Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 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 The Heights Of Tyler during CMS and state inspections, most recent first.
A resident with dementia, anxiety, and significant ADL dependence alleged a consensual sexual relationship with a CNA and demonstrated fixation on him, while also showing periods of confusion and inconsistent accounts of the event. The incident was documented on a PIR, and internal assessment noted no physical or emotional injury but increased confusion. Multiple staff, including LVNs, MDS nurses, the DON, ADON, and the administrator, were aware of the allegation and the resident’s focus on the CNA, yet the comprehensive care plan was not updated to include the allegation, related behaviors, or the change in staff assignments. The only related intervention, a preference for female staff, was added much later and did not reflect the resident’s known preference for the CNA, resulting in a failure to develop and implement a complete, person-centered care plan with measurable objectives and timetables as required by facility policy.
A facility failed to provide clear pharmaceutical services for a resident's Vitamin D3 administration. The physician's order lacked clarity on the strength and quantity of capsules needed for the prescribed dose, leading to confusion among medication aides. An aide administered an incorrect dose and did not report the unclear order to the nurse, contrary to facility policy.
A resident with significant wounds and an indwelling catheter did not receive care in accordance with the facility's infection control policies. RN A and CNA B failed to wear gowns during high-contact care activities, and initially, there was no signage indicating the need for Enhanced Barrier Precautions (EBP). This oversight was confirmed by staff interviews, highlighting a lapse in maintaining a safe and sanitary environment.
The facility failed to provide residents with reasonable access to a telephone and a private area for making calls, affecting several residents. Interviews revealed that residents had to use phones at the nurse's station or reception desk, where conversations could be overheard. Staff confirmed the absence of a cordless phone, and the facility lacked a policy on resident phone use, contributing to the deficiency.
Two residents in a LTC facility experienced inaccurate documentation of medication administration, with MAs failing to record correct vital signs before administering medications. One resident received metoprolol Tartrate despite a low heart rate, while another received entresto with a heart rate below prescribed parameters. Staff interviews highlighted the importance of accurate documentation for treatment decisions.
A resident with multiple health conditions was administered metoprolol despite having a pulse rate below the physician-ordered parameters on several occasions. Medication aides, including one working PRN, acknowledged potential documentation errors. The facility lacked a system to identify when medications were administered outside ordered parameters, although it could track when medications were held. The Administrator planned to consult with corporate to improve monitoring in the EMR system.
A resident with dementia and other medical conditions was verbally abused by a van driver during transportation to a medical appointment. The driver used inappropriate language after a mix-up with the appointment location, causing distress to the resident. The facility's policy defines such language as verbal abuse, and the driver was suspended and retrained following an investigation.
The facility failed to maintain proper infection control practices, leaving a wound vacuum canister with biohazardous material unattended in a shared room and allowing a brown substance to remain on a bathroom handrail for two weeks. These lapses in cleanliness and biohazard disposal were observed despite staff expectations to maintain sanitary conditions, posing potential infection risks to residents.
Failure to Care Plan Resident’s Allegation of Consensual Relationship With Staff
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timetables addressing a resident’s allegation of a consensual sexual relationship with a staff member and her related preferences. The resident was an older female with diagnoses including generalized anxiety disorder, chronic atrial fibrillation, osteoarthritis, and dementia without behaviors. A quarterly MDS showed she had adequate hearing, clear speech, intact cognition with a BIMS score of 15, and dependence on staff for transfers and bed mobility. Her care plan, dated 6/20/25, addressed self-care deficits related to osteoarthritis and indicated a two-person assist for bed mobility and turning, and that she took antianxiety medication. An intervention stating "I prefer female staff only" was present in the ADL care plan but was not initiated until 3/24/26. A Provider Incident Report dated 3/7/26 documented that the resident alleged she had consensual relations with a caregiver. The resident was offered transfer to a hospital for evaluation but refused. An internal assessment by a licensed nurse found no trauma, no injury, and no emotional effect, but noted increased confusion compared to baseline. The resident’s physician evaluated her in person. The PIR narrative stated that interviews supported that the resident had been fixated on the accused staff member and frequently requested that he perform her care, and the facility ultimately determined the alleged abuse did not occur. During surveyor interview and observation, the resident described being in love with the CNA, reported having consensual sex with him, gave inconsistent details about the timing and presence of her roommate, and expressed that she felt safe and was not afraid of anyone. She also stated she did not plan to have sex with him again because she did not want either of them to get into trouble. Multiple staff interviews confirmed that the allegation and the resident’s fixation on the CNA were known to facility staff but were not incorporated into the care plan. LVN A described the resident as sometimes confused, telling stories that did not happen, and said the resident was very fond of and obsessed with the CNA. The CNA denied any romantic or sexual relationship, reported that the resident had been calling him by a nickname combined with her last name, and stated he had been suspended during the investigation and later returned to work. The MDS nurse responsible for the resident’s care planning (MDS E) acknowledged she did not add the allegation or related issues to the care plan and stated she did not know how to word it, despite recognizing that everything about a resident should be care planned so staff know what is going on. Other nursing leadership and staff also confirmed the omission. MDS C stated that the allegation should have been care planned because the care plan tells the story of the resident and would help nurses and CNAs understand and manage the situation as a behavior. LVN D reviewed the care plan and confirmed there was no entry addressing the accusation or incident with the CNA and stated it should have been on the care plan. The DON acknowledged that the resident was obsessed with the CNA, that the care plan did not address the allegation, and that the preference for female staff was only added on 3/24/26. The ADON stated the resident was very confused at times, had a UTI when she made the allegation, and should have been care planned for claiming a consensual relationship with staff, including the fact that the staff member had been moved to a different hall. The administrator also acknowledged that the allegation might have needed to be care planned. Despite the facility’s written care plan policy requiring comprehensive care plans with measurable objectives that are updated with significant changes and as needed, the resident’s care plan was not updated to reflect her allegation, her fixation on the staff member, or the resulting care needs and staff assignment changes, leading to the cited deficiency.
Failure to Provide Clear Pharmaceutical Services for Vitamin D3 Administration
Penalty
Summary
The facility failed to provide clear and accurate pharmaceutical services for a resident, specifically regarding the administration of cholecalciferol (Vitamin D3). The physician's order for the resident specified a dose of 50,000 units to be given every Thursday, but it did not include the strength of the capsules or the number of capsules required to meet the prescribed dose. This lack of clarity in the physician's order led to confusion among the medication aides, as one aide was observed administering only one 5,000 IU capsule, which did not match the ordered dose. The aide admitted to not knowing if Vitamin D3 and cholecalciferol were the same or if units and IU were equivalent, and acknowledged that the order should have specified the strength and quantity of capsules needed. The medication aide also stated that she should have reported the unclear order to the nurse but failed to do so. Interviews with the LVN and DCO revealed that the 50,000 IU dose was not available as a stock medication and would typically come from the pharmacy with specific instructions. The facility's policy on medication administration requires that any discrepancies between the label and medication sheet be resolved before administration, and that medication aides are not permitted to calculate dosages. This failure to ensure clear and accurate medication orders could result in residents not receiving the correct dosage of their prescribed medications.
Inadequate Infection Control Practices
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of RN A and CNA B in the care of a resident with significant medical needs. The resident, a female with a history of cerebral infarction, heart failure, chronic kidney disease, and an indwelling urethral catheter, was admitted with open wounds to her coccyx, sacrum, and buttocks. During an observation, RN A was seen providing wound care to the resident without wearing a disposable gown, despite wearing gloves. This was a breach of the facility's policy, which requires the use of gowns and gloves during high-contact care activities for residents with significant wounds and indwelling medical devices. Additionally, CNA B also failed to wear a gown while providing incontinent care to the same resident. The facility's policy on Enhanced Barrier Precautions (EBP) mandates the use of gowns and gloves during high-contact care activities, and signage should be posted to indicate the need for such precautions. However, during the initial observation, there was no signage on the resident's door to indicate the requirement for EBP. It was only observed later that a sign was placed on the door. Interviews with staff, including RN A, who is the Infection Preventionist, confirmed the oversight in not wearing a gown and the importance of EBP in reducing infection spread. The absence of proper PPE and signage could potentially expose residents to communicable diseases and infections.
Lack of Private Phone Access for Residents
Penalty
Summary
The facility failed to ensure that residents had reasonable access to a telephone and a private area for making calls, affecting 3 out of 7 residents reviewed for telephone use. During a group interview, several residents expressed that the facility did not provide a phone that allowed for private conversations, as they had to use phones located at the nurse's station or reception desk, where conversations could be overheard. Interviews with staff, including LVNs and the Workforce Manager, confirmed that the facility no longer had a cordless phone, which was previously available but had stopped working during a system installation. The Administrator acknowledged the absence of a cordless phone and mentioned that residents could use an office for private calls, although this option was not communicated to the residents. The Activity Director also indicated that the issue of private phone conversations had not been addressed in Resident Council meetings. Additionally, the facility lacked a policy on resident phone use, contributing to the deficiency in providing residents with the right to privacy during phone calls.
Inaccurate Documentation of Medication Administration
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for two residents, leading to potential risks of unnecessary treatment or adverse drug reactions. For the first resident, the medical assistant (MA) incorrectly documented the administration of metoprolol Tartrate 50 mg despite the resident's heart rate being below the prescribed parameters on multiple occasions. The MA admitted to either documenting the incorrect heart rate or mistakenly documenting the administration of the medication. For the second resident, the MA administered entresto 24/46 mg with a heart rate below the prescribed parameters. The MA acknowledged the possibility of entering the wrong heart rate due to a keyboard error, as the '5' and '6' keys are adjacent. This incorrect documentation could have influenced treatment decisions made by healthcare providers. Interviews with facility staff, including registered nurses and the administrator, emphasized the importance of accurate documentation of vital signs and medication administration. The facility's policy on medical records, revised in January 2023, requires maintaining records in accordance with professional standards, but it did not elaborate on the significance of accurate vital signs and medication documentation.
Failure to Adhere to Physician-Ordered Medication Parameters
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of a resident, specifically in the administration of metoprolol, a medication used to treat high blood pressure and elevated heart rate. The resident, who had a history of stroke, Type II diabetes, COPD, A-Fib, and high blood pressure, was administered metoprolol despite having a pulse rate below the physician-ordered parameters on multiple occasions. The medication was administered by different medication aides, including MA B and MA C, on dates when the resident's heart rate was recorded as below 60 bpm, which was against the physician's orders. Interviews with staff revealed that MA C, who worked on a PRN basis, acknowledged the error and suggested it might have been a documentation mistake. MA B, who administered the medication on two occasions, admitted the possibility of incorrect documentation but could not confirm it. Both RN A and RN D, who were acting as Assistant Directors of Nursing, confirmed that the medication should not have been administered outside the ordered parameters, as it could lead to the resident's heart rate dropping too low. The facility's current system did not have a mechanism to identify when medications were administered outside of physician-ordered parameters, although it could track when medications were held. The Administrator acknowledged the importance of administering medications as ordered and expressed intentions to consult with corporate to improve the EMR system for better monitoring. The facility's policy on medication administration emphasized the need for accurate, safe, and timely administration of medications, including taking vital signs prior to administration.
Failure to Protect Resident from Verbal Abuse During Transportation
Penalty
Summary
The facility failed to protect a resident from verbal abuse during transportation to a medical appointment. The incident involved a van driver who was responsible for transporting the resident. The resident, who had a BIMS score of 05 and was diagnosed with unspecified dementia, severe protein-calorie malnutrition, and other medical conditions, reported that the driver called her a derogatory name during the trip. The driver admitted to using inappropriate language but denied the specific name-calling accusation. The driver had previously received abuse and neglect training. The incident occurred when the driver took the resident to an incorrect medical facility, leading to confusion and distress for the resident, who believed she was scheduled for surgery. The driver attempted to calm the resident by turning up the radio, but the resident became more agitated. The driver then used inappropriate language in response to the resident's distress. The facility's policy on abuse defines verbal abuse as the use of disparaging and derogatory terms, which the driver's actions violated. The facility conducted an investigation, and the driver was suspended and retrained.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper handling of a wound vacuum canister and unsanitary conditions in a resident's bathroom. In the case of Resident #1, a wound vacuum canister containing a brown-red liquid was left unattended in the resident's room, with the tube dangling off the bedside table to the floor. This situation persisted throughout multiple observations on the same day, despite the resident being in the hospital. Resident #2, who shared the room with Resident #1, expressed concern about the canister's presence, indicating that it had not been addressed by the staff. Additionally, the facility failed to maintain cleanliness in Resident #3's bathroom, where a brown substance was observed smeared on the toilet handrail. The resident reported that the substance, which appeared to be feces, had been present for two weeks and had not been cleaned despite the resident's dependency on staff for toileting assistance. Observations confirmed the presence of the substance during multiple checks on the same day. Interviews with facility staff, including the Administrator, ADON, and Corporate Nurse, revealed that there was an expectation for staff to properly dispose of biohazard materials and maintain cleanliness in resident areas. However, these expectations were not met, leading to potential infection risks for the residents. The facility's Infection and Prevention Control policy emphasized the importance of identifying and addressing potential infections, but the observed practices did not align with these guidelines.
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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) |
|---|---|---|---|---|
| Reunion Plaza Healthcare & Rehabilitation | 1.5 mi | — | 0 | 0 |
| Meadow Lake Health Center | 2 mi | — | 0 | 0 |
| Avir At Azalea Heights | 2.6 mi | — | 11 | 1 |
| Briarcliff Health Center | 2.7 mi | — | 0 | 0 |
| Providence Park Rehabilitation And Skilled Nursing | 3 mi | — | 1 | 1 |
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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.