Tyler, TX

The Heights Of Tyler

3-star overall rating with 3-star inspections with $39,574 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

2650 Elkton Trail, Tyler, TX

(903) 266-7200

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

109

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Touchstone Communities

Operator or chain grouping

Approved since

2010-12-07

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

28 facilities

Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars

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

0.45

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

0.62

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

2.17

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

3.24

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.08

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

2.84

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.40

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.05

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.50

CMS adjusted RN staffing hours

Adjusted total hours

3.55

CMS adjusted total nurse staffing hours

Case-mix index

1.25

Higher values indicate more complex resident acuity

RN turnover

36%

Annual RN turnover · state 52% · national 45%

Total nurse turnover

64%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

13,227

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

7.34

Composite VBP score used to determine payment impact.

Payment multiplier

0.9807

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

1.75

Baseline 23.07% · Performance 21.71% · Measure score 1.75 · Achievement 0 · Improvement 1.75

Healthcare-associated infections

0

Baseline 8.24% · Performance 8.61% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

0

Performance 71.43% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

1.19

Baseline 3.39 hours · Performance 3.42 hours · Measure score 1.19 · Achievement 1.19 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.94%	10.72% 0.2 pts worse	No Different than the National Rate · Eligible stays 115 · Observed rate 10.43% · Lower 95% interval 7.5%
Discharge to community	33.76%	50.57% 16.8 pts worse	Worse than the National Rate · Eligible stays 54 · Observed rate 22.22% · Lower 95% interval 22.9%
Medicare spending per beneficiary	1.03	1.02 About the same
Drug regimen review with follow-up	98.78%	95.27% 3.5 pts better	Numerator 81 · Denominator 82
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 82
Discharge self-care score	26.92%	53.69% 26.8 pts worse	Numerator 14 · Denominator 52
Discharge mobility score	30.77%	50.94% 20.2 pts worse	Numerator 16 · Denominator 52
Pressure ulcers or injuries, new or worsened	1.22%	2.29% 1.1 pts better	Numerator 1 · Denominator 82 · Adjusted rate 0.9%
Healthcare-associated infections requiring hospitalization	8.61%	7.12% 1.5 pts worse	No Different than the National Rate · Eligible stays 51 · Observed rate 11.76% · Lower 95% interval 4.39%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 109
Staff flu vaccination coverage	0%	42% 42 pts worse	Numerator 0 · Denominator 1270
Discharge function score	32.69%	56.45% 23.8 pts worse	Numerator 17 · Denominator 52
Transfer of health information to provider	96.88%	95.95% 0.9 pts better	Numerator 31 · Denominator 32
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	2.56%	25.2% 22.6 pts worse	Numerator 1 · Denominator 39

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	3.7	2.1 1.6 pts worse	1.9 1.8 pts worse	Long Stay · 20240701-20250630 · Adjusted 3.7 · Observed 3.8 · Expected 1.9 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	2.4	2.1 0.3 pts worse	1.8 0.6 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.3 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	90.8%	97.1% 6.3 pts worse	93.4% 2.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 66.0% · 4Q avg 90.8%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	81.3%	97.9% 16.6 pts worse	95.5% 14.2 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 81.3%
Percentage of long-stay residents experiencing one or more falls with major injury	4.7%	3.3% 1.4 pts worse	3.3% 1.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 4.9% · Q3 3.2% · Q4 6.2% · 4Q avg 4.7% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	1.8%	2.7% 0.9 pts better	11.4% 9.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 2.6% · Q3 3.3% · Q4 0.0% · 4Q avg 1.8%
Percentage of long-stay residents who lose too much weight	0.3%	3.3% 3 pts better	5.4% 5.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.2% · 4Q avg 0.3%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	22.6%	18.9% 3.7 pts worse	19.6% 3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 24.4% · Q2 27.0% · Q3 22.9% · Q4 17.0% · 4Q avg 22.6%
Percentage of long-stay residents who received an antipsychotic medication	5.8%	10.8% 5 pts better	16.7% 10.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 5.4% · Q3 7.6% · Q4 3.9% · 4Q avg 5.8% · 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	12.8%	15.4% 2.6 pts better	16.3% 3.5 pts better	Long Stay · 2024Q4-2025Q3 · Q3 13.2% · Q4 4.3% · 4Q avg 12.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	8.2%	16.1% 7.9 pts better	14.9% 6.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 14.9% · Q3 6.7% · Q4 6.1% · 4Q avg 8.2% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.6%	0.5% 0.1 pts worse	1.0% 0.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.6%	0.8% 0.2 pts better	1.7% 1.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	10.4%	15.0% 4.6 pts better	19.8% 9.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 8.5% · Q3 12.7% · Q4 6.3% · 4Q avg 10.4%
Percentage of long-stay residents with pressure ulcers	1.6%	4.2% 2.6 pts better	5.1% 3.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.0% · Q3 2.8% · Q4 1.7% · 4Q avg 1.6% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	91.8%	89.7% 2.1 pts better	81.7% 10.1 pts better	Short Stay · 2024Q4-2025Q3 · Q1 97.7% · Q2 99.0% · Q3 99.0% · Q4 71.1% · 4Q avg 91.8%
Percentage of short-stay residents who had an outpatient emergency department visit	11.3%	12.0% 0.7 pts better	12.0% 0.7 pts better	Short Stay · 20240701-20250630 · Adjusted 11.3% · Observed 11.5% · Expected 11.3% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.5% 1.5 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	11.3%	88.0% 76.7 pts worse	79.7% 68.4 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 11.3%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	26.2%	25.9% 0.3 pts worse	23.9% 2.3 pts worse	Short Stay · 20240701-20250630 · Adjusted 26.2% · Observed 26.2% · Expected 23.8% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-10-30 · Fire 2024-10-30

3 health deficiencies

Top issue: Infection Control (1 deficiency)

1 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 2 Health 2023-09-20 · Fire 2023-09-20

8 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2022-08-02 · Fire 2022-08-02

10 health deficiencies

Top issue: Pharmacy Service (4 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-10-30

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-11-01

F · Potential for more than minimal harm 2023-09-20

K352 · Smoke Deficiencies

Fire Safety

Properly install and monitor supervisory attachments on automatic sprinkler systems.

Corrected 2023-11-01

F · Potential for more than minimal harm 2023-09-20

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-11-01

D · Potential for more than minimal harm 2023-09-20

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2023-11-01

D · Potential for more than minimal harm 2023-09-20

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-11-04

F · Potential for more than minimal harm 2022-08-02

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2022-10-17

Inspection history

Recent health citations

D · Potential for more than minimal harm 2024-10-30

F576 · Resident Rights Deficiencies

Health

Ensure residents have reasonable access to and privacy in their use of communication methods.

Corrected 2024-10-30

D · Potential for more than minimal harm 2024-10-30

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 2024-10-30

D · Potential for more than minimal harm 2024-10-30

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-10-30

E · Potential for more than minimal harm 2024-10-04

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2024-10-23

D · Potential for more than minimal harm 2024-10-04

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 2024-10-23

D · Potential for more than minimal harm 2024-09-18

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 2023-09-27

D · Potential for more than minimal harm 2024-08-28

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-08-29

F · Potential for more than minimal harm 2023-09-20

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 2023-10-01

D · Potential for more than minimal harm 2023-09-20

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2023-10-01

D · Potential for more than minimal harm 2023-09-20

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-10-01

C · Minimal harm 2023-09-20

F868 · Administration Deficiencies

Health

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Corrected 2023-10-01

K · Immediate jeopardy 2023-09-01

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2023-08-17

E · Potential for more than minimal harm 2023-09-01

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2023-09-15

E · Potential for more than minimal harm 2023-09-01

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2023-09-15

J · Immediate jeopardy 2023-05-24

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2023-05-25

J · Immediate jeopardy 2023-05-24

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2023-05-25

E · Potential for more than minimal harm 2023-05-24

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2023-05-25

D · Potential for more than minimal harm 2023-05-24

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 2023-05-25

D · Potential for more than minimal harm 2023-05-24

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-05-25

E · Potential for more than minimal harm 2022-08-02

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2022-08-03

C · Minimal harm 2022-08-02

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2022-08-03

Penalties and ownership

What sits behind the stars

$14,276 2023-09-01

Fine

Fine · fine $14,276

Fine

$12,649 2023-05-24

Fine

Fine · fine $12,649

Fine

$12,649 2023-05-24

Fine

Fine · fine $12,649

Fine

Ownership

Liberty County Hospital District No. 1

5% Or Greater Direct Ownership Interest · Organization

100% 35 facilities 2017-04-01

Boening, Christopher