Greenbrier Nursing & Rehabilitation Center of Tyle

Name: Greenbrier Nursing & Rehabilitation Center of Tyle
Address: 3526 West Erwin Street, Tyler, TX, 75702, US
Telephone: 9035936441

3526 West Erwin Street, Tyler, TX 75702 · Smith County · 120 certified beds · avg 54 residents/day · certified since Feb 14, 1994

Part of chain: CREATIVE SOLUTIONS IN HEALTHCARE (149 facilities, chain avg rating 2.1★)

3/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

3.49

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 2/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

All citations in the current public record (28)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Mar 25, 2026	E · Potential for harm, repeated	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Mar 25, 2026	E · Potential for harm, repeated	The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care.
Mar 25, 2026	E · Potential for harm, repeated	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Mar 25, 2026	D · Potential for harm, one-off	The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Mar 25, 2026	D · Potential for harm, one-off	The facility did not update each resident's care assessment at least once every 3 months. These regular check-ins keep the resident's care plan matched to their current condition.
Mar 25, 2026	D · Potential for harm, one-off	The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Mar 25, 2026	D · Potential for harm, one-off	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Mar 25, 2026	D · Potential for harm, one-off	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Mar 25, 2026	D · Potential for harm, one-off	The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Mar 25, 2026	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Mar 25, 2026	D · Potential for harm, one-off	The facility did not have enough support staff to safely and effectively run its food and nutrition service.
Mar 25, 2026	D · Potential for harm, one-off	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Mar 25, 2026	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Mar 25, 2026	D · Potential for harm, one-off	The facility did not have firmly secured handrails on both sides of its hallways.
Mar 25, 2026	D · Potential for harm, one-off	The facility did not have policies on smoking.
Aug 13, 2025	D · Potential for harm, one-off	The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint
Aug 13, 2025	D · Potential for harm, one-off	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
Aug 13, 2025	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Dec 18, 2024	E · Potential for harm, repeated	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Dec 18, 2024	D · Potential for harm, one-off	The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes.
Dec 18, 2024	D · Potential for harm, one-off	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Dec 18, 2024	D · Potential for harm, one-off	The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors.
Oct 6, 2024	D · Potential for harm, one-off	The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Oct 6, 2024	D · Potential for harm, one-off	The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint
Oct 6, 2024	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
May 21, 2024	E · Potential for harm, repeated	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
Jan 8, 2024	E · Potential for harm, repeated	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Nov 15, 2023	E · Potential for harm, repeated	The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need.

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (4 → 15).

Year	Citations	Worst severity that year
2023	1	E
2024	9	E
2025	3	D
2026	15	E

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Texas avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	3.49	3.46	3.95	top 35% in Texas; bottom 36% in the U.S.
Registered Nurse hours	0.24	0.44	0.69	bottom 16% in Texas; bottom 5% in the U.S.
Weekend total nurse staffing	3.02	3.04	3.50	top 40% in Texas; bottom 32% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.21	0.34	0.48	bottom 24% in Texas; bottom 13% in the U.S.
Total nursing staff turnover (%)	96.6	55.3	45.8	bottom 4% in Texas; bottom 1% in the U.S.
RN turnover (%)	100.0	54.6	42.9	bottom 8% in Texas; bottom 1% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.06, RN 0.21, weekend 2.64. Staffing rating: 1/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 3/5 · long-stay residents: 4/5 · short-stay residents: 2/5

Who owns this facility

For profit - Corporation

Owner / manager	Type	Role	Stake	Since
Liberty County Hospital District No 1	Organization	5% or Greater Direct Ownership Interest	100%	04/01/2022
Blake, Gary	Individual	Operational/Managerial Control	NOT APPLICABLE	04/01/2022
Blake, Gary	Individual	ADP of the SNF	NOT APPLICABLE	04/01/2022
Blake, Malisa	Individual	Operational/Managerial Control	NOT APPLICABLE	04/01/2022
Fregia, Milton	Individual	Managing Control - Governing Body	NOT APPLICABLE	05/07/2022
Gardner, Shannon	Individual	Managing Control - Governing Body	NOT APPLICABLE	08/22/2022
Gardzina, Margaret	Individual	Managing Control - Governing Body	NOT APPLICABLE	02/26/2024
Hekimian, Khoren	Individual	ADP of the SNF	NOT APPLICABLE	04/11/2025
Henry, Paul	Individual	Managing Control - Governing Body	NOT APPLICABLE	05/09/2009
Huggins, Linda	Individual	Corporate Director	NOT APPLICABLE	04/01/2022
Stepps, Laurie	Individual	ADP of the SNF	NOT APPLICABLE	04/11/2025
Stratton, Charles	Individual	Managing Control - Governing Body	NOT APPLICABLE	05/01/2005
Stratton, Charles	Individual	Corporate Officer	NOT APPLICABLE	05/01/2005
Tyler II Enterprises, LLC	Organization	Operational/Managerial Control	NOT APPLICABLE	04/01/2022
Tyler II Enterprises, LLC	Organization	ADP of the SNF	NOT APPLICABLE	04/01/2022
Willig, Zachary	Individual	Corporate Director	NOT APPLICABLE	01/01/2025

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
"What is your nurse and aide staffing ratio on each shift, including nights and weekends?"
"How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
"If my family member falls or their condition changes, exactly when and how will I be notified?"
"How do you track that every resident's quarterly assessment happens on time?"
"Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
"How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
"What is your current medication error rate, and what have you changed to bring errors down?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
Briarcliff Health Center	3.0 mi	Tyler, TX	★★☆☆☆	3/5
Avir at Azalea Heights	3.1 mi	Tyler, TX	★★☆☆☆	3/5
Avir at Petal Hill	3.3 mi	Tyler, TX	★★☆☆☆	2/5	abuse
Avir at Rose Trail	3.3 mi	Tyler, TX	★☆☆☆☆	1/5	SFF
Park Place Nursing & Rehabilitation Center	4.3 mi	Tyler, TX	★☆☆☆☆	1/5	abuse
Reunion Plaza Healthcare & Rehabilitation	4.3 mi	Tyler, TX	★★★★☆	5/5
The Heights of Tyler	5.2 mi	Tyler, TX	★★★☆☆	4/5
Providence Park Rehabilitation and Skilled Nursing	5.2 mi	Tyler, TX	★★☆☆☆	2/5
Meadow Lake Health Center	5.5 mi	Tyler, TX	★★★★★	5/5
The Waterton Healthcare & Rehabilitation	5.9 mi	Tyler, TX	★★★★☆	4/5
The Center at Grande	7.1 mi	Tyler, TX	★★★★★	5/5
Chandler Nursing Center	8.8 mi	Chandler, TX	★★★★☆	4/5

Compare this facility with the 3 closest →

All facilities in Tyler →

Facility data as of CMS processing date 2026-08-01. CCN 675267.

The Care File

Visit checklist — Greenbrier Nursing & Rehabilitation Center of Tyle

3526 West Erwin Street, Tyler, TX 75702 · 9035936441

Health inspection rating 3/5 · CMS overall 2/5· Fines (3y): $0

Questions for the administrator:

☐ "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
☐ "What is your nurse and aide staffing ratio on each shift, including nights and weekends?"
☐ "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
☐ "If my family member falls or their condition changes, exactly when and how will I be notified?"
☐ "How do you track that every resident's quarterly assessment happens on time?"
☐ "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
☐ "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
☐ "What is your current medication error rate, and what have you changed to bring errors down?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 675267 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)