Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 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.
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.
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.
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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) |
|---|---|---|---|---|
| Briarcliff Health Center | 3 mi | — | 0 | 0 |
| Avir At Azalea Heights | 3.1 mi | — | 11 | 1 |
| Avir At Petal Hill | 3.3 mi | — | 7 | 1 |
| Avir At Rose Trail | 3.3 mi | — | 21 | 2 |
| 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 August 2026) and official state health department websites.