Greenbrier Nursing & Rehabilitation Center of Tyle

In the surveyor’s words

From the most serious findings on record at Greenbrier Nursing & Rehabilitation Center of Tyle, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF684Mar 25, 2026

  Based 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.Findings include:1. […]

• No harm, potential for more than minimal, patternF725Mar 25, 2026

  Based 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… […]

• No harm, potential for more than minimal, patternF755Mar 25, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF641Dec 18, 2024

  Based 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. […]

• No harm, potential for more than minimal, patternF755May 21, 2024

  Based 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. […]