Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Tyler's Retreat At Iron Bridge during CMS and state inspections, most recent first.
Facility staff failed to follow bed rail requirements for four residents who were observed with bilateral grab bars in the upright position. Record review did not show assessment for entrapment risk or attempts at alternative devices before the grab bars were used, and an LPN stated staff does not assess residents for entrapment risk or try alternative devices for residents using grab bars.
Facility staff did not provide a required bed hold notice to a resident during a hospital transfer and failed to send timely written notifications to a responsible party for two facility-initiated transfers. Documentation and staff interviews confirmed that these notifications were either missing or significantly delayed, contrary to facility policy and regulatory requirements.
A resident’s nebulizer mask was left uncovered on the nightstand, and another resident’s incentive spirometer was left uncovered on the overbed table. Staff stated both devices should be stored in a plastic bag for infection control, and an LPN said the incentive spirometer required a provider order because it was a treatment. The facility policy also called for sanitary storage of the nebulizer mask and incentive spirometry as ordered by a provider.
A resident with severe cognitive impairment had PRN morphine and acetaminophen ordered for pain, but the orders lacked pain level parameters to guide administration. eMAR review showed both meds were given based on documented pain scores at times, while staff stated they relied on facial expressions, grimacing, and behaviors to assess pain and expected the orders to specify when each analgesic should be used.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
Facility staff failed to implement bed rail requirements for four residents who were observed lying in bed with bilateral grab bars in the upright position. For Resident #6, Resident #100, Resident #101, and Resident #102, the clinical record review, including enabler-restraint observation forms, did not show documentation that staff assessed each resident for risk of entrapment or attempted appropriate alternatives before the grab bars were used. During interview, an LPN stated that facility staff does not assess residents for risk of entrapment or attempt alternative devices for residents who use grab bars. The administrator and the DON were informed of the concern. The facility policy stated that appropriate alternatives should be attempted before installing a side or bed rail and that the potential risks, including entrapment, should be evaluated prior to bed rail installation.
Failure to Provide Timely Bed Hold Notice and Written Transfer Notification
Penalty
Summary
Facility staff failed to implement required hospital transfer procedures for two residents. For one resident, staff did not provide a written bed hold notice when the resident was transferred to the hospital for evaluation of right jaw swelling, despite facility policy requiring that a bed hold notice be given to the resident or their representative at the time of transfer. Review of the clinical record did not show documentation that the notice was provided, and staff interviews confirmed that the process was not followed as required. For another resident, the facility did not provide timely written notification to the responsible party regarding two facility-initiated hospital transfers for abdominal pain. Although certified mail receipts showed that written notifications were eventually sent, they were mailed 17 and 7 days after the respective transfers, rather than within a practicable timeframe. Staff interviews confirmed that the notifications were not sent promptly, and the responsible party was not informed in writing within the expected period following the transfers.
Respiratory Equipment Not Stored Sanitarily and Incentive Spirometer Used Without Order
Penalty
Summary
Facility staff failed to provide respiratory care and services for two residents. For one resident, a physician’s order dated 8/8/25 was in place for ipratropium-albuterol inhalation solution by nebulization every six hours for shortness of breath and wheezing. On 8/11/25, the resident was observed lying in bed with the nebulizer mask uncovered and sitting against the nebulizer machine on top of the nightstand. The resident stated she had used the nebulizer mask and staff had not provided anything to cover it. An LPN stated the mask should be stored in a plastic bag for infection control purposes, and the facility policy also stated the mask should be wiped and stored in a plastic bag. For another resident, staff failed to obtain a physician’s order for the use of an incentive spirometer and failed to store the device in a sanitary manner. The resident was observed lying in bed with an incentive spirometer sitting on the overbed table and the mouthpiece uncovered. The resident stated she used the incentive spirometer and staff had not provided a cover for the mouthpiece. An LPN stated a physician’s order should be obtained because the device was a treatment and that the incentive spirometer should be stored in a plastic bag for infection control purposes. The facility policy stated incentive spirometry is provided as ordered by a provider and listed a plastic bag as equipment for storage.
Failure to Include Pain Level Parameters for PRN Analgesics
Penalty
Summary
Safe, appropriate pain management was not provided for Resident #63. The resident had a significant change MDS assessment with a BIMS score of 2 out of 15, indicating severe impairment in making daily decisions, and the assessment documented that the resident received PRN pain medications and had not had pain in the past five days. The physician orders included morphine concentrate 20 mg/ml, 0.25 ml orally every 4 hours PRN pain/SOB, and acetaminophen 650 mg, two tablets orally every 4 hours PRN pain, with non-pharmacological interventions to be offered before administration. The orders did not include pain level parameters to guide staff in when to administer each medication. The eMAR showed that acetaminophen was administered once in June for pain level 4 and once in July for pain level 5, while morphine was administered eight times in June for pain levels between 5 and 7 and once in July for pain level 6. The eMAR for August did not show administration of either acetaminophen or morphine. The comprehensive care plan identified pain related to ischemic cardiomyopathy, reflux, contracture of both pinky fingers, hiatal hernia, and tooth pain with caries, chipped teeth, and a history of infection. During interview, RN #3 stated that staff assessed pain using facial expressions, grimacing, and behaviors, and that the resident could sometimes verbalize pain but not always. She stated that the morphine and acetaminophen orders should have pain level parameters because staff did not want to overmedicate the resident. The DON stated that when a resident had multiple pain medications ordered, staff should perform a pain assessment and administer the milder medication for mild to moderate pain, and that for cognitively impaired residents staff relied on behaviors and facial expressions; she also stated she would expect the medication orders to include pain level parameters to guide administration.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Chester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Health Care Center Lucy Corr | 2.4 mi | ★★★★★ | 0 | 0 |
| Colonial Heights Rehabilitation And Nursing Center | 7.7 mi | ★★★★★ | 5 | 0 |
| Hiram W Davis Medical Ctr | 9.6 mi | ★★★★★ | 6 | 0 |
| Sitter And Barfoot Veterans Care Center | 9.8 mi | ★★★★★ | 0 | 0 |
| Wonder City Rehabilitation And Nursing Center | 10.6 mi | ★★★★★ | 21 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.