Greenbrier Nursing & Rehabilitation Center of Tyle

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents received care and services in accordance with professional standards of practice for 3 of 12 residents (Residents #11, #15, and #43) reviewed for quality of care.1. The facility failed to ensure neurological checks were performed on Resident #11 when she had an unwitnessed fall on 2/08/2026.2. The facility failed to ensure the full gamut of neurological checks were performed on Resident #15 after a fall on 3/12/2026.3. The facility failed to ensure neurological checks were performed on Resident #43 after an unwitnessed fall on 3/23/2026. This failure could place residents at risk of not receiving appropriate care and treatment and/or decline in their health.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient number of nursing staff on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans and the facility assessment for 7 of 31 (2026 in March 8, 12, 13, 14, 17, 20, and 23) days reviewed for care and services. The facility failed to provide sufficient CNAs according to the facility assessment on March 8, 12, 13, 14, 17, 20, and 23 in 2026. This failure placed residents at risk of inadequate supervision, an unsafe environment, falls, serious harm and injury, exacerbations of disease processes, abuse, and death. Findings Include: Record review of a grievance note dated 3/09/2026 indicated a family member filed a grievance due to being unable to find clinical staff over the weekend. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures accurate acquiring, receiving, dispensing, and administering of medications for 1 of 2 medication storage rooms (East Wing) reviewed for pharmacy services. The facility failed to remove (2) expired vials of pneumococcal vaccine and bisacodyl suppositories (used to treat constipation) from the refrigerator in the medication room on the East Wing on 3/24/2026. This failure could place residents at risk for the unsafe administration of medications, not receiving prescribed doses of ordered medications and infection.

Inspectors wroteBased on interview and record review, the facility failed to immediately inform the resident, consult with the resident's physician; and notify, consistent with his or her authority, the resident representative where there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 6 residents (Resident #43) reviewed for resident rights. The facility failed to inform Resident #43's responsible party when she fell on 3/23/2026. This failure could place residents at risk of not having family members or representatives notified of changes in condition and allowing them to participate in care decisions. Findings Include: Record review of Resident 43's face sheet, dated 3/24/2026, indicated Resident #43 was a [AGE] year-old female, admitted [DATE], with diagnosis of dementia. [...]

Inspectors wroteBased on interview and record review, the facility failed to assess each resident quarterly, once every three months, using the quarterly review instrument specified by the state and approved by CMS for 1 of 17 residents (Resident # 14) reviewed for resident assessments. The facility failed to ensure Resident # 14 had a quarterly MDS assessment completed within three months from the previous assessment on 2/21/26. This failure could place residents at risk of not receiving necessary care or receiving inappropriate care for their conditions.

Inspectors wroteBased on interview and record review, the facility failed to make sure a comprehensive care plan was prepared by an interdisciplinary team, that included but not limited to the participation of the resident and the resident representative for 1 of 17 residents (Resident #7) reviewed for care plans.1. The facility failed to ensure Resident #7's representative was invited to attend the resident's care plan conferences.2. The facility failed to ensure care plan conferences were held quarterly for Resident #7. This failure could place residents at risk of not receiving the care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain personal hygiene for 1 of 6 residents reviewed for ADL care. (Resident #2)The facility failed to ensure Resident #2 received timely incontinent care on 3/23/2026. This failure could place residents at risk of embarrassment, discomfort, and skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 2 errors out of 30 opportunities, resulting in a 6.67% percent medication error involving 1 of 4 residents (Resident #32) reviewed for pharmacy services. LVN B administered an incorrect dose of Novolog insulin (used to treat diabetes) to Resident #32 on 3/24/2026 during a medication pass. LVN B failed to administer a dose of Novolin R (used to treat diabetes) to Resident #32 on 3/24/2026 during a medication pass. These failures could place residents at risk for inaccurate drug administration resulting in decline in health and decreased quality of life.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 4 residents (Resident #32) reviewed for significant medication errors. The facility failed to ensure LVN B administered the correct dose of Novolog and Novolin R insulin (used to treat diabetes) to Resident #32 on 3/24/2026 during a medication pass. This failure could place residents at risk of not receiving desired therapeutic outcomes, increased side effects, or a decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 2 medication storage rooms (East Wing) and 1 of 4 medication carts (East Wing) reviewed for labeling and storage. The facility failed to store an unopened insulin pen in the refrigerator on 3/24/2026 it was in the East Wing nurse medication cart. These deficient practices could place residents at risk for not receiving the intended therapeutic effects of their medications causing a health decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition services for 1 of 1 kitchen reviewed for competent dietary support personnel. (Dietary Aide G) Dietary Aide G was preparing food and did not have a valid Food Handler's License. This failure could place residents in the facility who eat in the dining room at risk for food-borne illnesses. Findings Include: During an interview on 3/24/2026 at 11:20 am, Dietary Aide G said she had been employed at the facility since August of 2025. Dietary Aide G said she was responsible for preparing drinks and desserts as well as refilling the coffee/drink bar in the lobby and preparing trays. Dietary Aide G said she did not have a valid food handler's license. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food under sanitary conditions in 1 of 1 facility kitchens. There was expired coleslaw in a facility refrigerator. This failure could place residents who ate meals prepared in the kitchen at risk for food borne illness.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 staff (CNA C) reviewed for infection control. The facility failed to ensure CNA C washed or sanitized her hands when incontinent care was provided to Resident #2 on 3/24/2026. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.

Inspectors wroteBased on observations, interviews, and records review, the facility failed to ensure handrails were firmly affixed to the wall in 1 of 2 shower rooms (East Unit shower room) reviewed for handrails. The facility failed to ensure a handrail in the shower room of the East Unit was securely affixed to the wall, it was observed to be loose and pulled away from the wall. This failure could place residents who use the shower room at risk for falls, injuries, and hospitalizations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their own established smoking policy for 1 of 1 smoking areas. The facility failed to keep cigarette butts out of a trash can designated for trash. This failure could place residents at risk for injury, burns, and an unsafe smoking environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 1 of 1 residents (Residents#1) reviewed for grievances. The facility did not ensure the grievance dated 4/26/25 regarding Resident #1's showers was resolved. This failure could place resident at risk for grievances not being addressed or resolved promptly.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene were provided for 1 of 5 (Resident #1) residents reviewed for ADLs. The facility failed to ensure Resident #1 received his scheduled showers in May 2025, June 2025, and July 2025 These failures could place residents at risk of not receiving services/care and decreased quality of life. Findings Include: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 staff (CNA C) and 1 of 5 residents (Resident #2) reviewed for infection control. The facility failed to ensure CNA C changed gloves and performed hand hygiene during Resident #2's incontinent care. These failures could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure accurate assessments were completed for 7 of 20 residents (Residents #16, #19, #29, #30, #34, #41, and #53) reviewed for accuracy of assessments. The facility failed to ensure Residents ##16, #19, #29, #30, #34, #41, and #53's MDS assessment was accurately coded for Preadmission Screening and Resident Review (PASRR). These failures could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications for 1 of 2 residents reviewed for tube feeding management (Resident #31). The facility failed to follow their policy for administering medications via gastrostomy tube. This failure placed the resident at risk for not receiving his medication dose as ordered and at risk for a punctured gastrostomy tube and possible leakage of medications, formula, and/or water into the abdominal cavity.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure pharmaceutical services were provided to meet the needs of 1 of 2 residents reviewed for pharmacy services (Residents #31). LVN A mixed Resident #31's gastrostomy tube medications and administered them together. This failure could place residents at risk of not receiving medications as ordered by the physician.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 5 residents (Resident #5) reviewed for safe and comfortable environment. The facility failed to repair water discoloration marks and water leaks in the ceiling in Resident #5's room. These failures could place residents at risk for a diminished quality of life and safe environment due to the lack of a well-kept environment.

Inspectors wroteBased on interview and record review, the facility failed to protect the residents' right to be free from verbal abuse by staff for 1 of 9 residents reviewed for abuse. (Resident #2) The facility failed to ensure Resident #2 was free from abuse when CNA B told Resident #2 to shut up on 11/25/23. This failure could place the residents at risk for increased risk for abuse and neglect.

Inspectors wroteBased on interview and record review, the facility failed to ensure the right to be free from misappropriation of property was provided for 1 of 7 residents reviewed for misappropriation of property. (Resident #3) The facility failed to ensure Resident #3 was free from misappropriation of property when CNA C was caught on camera stealing snacks from Resident #3's personal refrigerator. This failure could place residents at risk for decreased quality of life, misappropriation of property, and dignity.

Inspectors wroteBased on interview and record review, the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet residents' mental and psychosocial needs, for 1 of 9 residents reviewed for care plans. (Resident #1) The facility failed to document Resident # 1's skin condition on her comprehensive care plan. This failure could affect residents in the facility by placing them at risk of not receiving care and services related to their identified needs to maintain or reach their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, 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 2 of 5 residents (Resident #1 and Resident #2) reviewed for pharmacy services. The facility failed to accurately transcribe Resident #1's morphine (narcotic medication used to treat pain) which resulted in him receiving an incorrect dosage of the medication. The facility failed to accurately transcribe Resident #2's medication orders for lorazepam (a benzodiazepine medication used to treat anxiety), tramadol (an opioid analgesic used to treat pain) and oxycodone (an opioid analgesic medication used to treat pain. These failures could place residents at risk of receiving incorrect dosages of medications and significant adverse effects from medication error.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident environment remained free of accident and hazards for 3 of 5 residents (Resident #1, #2 and #3) reviewed for accident hazards. The facility did not ensure Resident #1 had on slip proof footwear. The facility did not ensure the floor of secured unit hallway was free of water, where Resident #1, #2 and #3 routinely wandered. These failures could place residents at risk for falls, injury and decreased quality of life.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review Level 1(PASRR) Screening for 1 of 9 residents reviewed for PASRR (Resident #36). The facility failed to ensure Resident #36 had an accurate PASRR Level 1 Screening indicating a diagnosis of mental illness on 10/28/2022. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs.