Cycle 1
Health 2025-05-21 · Fire 2025-05-21
1 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Tyler, TX
Briarcliff Health Center
2-star overall rating with 3-star inspections with $51,034 in total fines with 1 recent health deficiencies
3403 S Vine Ave, Tyler, TX
(903) 581-5714
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
230
Certified beds
Average residents
126
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1993-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.53
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.85
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.27
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.66
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.38
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.24
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.64
CMS adjusted RN staffing hours
Adjusted total hours
4.38
CMS adjusted total nurse staffing hours
Case-mix index
1.14
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,689
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.11
Composite VBP score used to determine payment impact.
Payment multiplier
0.9961
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.30
Baseline 20.12% · Performance 19.90% · Measure score 3.30 · Achievement 3.30 · Improvement 0.22
Healthcare-associated infections
3.90
Baseline 9.76% · Performance 7.66% · Measure score 3.90 · Achievement 0.57 · Improvement 3.90
Total nurse turnover
2.31
Baseline 63.57% · Performance 54.22% · Measure score 2.31 · Achievement 2.31 · Improvement 1.91
Adjusted total nurse staffing
7.74
Baseline 4.32 hours · Performance 5.28 hours · Measure score 7.74 · Achievement 7.74 · Improvement 6.07
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.38% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 75 · Observed rate 8% · Lower 95% interval 6.88% |
| Discharge to community | 35.77% |
50.57%
14.8 pts worse
|
Worse than the National Rate · Eligible stays 47 · Observed rate 25.53% · Lower 95% interval 25.63% |
| Medicare spending per beneficiary | 1.76 |
1.02
0.7 pts worse
|
|
| Drug regimen review with follow-up | 73.91% |
95.27%
21.4 pts worse
|
Numerator 51 · Denominator 69 |
| Falls with major injury | 5.8% |
0.77%
5 pts worse
|
Numerator 4 · Denominator 69 |
| Discharge self-care score | 42.55% |
53.69%
11.1 pts worse
|
Numerator 20 · Denominator 47 |
| Discharge mobility score | 38.3% |
50.94%
12.6 pts worse
|
Numerator 18 · Denominator 47 |
| Pressure ulcers or injuries, new or worsened | 1.45% |
2.29%
0.8 pts better
|
Numerator 1 · Denominator 69 · Adjusted rate 1.17% |
| Healthcare-associated infections requiring hospitalization | 7.66% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 62 · Observed rate 8.06% · Lower 95% interval 4.26% |
| Staff COVID-19 vaccination coverage | 6.27% |
8.2%
1.9 pts worse
|
Numerator 17 · Denominator 271 |
| Staff flu vaccination coverage | 49.77% |
42%
7.8 pts better
|
Numerator 108 · Denominator 217 |
| Discharge function score | 44.68% |
56.45%
11.8 pts worse
|
Numerator 21 · Denominator 47 |
| Transfer of health information to provider | 95% |
95.95%
1 pts worse
|
Numerator 19 · Denominator 20 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 31 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.1
0.1 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.8 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
2.1
About the same
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.9 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 80.4% |
97.1%
16.7 pts worse
|
93.4%
13 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 78.0% · Q2 77.8% · Q3 72.8% · Q4 92.6% · 4Q avg 80.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.5% |
97.9%
0.6 pts better
|
95.5%
3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 9.4% |
3.3%
6.1 pts worse
|
3.3%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 12.8% · Q3 11.4% · Q4 5.0% · 4Q avg 9.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.6% |
2.7%
1.1 pts better
|
11.4%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 1.0% · Q4 3.5% · 4Q avg 1.6% |
| Percentage of long-stay residents who lose too much weight | 6.0% |
3.3%
2.7 pts worse
|
5.4%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 9.6% · Q3 5.5% · Q4 5.7% · 4Q avg 6.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 35.1% |
18.9%
16.2 pts worse
|
19.6%
15.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.0% · Q2 34.7% · Q3 37.9% · Q4 34.0% · 4Q avg 35.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 28.7% |
10.8%
17.9 pts worse
|
16.7%
12 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.2% · Q2 32.9% · Q3 27.4% · Q4 24.4% · 4Q avg 28.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 17.3% |
15.4%
1.9 pts worse
|
16.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.6% · Q2 31.6% · Q3 5.5% · Q4 6.4% · 4Q avg 17.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.1% |
16.1%
9 pts worse
|
14.9%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.0% · Q2 38.3% · Q3 19.3% · Q4 8.0% · 4Q avg 25.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.5%
0.2 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.7% · Q4 0.5% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
0.8%
0.4 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.6% |
15.0%
8.6 pts worse
|
19.8%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.3% · Q2 23.8% · Q3 14.8% · Q4 24.6% · 4Q avg 23.6% |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
4.2%
0.8 pts worse
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 4.3% · Q3 4.8% · Q4 6.0% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 60.5% |
89.7%
29.2 pts worse
|
81.7%
21.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 64.9% · Q2 44.2% · Q3 58.5% · Q4 75.5% · 4Q avg 60.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.1% |
12.0%
0.9 pts better
|
12.0%
0.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.1% · Observed 12.5% · Expected 12.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 10.5% |
1.5%
9 pts worse
|
1.6%
8.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q4 18.2% · 4Q avg 10.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 59.3% |
88.0%
28.7 pts worse
|
79.7%
20.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 59.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.8% |
25.9%
0.1 pts better
|
23.9%
1.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.8% · Observed 20.8% · Expected 19.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-10 · Fire 2024-04-10
8 health deficiencies
Top issue: Resident Rights (3 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2023-03-08 · Fire 2023-03-08
5 health deficiencies
Top issue: Administration (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-04-10
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-05-20
F · Potential for more than minimal harm
2024-04-10
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-05-20
E · Potential for more than minimal harm
2024-04-10
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-05-20
D · Potential for more than minimal harm
2024-04-10
K221 · Egress Deficiencies
Fire Safety
Provide rooms that can be unlocked from inside without a key.
Corrected 2024-05-20
E · Potential for more than minimal harm
2023-03-08
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-05-15
E · Potential for more than minimal harm
2023-03-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-05-15
D · Potential for more than minimal harm
2023-03-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-05-15
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-21
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-06-13
E · Potential for more than minimal harm
2024-08-13
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-09-24
E · Potential for more than minimal harm
2024-05-30
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-06-28
E · Potential for more than minimal harm
2024-04-10
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-11
D · Potential for more than minimal harm
2024-04-10
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-04-11
J · Immediate jeopardy
2024-04-05
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-03-21
G · Actual harm
2024-04-05
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-04-06
G · Actual harm
2024-04-05
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2024-04-06
D · Potential for more than minimal harm
2024-04-05
F620 · Resident Rights Deficiencies
Health
Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
Corrected 2024-04-06
J · Immediate jeopardy
2024-02-06
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-02-07
J · Immediate jeopardy
2024-02-06
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-02-07
D · Potential for more than minimal harm
2024-02-06
F836 · Administration Deficiencies
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2024-02-07
E · Potential for more than minimal harm
2023-03-08
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-04-15
C · Minimal harm
2023-03-08
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-04-15
Penalties and ownership
What sits behind the stars
$16,801
2024-04-05
Fine
Fine · fine $16,801
Fine
$34,233
2024-02-06
Fine
Fine · fine $34,233
Fine
Ownership
South Limestone Hospital District
5% Or Greater Direct Ownership Interest · Organization
Bates, Joshua
Operational/Managerial Control · Individual
Gray, Arnold
Corporate Officer · Individual
Hewitt, Herbert
Corporate Officer · Individual
Milstead, Jack
Corporate Officer · Individual
O'neal, Glenda
Corporate Officer · Individual
Price, Larry
Corporate Officer · Individual
Sbs Leaseco Briarcliff LLC
Operational/Managerial Control · Organization
Seelinger, Chet
Corporate Officer · Individual
Shelton, Chana
Operational/Managerial Control · Individual
Sims, Debra
Operational/Managerial Control · Individual
Sinclair, Lauren
Corporate Officer · Individual
Stanton, Martha
Corporate Officer · Individual
Williams, Michael
Corporate Officer · Individual
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#3
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