The Heights of Tyler

In the surveyor’s words

From the most serious findings on record at The Heights of Tyler, in the surveyor’s own words.

• Immediate jeopardy, patternF760Sep 1, 2023

  Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors for 1of 6 residents (Resident #1) reviewed for significant medication errors. The facility did not provide Resident #1's physician ordered Potassium Chloride ER Tablet for four days. The noncompliance was identified as PNC. The IJ began on 8/12/2023 and ended on 8/17/2023. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications. Findings included: Record review of Resident #1's face sheet, dated 8/25/23, indicated Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. […]

• Immediate jeopardy, isolatedF686May 24, 2023

  Based on interview and record review, the facility failed to ensure the necessary treatment and services, in accordance with comprehensive assessment and professional standards of practice, to prevent development of pressure injuries was provided for 1 of 4 (Resident #2) reviewed for pressure injuries. The facility failed to ensure Resident #2's did not develop a Stage 4 (a deep wound reaching muscle, ligaments, or bone) pressure ulcer. The facility failed to ensure Resident #2 received necessary treatment and services to promote healing and prevent infection of a Stage 4 pressure ulcer. The facility failed to update Resident #2's care plan to include development of a pressure ulcer and interventions to be taken. […]

• Immediate jeopardy, isolatedF760May 24, 2023

  Based on observation, interview and records review the facility failed to ensure residents were free of any significant medication errors for 1 of 4 (Resident #1) residents reviewed for medication errors. 1. The facility failed to administer Resident #1 the appropriate dose of morphine. Resident #1 was administered 5ml (100mg) of morphine 20mg/ml when her order was for morphine 20mg/ml give 0.25ml (5mg) every 3 hours as needed resulting in adverse reactions of vomiting, itching, shaking, and twitching of the eyes. 2. The facility failed to monitor Resident #1 after administering 20 times the ordered dose of morphine. 3. […]

• No harm, potential for more than minimal, widespreadF812Sep 20, 2023

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 kitchen and 4 of 4 satellite kitchens reviewed for food service. Opened food packaging in the pantry and walk-in freezer were not closed after opening. Packages of food items were not labeled, dated, and re-sealed. A bulk container of popcorn had cups left inside the product. Food storage containers were not kept clean when stored. Satellite kitchens on the halls had soiled microwaves and dried coffee spills inside cabinet drawers. A carton of thickened liquid was not dated when opened. These failures could place residents who ate food from the kitchen at risk of foodborne illness. […]

• No harm, potential for more than minimal, widespreadF921Sep 6, 2022

  Based on observation, interview, and record review, the facility failed to maintain a safe environment for all residents and RP A. The facility did not ensure the floors were clean and free from food and debris in hallways, dining areas, and resident rooms. This failure could place all residents at risk for an unsafe environment. Findings included: During an interview and record review on 09/01/2022 at 9:02 a.m., Resident #1's RP A said she had a concern that the floor was dirty below Resident #1's bed. The RP A said she reported the concern to administrative staff when she last visited the facility on 08/30/2022 and was informed the room would be deep cleaned. The RP A said she had not returned to the facility to verify if the facility had cleaned under Resident #1's bed. […]