Heritage Plaza Nursing Center: Wrong Medication Given - TX
Staff tried. Nobody could rouse her. The Director of Nursing was called.
The resident, identified in inspection records only as Resident 1, had been given Acetaminophen around 10:30 PM on July 17, 2025, by a licensed vocational nurse identified as LVN A. LVN A had a standing order to give the medication as needed for pain. She said someone had told her the resident was hurting and waiting for the medication to be given. She gave it. She did not document it properly. She did not complete the required pain scale assessment before or after administering it, the kind of record that tracks whether a resident actually needed the dose and whether it helped.
She also did not tell the resident she would check on her through the night.
The next morning, the Director of Rehabilitation found Resident 1 unable to hold a conversation, drowsy in a way that was not normal for her. The director notified the Director of Nursing and did not take the resident to therapy that morning. The Director of Nursing came to the room, was able to wake the resident, and then continued getting her dressed.
What nobody knew yet, or at least nobody had told LVN A, was that the resident's roommate believed something else had happened the night before. The roommate believed LVN A had given Resident 1 the roommate's Seroquel by mistake. Seroquel is an antipsychotic medication. LVN A said she did not learn about this concern until the following day, July 18, when the Director of Nursing called her by phone. She said she had no idea the roommate or Resident 1 thought she had received the wrong drug.
Federal inspectors from the Centers for Medicare and Medicaid Services visited Heritage Plaza on August 18, 2025, following a complaint. The inspection classified the violation as causing minimal harm or the potential for actual harm, and noted that only a few residents were affected.
LVN A, interviewed the day inspectors arrived, acknowledged that documenting pain assessments before and after giving pain medication was important. She acknowledged that skipping documentation put residents at risk of receiving too much medication, which she said could result in toxicity. Asked why she had not completed the required records, she said she guessed she was busy and forgot.
The Director of Nursing told inspectors she had not known until that same day that LVN A had failed to complete the pain assessment documentation. She said the facility's electronic system was designed to prompt the documentation automatically: once a medication is entered into the medication administration record, an assessment screen opens for the nurse to fill out. She said proper documentation was essential for staff coordination and for catching problems with dosage, whether a resident was getting too much or not enough.
She said she expected staff to follow the protocol.
Whether Resident 1 received her roommate's Seroquel or only her own Tylenol, the record of what actually happened that night is incomplete. LVN A did not document an assessment. She did not note the time she gave the medication in the required format. She did not check on the resident afterward. By the time anyone thought to ask questions, it was the next morning, and a woman who could not be woken was being dressed and sent on with her day.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Heritage Plaza Nursing Center from 2025-08-18 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
HERITAGE PLAZA NURSING CENTER in TEXARKANA, TX was cited for violations during a health inspection on August 18, 2025.
The Director of Nursing was called.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.