Resident #2, admitted in late November with cerebral infarction and severe swallowing difficulties, had been designated NPO — nothing by mouth — due to dysphagia. His medical orders specified nutrition delivery only through a gastrostomy tube, with Glucerna 1.5 formula administered at 60cc per shift via stationary pump.
Yet his care plan, last revised November 25, contained contradictory instructions. While it noted his NPO status and feeding tube, it simultaneously directed staff to "offer me an alternate meal or supplement if I eat less than 50% of my foods at each meal" and "encourage/offer/assist me to drink fluids during care time opportunities."
The MDS Nurse acknowledged the dangerous oversight during a November 26 interview. She told inspectors that Resident #2's care plan "had not been updated after a recent hospitalization" and "should reflect the NPO status without the interventions of encouraging oral intake."
She admitted the contradictory instructions had been "mistakenly overlooked."
The Director of Nursing expressed similar surprise when confronted with the care plan's contents. She stated she "was unaware the care plan included interventions for oral intake" and said her expectation was that care plans would be updated with necessary care to ensure proper treatment.
Inspectors observed Resident #2 resting in bed with the enteral feeding pump and nutrition solution attached to a pole nearby. They attempted an interview but found him unable to participate due to cognitive decline, consistent with his stroke-related brain damage.
The facility's own MDS assessment, submitted November 17, indicated Resident #2's cognitive impairment was too severe to assess using standard cognitive testing. The assessment confirmed he received nutrition exclusively via feeding tube.
For stroke patients with dysphagia, oral intake poses serious risks. Cerebral infarction can damage the brain's ability to coordinate swallowing, potentially causing food or liquid to enter the airways rather than the stomach. This can lead to aspiration pneumonia, a potentially fatal condition.
The contradictory care plan created a scenario where well-meaning staff following written instructions could have endangered the resident's life by offering food or fluids he was medically prohibited from consuming.
Care plans serve as the primary communication tool between nursing staff across shifts. They translate physicians' orders and assessments into specific daily care instructions that certified nursing assistants and other staff follow during routine care.
The MDS Nurse told inspectors that care plans should be updated "on a daily basis, after incidents or review by the interdisciplinary team." She emphasized "the importance of an updated care plan was to ensure residents ordered care."
Yet Resident #2's plan had remained unchanged despite his recent hospitalization and continued NPO status. The outdated instructions for oral intake had persisted from an August 1 care plan entry, apparently predating his current swallowing restrictions.
Inspectors found no evidence that the facility's interdisciplinary team had reviewed and corrected the plan following the resident's return from the hospital. The care plan's nutrition section contained multiple dated entries, but none had removed the dangerous oral intake instructions.
The facility's care planning policy, updated in December 2024, failed to include guidelines for ensuring accuracy of care plan content. This gap may have contributed to the oversight that left contradictory instructions in place.
Federal regulations require nursing homes to develop comprehensive, person-centered care plans that meet all identified resident needs with measurable actions and timetables. The plans must be updated whenever residents experience significant changes in condition.
Resident #2's case illustrates how administrative failures can translate into direct patient safety risks. Staff members following the written care plan could have unknowingly violated his NPO status, potentially causing aspiration or other serious complications.
The inspection occurred following a complaint, suggesting someone had raised concerns about care quality at the 78218 zip code facility on Eisenhauer Road.
Heritage Nursing & Rehabilitation now faces federal scrutiny over its care planning processes and oversight of medically complex residents like Resident #2, whose stroke-related conditions require precise adherence to feeding restrictions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Heritage Nursing & Rehabilitation from 2025-11-27 including all violations, facility responses, and corrective action plans.
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