Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Waterton Healthcare & Rehabilitation during CMS and state inspections, most recent first.
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.
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 | — | 21 | 2 |
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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.