot coffee, while another sustained a wedge compression fracture during transport in the facility van. The incidents revealed lapses in safety protocols, including the lack of proper equipment and staff training.
A facility failed to maintain accurate medical records when an RN Supervisor altered an incident report regarding a resident's fall during transportation. The original report by an LVN indicated improper strapping by transportation staff, but the RN Supervisor changed the details without proper documentation, leading to discrepancies and delayed communication about the incident.
Failure to Care Plan Aggressive Behavior
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with severe cognitive impairment and recurrent behavioral symptoms. The resident was an older male with diagnoses including Alzheimer’s disease with late onset, chronic atrial fibrillation, type 2 diabetes mellitus without complications, heart failure, and major depressive disorder, recurrent. His quarterly MDS showed a BIMS score of 4 and documented physical behavioral symptoms directed toward others, verbal behavioral symptoms directed toward others, and other behavioral symptoms not directed toward others every 1 to 3 days. The resident had multiple aggressive incidents documented in the record. On 05/23/2026, he told another resident to get the [f-word] away from me and hit that resident in the left jaw, after which he was transferred to the hospital and later returned to the facility. A psychiatric subsequent assessment showed an increase in Depakote Sprinkle to 250 mg twice daily and a new prescription for Sertraline 150 mg daily, along with Memantine 10 mg twice daily and Melatonin 5 mg at bedtime. On 06/01/2026, he was observed hitting another resident in the face with his hands and was again transferred to the hospital. The resident’s comprehensive care plan, most recently revised on 06/10/2026, did not include care planning for the potential to be physically aggressive until that date. The care plan then identified the potential for physical aggression related to Alzheimer’s and listed interventions such as one-to-one close observation for agitation, administering medications as ordered and monitoring for side effects and effectiveness, and psychiatric/psychogeriatric consult as needed. Interviews with the DON, SW, MDS Coordinator, and Regional Director of Clinical Operations indicated the care plan should reflect the resident’s behaviors and that the aggressive behavior should have been placed in the care plan earlier, but it had not been updated after the incidents.
Failure to Maintain Continuous 1:1 Supervision
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for two residents involved in repeated resident-to-resident altercations. Resident #1 had diagnoses including Alzheimer’s disease, chronic atrial fibrillation, type 2 diabetes mellitus, heart failure, and major depressive disorder, and his MDS showed severely impaired cognition with physical and verbal behavioral symptoms directed toward others every 1 to 3 days. Resident #2 also had Alzheimer’s disease and unspecified dementia with severe cognitive impairment. After an altercation in which Resident #1 told Resident #2 to get the [f-word] away from me and hit him in the left jaw, Resident #1 was placed on one-to-one observation for safety and behavior monitoring. Despite the one-to-one supervision, Resident #1 later struck Resident #2 again. On the day of the second incident, CNA A was assigned to supervise Resident #1, who had gone outdoors while CNA A remained indoors watching through a window. CNA A stated Resident #1 had been agitated and that she stepped away for a couple of minutes to assist another resident who had entered the wrong room. During that time, CNA C observed Resident #1 hit Resident #2 in the face with his hands. Staff separated the residents, and Resident #2 was assessed and found without distress, skin issues, pain, bruising, or redness. Interviews showed differing understandings of one-to-one supervision, but CNA A stated she had been trained that it meant staying within the resident’s line of sight. The DON stated staff were expected to keep the resident within line of sight and that the moment Resident #2 went outside with Resident #1, CNA A should have gone out as well. The Regional Director of Clinical Operations stated there was no facility policy regarding one-to-one supervision and was unsure whether staff had been trained on expectations. A signed in-service document stated staff assigned to 1:1 supervision were expected to remain at the resident’s bedside or within direct line of sight at all times and provide continuous monitoring, and an Employee Counseling Form stated staff assigned to one-on-one supervision were expected to remain with the resident at all times and provide continuous monitoring for the safety of the resident and others.
Failure to Orally Inform Residents of Their Rights
Penalty
Summary
The facility failed to ensure that residents were informed orally of their rights during their stay. Specifically, seven residents reported that their rights had not been reviewed or explained to them by either the Activity Director or the Administrator. The residents indicated that they had not received ongoing communication about their rights since their admission. This was corroborated by the Activity Director, who admitted that he had not reviewed resident rights during resident council meetings, and by the Administrator, who stated that resident rights were only provided in the admission packet and not reviewed regularly thereafter. A review of the resident council meeting minutes over the past five months confirmed that resident rights had not been discussed. The facility's policy, which requires that resident rights be communicated both orally and in writing, was not followed. This lack of communication could potentially impact the residents' quality of life and awareness of their rights. The deficiency was identified through interviews and record reviews conducted by the surveyors.
Failure to Ensure Timely Mail Delivery to Residents
Penalty
Summary
The facility failed to ensure that residents received their mail in a timely manner, specifically on Saturdays. This deficiency affected 11 residents, who reported that their mail delivered on Saturdays was not distributed until the following Monday. The weekend receptionist would lock the Saturday mail in the administration building, and it would not be provided to the resident responsible for mail delivery until Monday. This practice was confirmed through interviews with the residents, the on-duty receptionist, the weekend receptionist, and the facility administrator. The on-duty receptionist handled mail from Monday to Friday, sorting it and setting it aside for the Activity Director to pick up and deliver to the residents. The weekend receptionist followed a similar process but did not distribute the mail to residents unless they specifically came to check for it. The facility's policy on resident rights indicated that residents have the right to send and receive unopened mail, but this policy was not adhered to on weekends, leading to the deficiency noted in the report.
Inadequate Supervision and Assistance Devices Lead to Resident Injuries
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for two residents. One resident, who had a history of muscle weakness, tremors, PTSD, Type 2 diabetes with chronic kidney disease, polyneuropathy, and major depression, suffered a second-degree burn on his right thigh after spilling hot coffee on himself. The resident's care plan included interventions such as allowing time for hot liquids to cool, providing a spill-proof coffee cup, and using an apron while consuming hot liquids. However, on the day of the incident, the resident's coffee cup did not have a lid, and staff did not observe the spill on his clothes due to the dark-colored pants he was wearing. The resident did not report the spill until several hours later, resulting in a significant burn that required further medical treatment. Staff interviews revealed that the facility did not have plastic lids for coffee cups before the incident, and residents were allowed to pour their own coffee from a self-dispensing canister. Another resident, who was cognitively intact and had diagnoses including hypertension, Type 2 diabetes, low back pain, and back spasms, suffered a wedge compression fracture of the mid-thoracic spine while being transported in the facility van. The incident occurred when the resident's wheelchair tilted backward and flipped over as the van crossed a railroad track. The van driver and a helper assisted the resident off the floor and offered to take him to the emergency room, but the resident declined and insisted on proceeding to his eye appointment. The resident later complained of pain, and x-rays confirmed the fracture. The facility's investigation revealed that the van's straps used to secure wheelchairs were not functioning correctly, and the driver had not been trained on what to do in case of a wheelchair flipping over during transport. The facility's failure to provide adequate supervision and properly functioning assistance devices resulted in significant injuries to both residents. The incidents highlight lapses in the facility's safety protocols, including the lack of proper equipment and training for staff. The facility's policies on hot liquid safety and transportation were not adequately followed, leading to preventable accidents and injuries.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for a resident, leading to a deficiency. Specifically, an RN Supervisor altered the contents of an incident report related to a resident's fall during transportation. The original incident report, completed by an LVN, indicated that the resident fell while boarding the van due to improper strapping by the transportation staff. However, the RN Supervisor later changed the details of the incident report to reflect a different account of the event, based on what the transportation driver had told her. This alteration was made without proper documentation of the changes, leading to discrepancies between the progress notes and the incident report. The resident involved was an elderly male with multiple diagnoses, including hypertension, Type 2 diabetes, low back pain, and back spasms. On the day of the incident, the resident was being transported to an eye appointment when he fell in the van. The LVN documented the incident and assessed the resident for injuries, noting no discoloration at the time. However, the RN Supervisor later edited the incident report to change the description of the event, which led to confusion and delayed communication about the resident's condition and the incident's details. Interviews with the RN Supervisor revealed that she was trained to make such corrections by a former staff member and believed it was standard practice. The facility's Administrator and Regional Clinical Consultant were unaware of these practices and stated that no staff should be making changes to records without proper documentation. The facility's policy on medical records emphasizes the importance of accurate and timely documentation, which was not followed in this case, leading to the deficiency.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 244 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
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) |
|---|---|---|---|---|
| Park Place Nursing & Rehabilitation Center | 7.7 mi | ★★★★★ | 11 | 0 |
| Avir At Petal Hill | 7.9 mi | ★★★★★ | 8 | 2 |
| Avir At Rose Trail | 7.9 mi | ★★★★★ | 24 | 2 |
| Greenbrier Nursing & Rehabilitation Center Of Tyle | 9.5 mi | ★★★★★ | 19 | 0 |
| The Waterton Healthcare & Rehabilitation | 9.9 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Watkins-logan-garrison Texas State Veteran's Home.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.