Inspection visit
Inspection
6 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0655
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being
admitted
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to develop and implement a baseline care plan
for Resident#197 that included the instructions needed to provide effective and person-centered care of the
resident that meet professional standards of quality care for one of one resident (Resident #197) reviewed
for baseline care plan.
The facility failed to ensure Resident #197's baseline care plan included information related to Resident
#197's respiratory needs.
This failure could place newly admitted residents at risk of not receiving continuity of care and
communication among nursing home staff to ensure their immediate care needs are met.
The findings were:
Record review of Resident #197's face sheet, dated 01/17/2024, revealed an admission date of 01/17/2024
with diagnoses that included: Closed left hip fracture, high blood pressure, dependence on supplemental
oxygen, chronic bronchitis (long-term inflammation of the bronchi, It is common among smokers. People
with chronic bronchitis tend to get lung infections more easily. They also have episodes of acute bronchitis,
when symptoms are worse, anxiety, and chronic obstructive pulmonary disease (COPD) refers to a group
of diseases that cause airflow blockage and breathing-related problems.
Record review of Resident #197's MDS, dated [DATE], revealed a BIMS score of 12 which suggested
moderate cognitive impairment. Further review in Section J, Health Conditions, revealed Resident #197 had
shortness of breath with exertion and when lying flat.
Record review of Resident #197's baseline care plan, initiated 01/17/2024 with no revision, revealed no
focus area for Resident #197's respiratory or therapy needs. Section 13a Special Treatments & Procedures
(p) other indicated no other devices and Treatment.
Record review of Resident #197's Order Summary Report, dated 01/17/2024, revealed an order for
Inhalation Nebulization Solution (Albuterol) to inhale orally four times a day for COPD for 30 days
administrator for 15 minutes. Further review revealed an order for Albuterol Sulfate Nebulization Solution, 1
vial inhale orally via nebulizer every 4 hours as needed for Shortness of Breath.
Record review of Resident #197's medication Administration Record, form 1/17/2024 to 02/06/2024,
revealed Resident #197 was administered Albuterol Nebulizer every 4 hours and received prn dose once
on 2/4/2024 at 0325A.M.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 10
Event ID:
676443
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676443
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/07/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Center at Grande
3219 East Grande Boulevard
Tyler, TX 75707
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0655
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During an observation and interview on 02/05/2024 and 02/06/2024 resident #197 was observed with
handheld portable nebulizer with medication in chamber, the resident said she can use this nebulizer as
needed.
During an observation and interview on 02/07/2024 at 10:30 am resident #197 was observed with a vial of
Albuterol to instill in her nebulizer, the resident said she always has done this.
In an interview with the MDS Coordinator and the Administrator on 02/06/2024 at 11:30 a.m., the MDS
Coordinator confirmed Resident #197's respiratory orders had not been addressed on the baseline care
plan. The MDS Coordinator revealed the care plan was created from the initial nursing assessment and
updated when the MDS assessment was completed. The MDS Coordinator added that respiratory orders
and therapy orders were given on admission and should have been in Resident #197's care plan. The MDS
Coordinator stated it was the responsibility of the MDS Coordinators to review orders to ensure all resident
needs were captured on the care plan , that the services to be furnished to attain or maintain the resident's
highest practicable physical, mental, and psychosocial well-being The care plan must be based on the
assessment.
Record review of the facility's policy titled, Comprehensive Care Planning, undated, revealed, The facility
will develop and implement a comprehensive person-centered care plan for each resident, consistent with
the resident rights that includes measurable objectives and timeframes to meet a resident's medical,
nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The
services that are to be furnished to attain or maintain the resident's highest practicable physical, mental,
and psychological well-being; and .any specialized services or specialized rehabilitative services .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676443
If continuation sheet
Page 2 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676443
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/07/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Center at Grande
3219 East Grande Boulevard
Tyler, TX 75707
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to develop and revise the comprehensive care
plan for one of one residents (Resident #197) reviewed for care plans.
The facility failed to ensure Resident #197's care plan included information related to Resident #197's
respiratory needs was developed within 7 days of the comprehensive assessment and included that the
resident was receiving Albuterol for (chronic obstructive pulmonary disease) COPD and shortness of
breath.
This failure could place residents at risk of not receiving medication as ordered to meet their current
Respiratory needs.
The findings were:
Record review of Resident #197's face sheet, dated 01/17/2024, revealed an admission date of 01/17/2024
with diagnoses that included: Closes left hip fracture, high blood pressure, dependence on supplemental
oxygen, chronic bronchitis, anxiety, and chronic obstructive pulmonary disease (COPD).
Record review of Resident #197's MDS, dated [DATE], revealed a BIMS score of 12 which suggest
moderate cognitive impairment. Further review in Section J, Health Conditions, revealed Resident #197 had
shortness of breath with exertion and when lying flat.
Record review of Resident #197's baseline care plan, initiated 01/17/2024 with no revision, revealed no
focus area for Resident #197's respiratory or therapy needs. Section 13a Special Treatments & Procedures
(p) other indicated no other devices and Treatment.
Record review of Resident #197's Order Summary Report, dated 01/17/2024, revealed an order for
Inhalation Nebulization Solution (Albuterol) to inhale orally four times a day for COPD for 30 days
administrator for 15 minutes. Further review revealed an order for Albuterol Sulfate Nebulization Solution, 1
vial inhale orally via nebulizer every 4 hours as needed for Shortness of Breath.
Record review of Resident #197's medication Administration Record, form 1/17/2024 to 02/06/2024,
revealed Resident #197 was administered Albuterol Nebulizer every 4 hours and received prn dose once
on 2/4/2024 at 0325A.M.
During an observation and interview on 02/05/24 and 02/06/2024 Resident #197 was observed with
handheld portable nebulizer with medication in chamber, the resident said she can use this nebulizer as
she wills.
During an observation and interview on 02/07/2024 at 10:30 am Resident #197 was observed with a vial of
Albuterol to instill in her nebulizer, the resident said she always has done this.
During an interview with the MDS Coordinator and Administrator on 02/06/2024 at 11:30 a.m., the MDS
Coordinator confirmed Resident #197's respiratory orders had not been addressed on the care plan. The
MDS Coordinator revealed the care plan was created from the initial nursing assessment and updated
when the MDS was completed. The MDS Coordinator added that respiratory orders and therapy orders
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676443
If continuation sheet
Page 3 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676443
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/07/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Center at Grande
3219 East Grande Boulevard
Tyler, TX 75707
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
were given on admission and should have been in Resident #197's care plan. The MDS Coordinator stated
it was the responsibility of the MDS Coordinators to review orders to ensure all resident needs were
captured on the care plan.
Record review of the facility's policy titled, Comprehensive Care Planning, undated, revealed, The facility
will develop and implement a comprehensive person-centered care plan for each resident, consistent with
the resident rights that includes measurable objectives and timeframes to meet a resident's medical,
nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The
services that are to be furnished to attain or maintain the resident's highest practicable physical, mental,
and psychological well-being; and .any specialized services or specialized rehabilitative services .
Event ID:
Facility ID:
676443
If continuation sheet
Page 4 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676443
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/07/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Center at Grande
3219 East Grande Boulevard
Tyler, TX 75707
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, and record reviews. the facility failed to ensure that a resident who needs
respiratory care, including tracheostomy care and tracheal suctioning is provided such care consistent with
professional standards of practice, the comprehensive person-centered care plan and the residents goals
and preferences for (Resident #197) reviewed for Nebulizer therapy.
Residents Affected - Few
Resident #197's Nebulizer therapy ordered by the physician dated 1/17/2024 Albuterol Sulfate inhalation
Nebulization solution, 0.083%, to Inhale orally four times a day for COPD for 30 days administer for 15
minutes. Order date 1/17/2024, there was no order for self-administration.
This failure could place residents who receive Nebulization therapy at risk for respiratory distress.
The findings were:
Record review of Resident #197's electronic face sheet, dated 01/17/2024, revealed an admission date of
01/17/2024 with diagnoses that included: Closed left hip fracture, high blood pressure, dependence on
supplemental oxygen, chronic bronchitis, anxiety, and chronic obstructive pulmonary disease (COPD).
Review of resident #197's MDS dated [DATE] had not been completed.
Record review of Resident #197's Order Summary Report, dated 01/17/2024, revealed an order for
Inhalation Nebulization Solution (Albuterol) to inhale orally four times a day for COPD for 30 days
administrator for 15 minutes. Further review revealed an order for Albuterol Sulfate Nebulization Solution, 1
vial inhale orally via nebulizer every 4 hours as needed for Shortness of Breath.
A review of Resident #197's physicians orders for January 17,2024 did not indicate any orders for
self-administration of medication. It is the policy of this facility that medications are to be administered as
prescribed by attending physician.
For a patient receiving a nebulizer treatment, the nurse must ensure that patient completed the nebulizer
treatment. Nurse must follow physician's orders of administering the nebulizer treatment.
During observations Resident #197 was Inhalation Nebulization on the following dates and times:
02/05/2024 at 10:24AM with no staff observation and with her own personal hand-held nebulizer
02/06/2024 at 10 AM opening the Albuterol vial on her own and instilling medication into her personal
hand-held nebulizer.
02/07/2024 at 10:30 am with no staff observation as she had been to therapy and returning to room.
During an interview on 02/05/2024 at 10:24AM Resident #197 said she can use her personal nebulizer as
she needs it, her husband was at the bedside and agreed.
During an interview with LVN A on 02/05/2024 at 11:30 am she said that she was to monitor and make sure
residents with Nebulizer therapy get their entire treatment, but she knew that resident #197 has her own
personal nebulizer and carries it around .
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676443
If continuation sheet
Page 5 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676443
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/07/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Center at Grande
3219 East Grande Boulevard
Tyler, TX 75707
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During an interview on 02/05/2024 at 04:07 pm with DON, she said, residents are to be assessed before
and after any inhalation treatment, nurses are to follow the physicians' orders, and no medication is to be
left at bedside for residents to administer themselves .
During an interview on 02/07/2024 at 4:00pm with the ADON, she said that none of the nurses on staff
have had skills training to administer respiratory therapy .
A review of the facility's policy on Respiratory Therapy Program dated 1/15/2023: #4 The Services are
required and provided by qualified personnel. Nurses administered respiratory therapy will have respiratory
therapy training and competency evaluation will reflect proficiency in providing respiratory modalities.
A review of the facility's Nebulizer Policy dated 8/16/2022 indicated the following:
Purpose:
Nebulizer therapy may be provider through various types of supply and delivery systems. Equipment may
include the provision of trans-tracheal nebulizer, mask, or handheld.
Procedure:
For a patient receiving a nebulizer treatment, the nurse must ensure that patient completed the nebulizer
treatment. Nurse must follow physician's orders of administering the nebulizer treatment. Patient's door is
recommended to be closed during nebulizer treatment.
Nurse must rinse the mouthpiece or face mask when completed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676443
If continuation sheet
Page 6 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676443
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/07/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Center at Grande
3219 East Grande Boulevard
Tyler, TX 75707
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, and record reviews, the facility failed to provide pharmaceutical services, including
procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and
biologicals, to meet the needs of each resident for 1 of 1 resident (Resident #197) reviewed for pharmacy
services.
LVN A failed to ensure Resident # 197's medications were secure and left physician ordered medications at
the bedside.
LVN A failed to ensure Resident #197 inhaled her medications.
These failures placed Resident #197 at risk of not receiving full dosage and treatment of medication as
ordered.
Findings included:
Record review of Resident #197's electronic face sheet dated 01/17/2023 reflected a[AGE] year-old female
who was admitted to the facility on [DATE]. She had diagnoses which included hypertension (elevated blood
pressure), left hip fracture, dependence on supplemental oxygen, chronic bronchitis, anxiety, and chronic
obstructive pulmonary disease (COPD).
Record review of Resident #197's Order Summary Report, dated 01/17/2024, revealed an order for
Inhalation Nebulization Solution (Albuterol) to inhale orally four times a day for COPD for 30 days
administrator for 15 minutes. Further review revealed an order for Albuterol Sulfate Nebulization Solution, 1
vial inhale orally via nebulizer every 4 hours as needed for Shortness of Breath.
Record review of Resident #197's Medication Administration Record for 02/05/2024 reflected LVN A had
administered the medications ordered to be given between 08:00, 12:00, and 16:00 over a 15-minute
period.
Record review of Resident #197's physician orders dated January/February 2024 did not reflect an order
for the resident to self-administer medications.
Record review of Resident #197s medical records did not reflect an assessment of the residents' ability to
self-administer medications safely was completed.
Review of Resident #197's Care Plan for January/February 2024 did not reflect Resident #197's was to be
allowed to self-administer her own medications.
During an observation and interview on 02/05/2024 at 10:24 AM, Resident #197 was noted to be sitting in a
wheelchair in her room with an over-the-bed table in front of her. No staff were in the room. The resident's
husband was sitting in the room in a bedside chair. The residents' personal hand-held nebulizer was in her
hand with medication in the chamber. In an observation and interview on 01/06/2024 at 10 AM, the resident
had a vial of Albuterol in her hand ready to open and instill in her personal hand-held nebulizer. The
resident and her husband said they didn't want to get anyone in trouble, but this is what they do all the time
with the Albuterol treatment. Resident #197 said Nurses
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676443
If continuation sheet
Page 7 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676443
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/07/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Center at Grande
3219 East Grande Boulevard
Tyler, TX 75707
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
will give her the vial to put in her nebulizer and maybe check later to see if she needs anything else, but
they trust me to take on her own.
During an interview with LVN A on 02/05/2024 at 11:30AM, she said she left Resident #197's medications
on the over-the-bed table for the resident to take. LVN A said she was supposed to stay/or return within
15minutes with the resident until she had taken all her medications. LVN A said the policy for administering
medications was for the nurse to stay with the resident to ensure the medications are taken. LVN A did not
respond to being asked if there was a reason for leaving the medications at bedside and not ensuring the
resident took her medications , It is the policy of this facility that medications are to be administered as
prescribed by attending physician.
For a patient receiving a nebulizer treatment, the nurse must ensure that patient completed the nebulizer
treatment. Nurse must follow physician's orders of administering the nebulizer treatment.
During an interview with the DON on 02/05/2024 at 11:05 AM, she said she expected the nurses to stay
with the residents when giving medications and ensure they took them. She said residents who did not take
their medications were at risk for not receiving the intended therapeutic effect of their medications. She said
residents could hoard their untaken medications and risk overdosing themselves and residents who wander
may take unattended medications if it was left sitting out. She said that she had done an employee
disciplinary review with LVN A, and the nurse should be following policy . It is the policy of this facility that
medications are to be administered as prescribed by attending physician.
For a patient receiving a nebulizer treatment, the nurse must ensure that patient completed the nebulizer
treatment. Nurse must follow physician's orders of administering the nebulizer treatment.
During an interview with LVN B on 02/07/2024 at 11:40 AM, she said the nurses were responsible for
administering medications to residents. LVN B said nurses were required to stay with each resident until
medications were taken and swallowed .
Record review of the facility's general policy titled Medication Administration dated 3/31/2023, including the
following:
It is the policy of this facility that medications are to be administered as prescribed by attending physician.
For a patient receiving a nebulizer treatment, the nurse must ensure that patient completed the nebulizer
treatment. Nurse must follow physician's orders of administering the nebulizer treatment.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676443
If continuation sheet
Page 8 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676443
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/07/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Center at Grande
3219 East Grande Boulevard
Tyler, TX 75707
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interviews and record reviews the facility failed to maintain medical records on each resident, in accordance
with accepted professional standards and practices, that were complete and accurate for (Resident #197)
resident reviewed for resident records.
The facility failed to ensure Resident #197's Medication Administration Record (MAR) reflected
documentation of Cleanse Nebulizer mask with soap and water after every use. Allow to dry to air, placed
on a paper towel, and taken apart. Once dry and place back together and on hook of nebulizer machine in
her Electronic Health Record (EHR).
This failure could place all residents who receive nebulizer treatment at risk of having errors in care and
treatment.
The findings included:
Record review of Resident #197's electronic face sheet dated 01/17/2023 reflected a [AGE] year-old female
who was admitted to the facility on [DATE]. She had diagnoses which included hypertension (elevated blood
pressure), left hip fracture, dependence on supplemental oxygen, chronic bronchitis, anxiety, and chronic
obstructive pulmonary disease (COPD).
Record review of Resident #197's Medication Administration Record revealed documentation of Cleanse
Nebulizer mask with soap and water after every use. Allow to dry to air, placed on a paper towel, and taken
apart. Once dry and place back together and on hook of nebulizer machine every shift, in her Electronic
Health Record (EHR) had never been done but was being signed as done from 1/17/2024 - 2/6/2024.
During an interview with LVN A on 02/06/2024 at 12:30 pm, she stated she never cleaned nebulizer
machine on her shift because the resident had her own hand-held nebulizer, she said she just signed the
Electronic Health Record (EHR ) Which can Compromised Patient Safety: Missing information can lead to
treatment errors, posing a significant risk to patient safety. Delayed Care: Missing or incomplete data can
delay care as medical professionals. Each Nurse is responsible to make sure the Electronic Health Record
is correct and when signing the task is complete.
During an interview with LVN B on 02/07/2024 at 11:40 AM, she said the nurses were responsible for
administering medications to residents. She stated she never cleaned nebulizer machine on her shift
because the resident had her own hand-held nebulizer, she said she just signed the Electronic Health
Record (EHR) Which can Compromised Patient Safety: Missing information can lead to treatment errors,
posing a significant risk to patient safety. Delayed Care: Missing or incomplete data can delay care as
medical professionals. Each Nurse is responsible to make sure the Electronic Health Record is correct and
when signing the task is complete.
During an interview with resident on 02/07/2024 at 12:30 pm, she said her, or her husband would clean the
nebulizer machine and alternate with her second machine, she said that's what she did at home, and they
followed the manufacturer instructions on cleaning. Staff was just signing the Electronic Health Record and
not doing the task of cleaning.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676443
If continuation sheet
Page 9 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676443
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/07/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Center at Grande
3219 East Grande Boulevard
Tyler, TX 75707
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
During an interview with ADON on 02/07/2024 at 2:30 pm, who said she would review orders for the
Nebulizer, call the physician and make sure staff and resident have respiratory therapy training and
competency evaluation that will reflect proficiency in providing respiratory modalities as stated in the
centers policy & Procedure.
The facility could not produce a policy on resident use of own equipment or policy of staff signage of orders
that were not being done.
Event ID:
Facility ID:
676443
If continuation sheet
Page 10 of 10
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Back to topCitations
6 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- 0374GeneralS&S Dpotential for harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
FAQ · About this visit
Common questions about this visit
What happened during the February 7, 2024 survey of THE CENTER AT GRANDE?
This was a inspection survey of THE CENTER AT GRANDE on February 7, 2024. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at THE CENTER AT GRANDE on February 7, 2024?
Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted"
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.