Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Heritage At Longview Healthcare Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, positive PASRR status, and a need for a manual wheelchair was identified by the IDT and PCSP as requiring a customized manual wheelchair (CMWC). Facility records and the PASRR Compliance Call Report showed that the NF was required to submit an NFSS request for this specialized service in the LTC Online Portal within 20 business days of the IDT meeting, but the Simple LTC PASRR NFSS Activity Portal History and staff interviews confirmed the request was not submitted until well after the required timeframe. The Director of Therapy, identified by the DON and Administrator as responsible for meeting this deadline, acknowledged the late submission as an oversight, resulting in noncompliance with the facility’s PASRR policy and regulatory timeframes for specialized services authorization.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident at high risk for pressure ulcers developed an unstageable ulcer due to the facility's failure to implement necessary interventions and provide adequate care. Despite being identified as high risk, the resident's skin condition was not properly assessed or documented, and the family was not informed of the new skin breakdown. Staff interviews revealed inconsistencies in wound assessment and treatment, indicating a lack of adherence to facility policies.
A facility failed to properly handle and destroy discontinued controlled medications for three residents who had expired. An LVN improperly disposed of the medications by flushing them down the toilet, contrary to facility policy, which requires handing them over to the DON for destruction with a pharmacy consultant. The LVN was suspended and terminated after a positive drug test.
A resident with a history of cerebral infarction, schizophrenia, and dementia developed a new wound on her buttocks, but the LTC facility failed to notify the physician and the resident's family. Despite the care plan's directives and facility policies requiring notification, the responsible party was not informed until the resident was transferred to the hospital for altered mental status. Interviews confirmed the oversight, highlighting a lapse in communication regarding the resident's condition change.
A facility failed to implement a comprehensive care plan for a resident with a diabetic ulcer, resulting in missed daily dressing changes as per physician orders. The resident, with a history of heart failure and diabetes, did not receive proper wound care for several days, as confirmed by record reviews and family member concerns. Facility staff were unaware of the missed treatments, citing the absence of the treatment nurse.
A resident experienced unmanaged pain due to the facility's failure to effectively manage pain and ensure the proper functioning of a low air loss mattress. Despite having a care plan, the resident's pain was not consistently reported to the physician, and a family member's request for a medication change was not communicated. The unplugged mattress caused severe discomfort until surveyor intervention led to its re-inflation.
A facility failed to maintain food safety standards due to a persistent roof leak in the kitchen, with water dripping near food preparation areas. Staff confirmed the leak had been ongoing for over a year, and repair estimates were obtained but not acted upon. Despite the Administrator's belief that the leak posed no risk, the Dietary Manager expressed concerns about potential food contamination.
Two residents in an LTC facility did not receive their scheduled baths, despite requiring assistance with personal hygiene. One resident, with brain damage and reduced mobility, received only three baths in May and none in early June, while another, with heart failure and limited mobility, received only two baths in May and none in early June. Staff interviews revealed inconsistencies in bathing schedules and documentation, with no recorded refusals from the residents.
A long-term care facility failed to maintain an effective infection prevention and control program, as evidenced by the absence of proper signage and adherence to Enhanced Barrier Precautions for two residents. Staff members did not consistently wear gowns while providing care to residents with urinary catheters and wounds, despite the requirement to do so. Interviews revealed a lack of understanding and inconsistent application of Enhanced Barrier Precautions, leading to potential risks of cross-contamination and infection spread.
A resident with Huntington's disease was inaccurately documented as having bipolar disorder on the MDS, despite no such diagnosis in her chart. The MDS nurse acknowledged the error, which could affect the resident's care. Interviews with staff highlighted the importance of accurate assessments for proper treatment, as per facility policy and federal regulations.
A facility failed to develop a comprehensive care plan for a resident with severe cognitive impairment and multiple medical conditions, including traumatic hemorrhage and vascular dementia. The resident's PASRR positive status, requiring specialized therapies and equipment, was not included in the care plan. Interviews with staff revealed confusion over responsibility for ensuring the care plan reflected the resident's needs, contrary to facility policy.
A resident with COPD and other health issues was found to have a dirty oxygen concentrator filter, despite documentation indicating regular checks. Staff interviews revealed that the responsibility for cleaning the filters was assigned to weekend night shift nurses, but the filter remained unclean for several days. This failure contradicted the facility's policy on maintaining optimal breathing patterns and preventing infections.
A resident with dementia and other health issues had Lantiseptic cream improperly stored on her bedside table, contrary to facility policy. The cream, brought from a hospital stay, was not documented in her treatment records, and staff were unclear if it was a medication. Interviews revealed inconsistencies in understanding and implementing storage protocols, risking misuse or harm.
The facility failed to develop and implement a comprehensive care plan for a resident, omitting fall risk interventions and hospice care needs. The resident, with multiple severe diagnoses and cognitive impairment, experienced a fall resulting in a brain bleed. Staff interviews revealed delays and inconsistencies in updating the care plan, contrary to facility policy.
Failure to Timely Submit PASRR NFSS Request for Customized Wheelchair
Penalty
Summary
The deficiency involves the facility’s failure to timely coordinate a PASRR Nursing Facility Specialized Services (NFSS) request for a customized manual wheelchair (CMWC) for a resident with intellectual and developmental disabilities. The resident was an adult male with diagnoses including cerebral infarction, convulsions, and a cognitive communication deficit, and his quarterly MDS showed severe cognitive impairment with a BIMS score of 00 and a need for a manual wheelchair. His care plan documented a positive PASRR status and the expectation that he would receive specialized services recommended by the local authority. A PASRR IDT meeting and Person-Centered Service Plan (PCSP) were completed on 08/18/2025, identifying the need for a new CMWC. The PASRR Compliance Call Report indicated that, based on this IDT date, the NF was required to submit the NFSS form for therapies, including the CMWC, in the LTC Online Portal by 09/12/2025 (within 20 business days of the IDT meeting). Record review of the Simple LTC PASRR NFSS Activity Portal History showed that the NFSS request for the CMWC was not submitted within the required 20 business days. The Director of Therapy stated in interview that the NFSS request for the custom wheelchair was actually submitted on 11/07/2025, which was past the 20-business-day requirement, and described this as an oversight. The DON and the Administrator both stated in interviews that the Director of Therapy was responsible for ensuring the NFSS deadline was met and acknowledged that the deadline had been missed. During observation, the resident was seen seated on a couch with his CMWC next to him, but he was non-verbal and could not be interviewed. The facility’s PASRR policy stated that, after the IDT meeting, the NF must submit information from the IDT meeting on the LTC Online Portal and must submit prior authorization requests for NF specialized services via the NFSS form, which did not occur within the required timeframe for this resident’s CMWC request.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Prevent and Treat Pressure Ulcer
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development of pressure injuries for a resident, leading to the development of an unstageable pressure ulcer. The resident, who was at high risk for pressure ulcers due to severe cognitive impairment, decreased mobility, and incontinence, was not properly assessed or treated for pressure injuries. Despite being identified as high risk on the Braden Scale, the facility did not implement adequate interventions to prevent pressure ulcer development. The resident's care plan included interventions for pressure ulcer prevention, such as educating caregivers, following facility protocols, and providing incontinent care. However, these interventions were not effectively implemented. The facility staff failed to identify and document the presence of an unstageable pressure ulcer on the resident's sacral area. There was a lack of communication and documentation regarding the resident's skin condition, and the family was not notified of the new skin breakdown. Interviews with facility staff revealed inconsistencies in the assessment and treatment of the resident's skin condition. The staff did not perform proper wound assessments, and there was confusion about the presence and severity of the wound. The facility's policies for pressure injury prevention and treatment were not followed, leading to the development of an unstageable pressure ulcer that was only identified after the resident was transferred to the hospital.
Improper Handling and Destruction of Controlled Medications
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring the proper handling and destruction of discontinued controlled medications for three residents who had expired. These residents had been receiving hospice care and had various diagnoses, including liver cancer, lung cancer, and prostate cancer. The medications in question included Hydrocodone, Lorazepam, and Morphine Sulfate, which were not removed from the medication cart or destroyed according to facility policy after the residents' deaths. The deficiency was further compounded by the actions of an LVN who, instead of following the proper protocol of handing over the medications to the Director of Nursing (DON) for destruction with the pharmacy consultant, decided to destroy the medications himself by flushing them down the toilet. This action was taken without a witness and without proper documentation, which is against the facility's policy. The LVN admitted to being tired and frustrated, which led to his decision to improperly dispose of the medications. Interviews with the DON and the Administrator revealed that the facility's expectation was for nurses to turn in all discontinued narcotic medications to the DON for proper destruction. The LVN involved was suspended and ultimately terminated after a drug test returned positive results for several substances, and he failed to provide prescriptions for them. The facility's policies clearly outlined the correct procedures for handling discontinued medications, which were not followed in this instance.
Failure to Notify Physician and Family of Resident's Condition Change
Penalty
Summary
The facility failed to consult with the physician and notify the responsible party when a resident experienced a change in condition. Specifically, the facility did not inform the physician or the resident's family when a new wound was discovered on the resident's buttocks. This oversight was identified during a review of records and interviews, revealing that the resident had a history of cerebral infarction, paranoid schizophrenia, contractures, and dementia, and was at high risk for developing pressure ulcers due to her condition. The resident's care plan included interventions for preventing skin breakdown, such as educating family and caregivers, following facility protocols, and notifying family and caregivers of any new skin breakdown. However, when a CNA informed an LVN of the new wound, the LVN consulted a nurse practitioner but did not notify the resident's family or the physician. The resident's daughter, who was the responsible party, was not informed of the wound until the resident was transferred to the hospital for altered mental status. Interviews with facility staff, including the ADON and the DON, confirmed that the responsible party was not notified of the new wound as required by the facility's policies. The facility's policy on notifying the physician of a change in status and the policy on pressure injury prevention and treatment both emphasize the importance of notifying the physician and family of significant changes in a resident's condition. Despite these policies, the facility failed to communicate the resident's change in condition, leading to a delay in addressing the wound appropriately.
Failure to Implement Care Plan for Diabetic Ulcer
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, specifically in the management of a diabetic ulcer on the resident's left second toe. The care plan required daily dressing changes as per physician orders, but the dressing was not changed for several days, as evidenced by the dressing being dated 2/9/2025 and not changed until 2/12/2025. This lapse in care was confirmed through record reviews, observations, and interviews with the resident's family member, who expressed concern about the lack of adherence to the care plan. The resident, a female with a history of diastolic congestive heart failure, protein calorie malnutrition, and type 2 diabetes mellitus, was admitted to the facility with intact cognition and at risk for pressure ulcers. Despite the physician's orders and the care plan specifying daily treatment, the treatment administration record showed missed treatments on 2/9/2025, 2/10/2025, and 2/11/2025. Interviews with facility staff, including the DON and Administrator, revealed a lack of awareness and accountability for the missed treatments, with explanations citing the absence of the treatment nurse and failure of the charge nurse to complete the wound care.
Inadequate Pain Management and Equipment Oversight
Penalty
Summary
The facility failed to provide adequate pain management for a resident, leading to unnecessary pain and decreased quality of life. The resident, who had a history of muscle spasms and pain, was not effectively managed for pain despite having a care plan that included interventions for pain relief. The resident's pain was not consistently reported to the physician, and a family member's request for a medication change to address muscle spasms was not communicated to the physician by the LVN. Additionally, the resident's low air loss mattress, which was intended to prevent pain and pressure ulcers, was found unplugged and not functioning. This oversight resulted in the resident experiencing severe pain, as he felt like he was lying on a board. The mattress was only plugged back in after surveyor intervention, which significantly alleviated the resident's pain once it was re-inflated. Interviews with staff revealed a lack of communication and follow-through regarding the resident's pain management needs. The resident frequently complained of pain, especially during repositioning and wound care, yet there was no documentation of these complaints being addressed or reported to the physician. The facility's failure to manage the resident's pain effectively and ensure the proper functioning of equipment contributed to the resident's ongoing discomfort.
Persistent Roof Leak in Kitchen Raises Food Safety Concerns
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards due to a persistent roof leak in the kitchen. Observations revealed water dripping from the range hood and nearby ceiling tiles, with the water collecting in buckets placed on the floor. The leak was noted to be ongoing for a significant period, with staff indicating it had been an issue for over a year. The water was observed dripping near food preparation areas, specifically near the deep fryer where chicken was being prepared, raising concerns about potential food contamination. Interviews with staff, including the Dietary Aide, Dietary Manager, Maintenance Supervisor, and Administrator, confirmed awareness of the leak. The Maintenance Supervisor mentioned that repair estimates had been obtained from three roofing companies, but no repairs had been attempted. The Administrator acknowledged the issue was brought to his attention in November 2023, and bids for repairs were received, but corporate had not yet addressed the problem. Despite the Administrator's belief that the leak did not pose a risk to food safety, the Dietary Manager expressed concerns about the possibility of water dripping into residents' food.
Failure to Provide Scheduled Baths for Residents
Penalty
Summary
The facility failed to provide necessary services to maintain personal hygiene for two residents who were unable to perform activities of daily living independently. Resident #25, who had diagnoses including brain damage, reduced mobility, and depression, required substantial assistance with bathing. Despite being scheduled for baths three times a week, documentation showed that Resident #25 received only three baths in May 2024 and none in early June 2024. Interviews with Resident #25 confirmed infrequent bathing, and there was no documentation of refusal to bathe. Similarly, Resident #43, who had diagnoses including heart failure, depression, and reduced mobility, required partial assistance with bathing. The resident was scheduled for baths on Mondays, Wednesdays, and Fridays, but records indicated only two baths in May 2024 and none in early June 2024. Resident #43 expressed dissatisfaction with the infrequency of baths, preferring bed baths due to discomfort with the shower chair. There was no documentation of refusal, and staff interviews revealed inconsistencies in the provision of scheduled baths. Interviews with staff, including CNAs and an LVN, highlighted a lack of adherence to the bathing schedule and inadequate documentation of refusals. The ADON and Administrator acknowledged the issue, attributing it to potential documentation errors and problems with the electronic charting system. Despite the lack of documented refusals, both residents reported not receiving their scheduled baths, which could lead to dignity issues and skin problems.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of proper signage and adherence to Enhanced Barrier Precautions for two residents. Resident #34, who had a urinary catheter, did not have a sign on her door indicating the need for Enhanced Barrier Precautions, which are necessary to prevent the spread of infection. The Assistant Director of Nursing (ADON), who also served as the Infection Preventionist, acknowledged the absence of the sign and stated it should have been there. Similarly, Resident #203, who had a stage 4 pressure ulcer, a urinary catheter, and a gallbladder drain, also lacked proper signage on his door. During observations, it was noted that staff members, including CNA E, LVN G, and RN F, did not wear gowns while providing care to Resident #203, despite the requirement to do so under Enhanced Barrier Precautions. The ADON confirmed that Enhanced Barrier Precautions were in place for residents with urinary catheters and wounds to prevent infection spread. Interviews with staff revealed a lack of understanding and inconsistent application of Enhanced Barrier Precautions. CNA E and LVN G admitted to not wearing gowns during care activities, and CNA E was unaware of what Enhanced Barrier Precautions entailed. The facility's policy required the use of gowns and gloves during high-contact resident care activities to prevent the transmission of multidrug-resistant organisms, but this was not consistently followed, leading to potential risks of cross-contamination and infection spread.
Inaccurate Resident Assessment Leads to Incorrect Diagnosis
Penalty
Summary
The facility failed to ensure an accurate assessment for one resident, leading to an incorrect diagnosis of bipolar disorder. The resident, a female with Huntington's disease, mood disorder, and cognitive communication disorder, was inaccurately documented as having bipolar disorder on the Minimum Data Set (MDS). The MDS nurse, responsible for the accuracy of the MDS, acknowledged the absence of a bipolar diagnosis in the resident's chart and planned to correct the error with the assistance of the Regional Nurse. The inaccurate assessment could potentially impact the resident's treatment and care. Interviews with facility staff, including the MDS nurse, Assistant Director of Nursing (ADON), and Administrator (ADM), highlighted the importance of accurate assessments for proper resident care. The ADON emphasized that incorrect diagnoses could lead to inappropriate interventions and care plans. The facility's policy on MDS assessment data accuracy, aligned with federal regulations, mandates that assessments accurately reflect the resident's status through direct observation and communication with staff. The policy requires staff to certify the accuracy of their assessment portions, underscoring the significance of precise documentation.
Failure to Implement Comprehensive Care Plan for PASRR Positive Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, identified as Resident #12, who was readmitted with multiple medical conditions including traumatic hemorrhage of the cerebrum, cognitive communication deficit, vascular dementia, and severe protein-calorie malnutrition. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and dependency on two or more staff for activities of daily living (ADLs). Despite these needs, the facility did not create a care plan that addressed the resident's PASRR (Preadmission Screening and Resident Review) positive status, which required specialized occupational therapy, physical therapy, and durable medical equipment. Interviews with facility staff, including the social worker, LVN, MDS nurse, ADON, and ADM, revealed a lack of clarity and responsibility in ensuring that the resident's PASRR positive status was included in the care plan. The MDS nurse was identified as responsible for completing the PASRR and ensuring it was reflected in the care plan, but this was not done. The facility's policy on comprehensive care planning emphasized the need for a person-centered care plan with measurable objectives and timeframes, but this was not adhered to for Resident #12, potentially impacting the resident's quality of life and access to necessary services.
Failure to Maintain Clean Oxygen Concentrator Filter
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident with COPD, heart failure, and other conditions. The resident's oxygen concentrator filter was observed to be covered in gray fuzz and dust-like particles, despite documentation indicating that the filter had been checked for cleanliness on multiple occasions. Interviews with staff revealed that the responsibility for cleaning the oxygen concentrator filters fell on the weekend night shift nurses, but the filter remained dirty over several days. Staff members, including an RN, an LVN, the ADON, and the ADM, acknowledged that a dirty oxygen concentrator filter could lead to allergens, reduced oxygen intake, and potential respiratory issues for the resident. The facility's policy on breathing therapy devices emphasized maintaining optimal breathing patterns and preventing infections, yet the observed condition of the oxygen concentrator filter contradicted these goals. The deficiency was identified through observations and interviews, highlighting a lapse in the facility's adherence to its own policies and procedures regarding respiratory care.
Improper Storage of Lantiseptic Cream
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments under proper temperature controls, and only authorized personnel had access to the keys. This deficiency was observed in the case of a resident who had a container of Lantiseptic skin protectant 50% cream on her bedside table. The cream was not stored in accordance with professional standards, as it was not locked away, and there was no order for its use in the resident's medication or treatment administration records. The resident involved was an elderly female with a history of dementia, atherosclerosis with gangrene, hypertensive heart disease, and a chronic ulcer. Her care plan included enhanced barrier precautions and the application of a moisture barrier after incontinence episodes. However, the Lantiseptic cream, which was supposed to be applied after such episodes, was not documented in her treatment records, and there was no order for its use. The cream was reportedly brought back by the resident from a hospital stay, and staff interviews revealed confusion about whether it was considered a medication and how it should be stored. Interviews with facility staff, including CNAs, LVNs, and the ADON, highlighted inconsistencies in the understanding and implementation of medication storage policies. Some staff considered Lantiseptic a medication that should be stored in a medication cart, while others did not. The facility's policy allowed for bedside storage of certain medications under specific conditions, but these conditions were not met in this case. The lack of clarity and adherence to storage protocols could potentially lead to misuse or harm, especially given the cognitive impairments of some residents.
Failure to Develop and Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, leading to deficiencies in addressing the resident's medical, nursing, mental, and psychosocial needs. Specifically, the facility did not include an intervention for a fall mat in the care plan, despite the resident being at risk for falls. Additionally, the facility did not develop a hospice care plan for the resident, even though hospice services had been initiated. These omissions were identified through record reviews and staff interviews, which revealed inconsistencies and delays in updating the care plan to reflect the resident's current needs and conditions. The resident in question was an elderly female with multiple diagnoses, including encephalopathy, intracerebral hemorrhage, brain tumor, protein-calorie malnutrition, diabetes with hyperglycemia, osteoporosis, and muscle weakness. Her cognitive function was severely impaired, requiring extensive assistance for transfers and bed mobility. Despite these conditions, the care plan did not adequately address fall risks or hospice care needs. The resident had a fall that resulted in her hitting her head on a bedside table, leading to a brain bleed, which further highlighted the inadequacies in her care plan. Interviews with various staff members, including an LVN, the MDS nurse, the DON, and the ADM, revealed a lack of clarity and communication regarding the resident's care plan updates. The MDS nurse mentioned that care plans should be updated within 24 hours of any significant change, but this was not done in the resident's case. The DON and ADM were unsure about the resident's fall risk status and whether hospice care had been properly care planned. The facility's policy on comprehensive care planning was not followed, resulting in the resident's needs not being fully met.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Longview
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Oaks At Longview | 0 mi | ★★★★★ | 8 | 0 |
| Avir At Longview | 0.2 mi | ★★★★★ | 8 | 0 |
| Buckner Westminster Place | 0.5 mi | ★★★★★ | 0 | 0 |
| Longview Hill Nursing And Rehabilitation Center | 0.9 mi | ★★★★★ | 13 | 0 |
| Highland Pines Nursing Home | 1.6 mi | ★★★★★ | 10 | 0 |
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