Cycle 1
Health 2025-12-04 · Fire 2025-12-04
23 health deficiencies
Top issue: Resident Assessment and Care Planning (7 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Tyler, TX
Rose Trail Nursing And Rehabilitation Center
1-star overall rating with 1-star inspections with Special Focus status with $539,122 in total fines with 23 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
930 S Baxter, Tyler, TX
(903) 597-2068
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
172
Certified beds
Average residents
79
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Avir Health Group
Operator or chain grouping
Approved since
1977-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.32
Registered nurse staffing
LPN hours / resident day
0.66
Licensed practical nurse staffing
Aide hours / resident day
1.96
Nurse aide staffing
Weekend hours
2.50
Weekend nurse staffing
RN turnover
100%
Annual RN turnover
Total nurse turnover
86%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 4.4 |
2.1
2.3 pts worse
|
1.9
2.5 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.6 |
2.1
2.5 pts worse
|
1.8
2.8 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.8% |
97.1%
5.3 pts worse
|
93.4%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.8% |
97.9%
6.1 pts worse
|
95.5%
3.7 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.9% |
3.3%
1.4 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 3.0% |
2.7%
0.3 pts worse
|
11.4%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 2.1% |
3.3%
1.2 pts better
|
5.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 32.1% |
18.9%
13.2 pts worse
|
19.6%
12.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 18.6% |
10.8%
7.8 pts worse
|
16.7%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 8.0% |
15.4%
7.4 pts better
|
16.3%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.7% |
16.1%
5.4 pts better
|
14.9%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.5%
0.3 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.7% |
15.0%
0.3 pts better
|
19.8%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 14.5% |
4.2%
10.3 pts worse
|
5.1%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 57.1% |
89.7%
32.6 pts worse
|
81.7%
24.6 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.9% |
12.0%
4.9 pts worse
|
12.0%
4.9 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.9% |
1.5%
2.4 pts worse
|
1.6%
2.3 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 54.3% |
88.0%
33.7 pts worse
|
79.7%
25.4 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.3% |
25.9%
0.4 pts worse
|
23.9%
2.4 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-25 · Fire 2024-09-25
14 health deficiencies
Top issue: Resident Rights (3 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2023-08-18 · Fire 2023-08-18
26 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (7 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-12-04
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 2025-12-08
E · Potential for more than minimal harm
2025-12-04
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-12-08
F · Potential for more than minimal harm
2024-09-25
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-09-27
E · Potential for more than minimal harm
2024-09-25
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-09-27
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-02
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2026-01-03
E · Potential for more than minimal harm
2025-12-04
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 2025-12-05
E · Potential for more than minimal harm
2025-12-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-11
D · Potential for more than minimal harm
2025-12-04
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 2025-12-05
D · Potential for more than minimal harm
2025-12-04
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 2025-12-05
D · Potential for more than minimal harm
2025-12-04
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-12-08
D · Potential for more than minimal harm
2025-12-04
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-12-24
D · Potential for more than minimal harm
2025-12-04
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-12-05
D · Potential for more than minimal harm
2025-12-04
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-12-05
D · Potential for more than minimal harm
2025-12-04
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-12-05
D · Potential for more than minimal harm
2025-12-04
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-12-05
E · Potential for more than minimal harm
2025-11-18
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-11-19
E · Potential for more than minimal harm
2025-11-18
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-11-19
K · Immediate jeopardy
2025-10-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-10-04
K · Immediate jeopardy
2025-10-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-04
D · Potential for more than minimal harm
2025-10-02
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 2025-10-04
D · Potential for more than minimal harm
2025-10-02
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-10-04
D · Potential for more than minimal harm
2025-10-02
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-10-04
J · Immediate jeopardy
2025-08-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-12
D · Potential for more than minimal harm
2025-08-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-08-18
D · Potential for more than minimal harm
2025-03-25
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-03-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-03-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-28
E · Potential for more than minimal harm
2024-09-25
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-09-27
E · Potential for more than minimal harm
2024-09-25
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-09-27
D · Potential for more than minimal harm
2024-09-25
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 2024-09-27
D · Potential for more than minimal harm
2024-09-25
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-09-27
D · Potential for more than minimal harm
2024-09-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-27
D · Potential for more than minimal harm
2024-08-25
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-08-25
D · Potential for more than minimal harm
2024-07-10
F850 · Administration Deficiencies
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2024-07-15
G · Actual harm
2024-05-17
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 2024-05-18
D · Potential for more than minimal harm
2024-05-17
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-05-18
K · Immediate jeopardy
2024-04-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-22
D · Potential for more than minimal harm
2024-04-03
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-04-22
D · Potential for more than minimal harm
2024-03-18
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-04-02
D · Potential for more than minimal harm
2024-03-18
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-04-02
D · Potential for more than minimal harm
2024-03-18
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2024-04-02
F · Potential for more than minimal harm
2024-01-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-10
G · Actual harm
2023-12-18
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 2023-12-19
G · Actual harm
2023-12-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-19
D · Potential for more than minimal harm
2023-12-18
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-12-19
E · Potential for more than minimal harm
2023-11-02
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2023-11-07
D · Potential for more than minimal harm
2023-11-02
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-11-07
D · Potential for more than minimal harm
2023-11-02
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-11-07
E · Potential for more than minimal harm
2023-09-22
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 2023-09-23
E · Potential for more than minimal harm
2023-09-22
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-09-23
E · Potential for more than minimal harm
2023-09-22
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-09-23
J · Immediate jeopardy
2023-08-18
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 2023-08-21
J · Immediate jeopardy
2023-08-18
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-08-21
J · Immediate jeopardy
2023-08-18
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-08-21
E · Potential for more than minimal harm
2023-08-18
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-08-21
E · Potential for more than minimal harm
2023-08-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-08-21
E · Potential for more than minimal harm
2023-08-18
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 2023-08-21
D · Potential for more than minimal harm
2023-08-18
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 2023-08-21
D · Potential for more than minimal harm
2023-08-18
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-08-21
C · Minimal harm
2023-08-18
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-08-21
E · Potential for more than minimal harm
2023-08-04
F606 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Corrected 2023-08-05
D · Potential for more than minimal harm
2023-08-04
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-08-05
J · Immediate jeopardy
2023-06-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-30
J · Immediate jeopardy
2023-04-03
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-05
D · Potential for more than minimal harm
2023-04-03
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-04-05
D · Potential for more than minimal harm
2023-04-03
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-04-05
D · Potential for more than minimal harm
2023-04-03
F926 · Environmental Deficiencies
Health
Have policies on smoking.
Corrected 2023-04-05
Penalties and ownership
What sits behind the stars
$18,520
2025-08-15
Fine
Fine · fine $18,520
Fine
$161,475
2025-08-15
Fine
Fine · fine $161,475
Fine
$230,484
2024-03-18
Fine
Fine · fine $230,484
Fine
$44,590
2023-12-18
Fine
Fine · fine $44,590
Fine
$49,470
2023-08-04
Fine
Fine · fine $49,470
Fine
$14,518
2023-06-29
Fine
Fine · fine $14,518
Fine
$20,065
2023-04-03
Fine
Fine · fine $20,065
Fine
Ownership
West Wharton County Hospital District
5% Or Greater Direct Ownership Interest · Organization
930 S Baxter Opco, LLC
Operational/Managerial Control · Organization
930 S Baxter Property Owner, LLC
5% Or Greater Security Interest · Organization
Augustus, Lazel
Operational/Managerial Control · Individual
Bell, Robbin
Operational/Managerial Control · Individual
Freund, Nochum
Operational/Managerial Control · Individual
Thompson, Johnny
Corporate Director · Individual
Travitsky, Aaron
Operational/Managerial Control · Individual
Welltower Inc
5% Or Greater Security Interest · Organization
Welltower Nnn Group, LLC
5% Or Greater Security Interest · Organization
Welltower Op LLC
5% Or Greater Security Interest · Organization
Nearby options
Other facilities in reach
#1
Avir At Petal Hill
Tyler, TX
2-star overall rating with 2-star inspections with abuse icon flag with $61,847 in total fines with 7 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Park Place Nursing & Rehabilitation Center
Tyler, TX
1-star overall rating with 1-star inspections with abuse icon flag with $272,779 in total fines with 17 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Briarcliff Health Center
Tyler, TX
2-star overall rating with 3-star inspections with $51,034 in total fines with 1 recent health deficiencies
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