Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 The Oaks At Longview during CMS and state inspections, most recent first.
A resident with diabetes and severe cognitive impairment did not receive a physician-ordered diabetic diet, despite elevated HGBA1C levels and family requests. Facility staff were unaware or misinformed about the availability of diabetic diets, and the dietary manager and RD were not notified of the need for a special diet. The attending physician was not informed of the family's request until prompted by a surveyor, and the facility's policy for therapeutic diets was not followed.
The facility did not promote or facilitate resident self-determination by failing to support resident choice, as required by regulations.
Residents were not given the opportunity or support to organize and participate in resident or family groups, as required by regulations.
A resident with severe cognitive impairment was exposed to excessive noise in the dining area when loud gospel music and a television were played simultaneously, causing distress. Despite care plan interventions to reduce distractions, staff were unaware of prior complaints and did not ensure a comfortable environment as required by facility policy.
Two residents had MDS assessments that inaccurately documented the use of anticoagulant medications, despite physician orders and care plans indicating they were only prescribed antiplatelet medications such as aspirin and clopidogrel. Staff interviews confirmed the assessments were marked incorrectly, and facility policy requiring accurate use of the RAI for MDS processes was not followed.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain the services of a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A facility failed to perform weekly skin assessments for four residents, as required by their care plans and policy. The Treatment Nurse was off work during the missed assessments, and the responsibility was not effectively delegated to charge nurses. This oversight occurred despite a new EMR system designed to alert staff when assessments were due.
The facility failed to obtain informed consent for psychotropic medications for five residents, as required by policy. Interviews revealed that staff were unclear about the process for obtaining consents, and the responsible ADON was unavailable. This resulted in medications being administered without residents or their responsible parties being informed of the risks and benefits.
The facility failed to implement its abuse prevention policies by not conducting required criminal background checks and EMR reports for certain staff members, potentially placing residents at risk. Interviews revealed a lack of clarity in responsibilities for these checks, despite policies mandating them.
The facility failed to accurately code the MDS assessments for three residents, omitting diagnoses of anxiety, depression, and bipolar disorder. This oversight, attributed to a staff member in training, led to discrepancies between the residents' actual conditions and their documented assessments, potentially affecting their care plans.
The facility failed to conduct annual competency evaluations for five CNAs, as revealed by a review of personnel files. The DON and ADM acknowledged that the lack of evaluations could lead to inadequate care due to CNAs not being informed of new processes. The facility also lacked a policy for staff development and training, as confirmed by the employee handbook.
The facility failed to ensure adequate behavior and side effect monitoring for several residents prescribed psychotropic medications. A resident did not have side effect monitoring for Seroquel, Buspirone, Venlafaxine, and Remeron, while another lacked monitoring for Paroxetine and Lorazepam. Additionally, a resident was prescribed Depakote without proper monitoring, and another was given Seroquel and Hydroxyzine without an appropriate diagnosis or monitoring. Staff acknowledged the importance of these measures but did not implement them effectively.
The facility failed to document and administer influenza and pneumococcal vaccinations to 19 residents, as revealed through interviews and record reviews. The DON and ADM were unaware of these deficiencies, despite acknowledging the importance of vaccinations. The ADON noted that vaccines were offered during admission, but records were not accurately maintained, contrary to the facility's policies.
The facility failed to provide the required 12 hours of annual in-service training for CNAs, affecting five staff members. Interviews revealed confusion over responsibility for training records, with HR, the DON, and the ADM all indicating different roles. The absence of a policy for staff development and training was confirmed, potentially placing residents at risk due to untrained staff.
A resident with dementia and Parkinsonism was instructed by staff to urinate in her brief, compromising her dignity. Despite requiring assistance for toileting, staff failed to respond to her call light, leading to her family taking her home. Interviews revealed that while staff generally tried to assist, inappropriate instructions were given, which the DON and ADM acknowledged as a dignity issue.
A resident with dementia and cognitive impairments developed a bruise on her jaw, which was not reported as an injury of unknown origin within the required timeframe. The facility attributed the bruise to the resident's habit of sleeping with a bed controller and a baby doll, but failed to report it to the state agency as required by their abuse prevention policy.
A resident with Alzheimer's disease was observed using a wheelchair with dried substances and tangled hair on the wheels, indicating a lack of cleanliness. Interviews with staff revealed confusion over responsibilities for cleaning and maintaining wheelchairs, with CNAs and maintenance both cited as responsible. The deficiency highlights an infection control issue due to the unclean wheelchair.
A facility failed to complete a baseline care plan for a newly admitted resident with dementia within 48 hours, as required by policy. The resident's responsible party was not involved in care planning or provided with a care plan copy. Staff interviews revealed confusion about responsibility for care plan initiation and completion, leading to the deficiency.
The facility failed to implement comprehensive care plans for two residents, leading to deficiencies in addressing their needs. One resident's care plan did not include the use of a necessary bed rail, while another resident lacked a smoking care plan and quarterly assessments for smoking and elopement risk. Staff interviews revealed confusion about responsibilities for updating care plans and completing assessments, resulting in potential risks to residents' safety and well-being.
A facility failed to document catheter orders and care for a resident with an indwelling urinary catheter, leading to potential risks of urinary tract infections. The resident, with chronic kidney disease, was admitted without documented catheter size, bulb fluid amount, or care orders. Staff interviews revealed the omission was due to a new charting system and lack of training. Facility policies emphasized the need for complete documentation to prevent infections.
A resident with COPD and respiratory failure did not receive proper respiratory care as their nasal cannula and nebulizer mask were not stored in bags when not in use. Observations and staff interviews confirmed this oversight, which could lead to contamination and respiratory infections. Facility policy requires such equipment to be free from microorganisms.
A dietary aide in the facility's food and nutrition service department did not obtain a required food handler's certificate, despite being hired months prior and receiving multiple reminders. The lack of certification was attributed to unclear responsibilities among staff and management transitions, potentially impacting food safety for all residents.
A facility failed to maintain safe wheelchair equipment for a resident with Alzheimer's, resulting in a loose brake handle. Staff, including a CNA and maintenance supervisor, acknowledged the risk of falls but had not previously identified the issue. Despite expectations for staff to report equipment problems, the facility did not provide a policy on maintenance responsibilities.
Failure to Provide Physician-Ordered Therapeutic Diabetic Diet
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a therapeutic diabetic diet was prescribed and provided to a resident with type 2 diabetes mellitus, noninfective gastroenteritis and colitis, and gastrointestinal hemorrhage. The resident, who had severely impaired cognition and required assistance with eating, was admitted with a history of diabetes and had care plan interventions indicating the need for a diabetic diet and small, frequent meals. However, the electronic health record and care plan did not reflect an order for a therapeutic diet, and the nutrition assessment did not address the resident's diabetes or the need for small, frequent meals. Despite elevated HGBA1C levels documented in the resident's record, family members' concerns about uncontrolled blood sugars, and requests for a diabetic diet, facility staff—including the ADON and LVNs—communicated to the family that a diabetic diet was not available. The dietary manager and registered dietitian were not made aware of the need for a diabetic diet or small, frequent meals, and no diet order was provided to the kitchen. The registered dietitian had not assessed the resident, as the resident had not triggered for assessment based on the facility's criteria. The attending physician was not informed of the family's request for a diabetic diet and only became aware after state surveyor intervention. The physician stated that he would have ordered a diabetic diet if he had been informed. The facility's own policy required physician orders for therapeutic diets and consultation with the registered dietitian, but these procedures were not followed, resulting in the resident not receiving the prescribed therapeutic diet.
Failure to Support Resident Self-Determination and Choice
Penalty
Summary
The facility failed to honor the resident's right to self-determination by not promoting and facilitating resident choice. This deficiency was identified based on observations or findings that the facility did not adequately support or encourage residents to make their own choices regarding their care or daily life, as required by regulations. No additional details about specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Failure to Support Resident/Family Group Participation
Penalty
Summary
The facility failed to honor the right of residents to organize and participate in resident and family groups. This deficiency was identified based on observations and interviews indicating that residents were not provided the opportunity or support to form or participate in such groups within the facility. There were no specific details provided about individual residents, their medical history, or their condition at the time of the deficiency.
Failure to Maintain Comfortable Noise Levels in Dining Area
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment by not ensuring a comfortable noise level in the dining room for a resident with severe cognitive impairment. During a lunch meal, gospel music was played loudly over a speaker while the television was also on, resulting in the resident covering her ears and expressing that it was too loud. The resident, who had a history of dementia, stroke, and traumatic brain injury, was observed to be distressed by the noise and indicated that the music was often played too loudly. Her care plan included interventions to reduce distractions such as turning off the TV or radio. Staff interviews revealed that the music and television were not usually played simultaneously, and staff were generally unaware of any prior complaints about noise levels from the resident. The staff responsible for entertainment and the DON both stated that they would have turned down the music if a complaint was made, but were not aware of any previous issues. The facility's policy emphasized the importance of maintaining comfortable noise levels to create a homelike atmosphere, but this was not followed during the observed incident.
Inaccurate MDS Medication Assessment for Two Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the medication status of two residents. For both residents, the MDS assessments incorrectly indicated the use of anticoagulant medications, when in fact, physician orders and care plans showed that they were prescribed antiplatelet medications (aspirin and clopidogrel) and not anticoagulants. The care plans for both residents specifically addressed antiplatelet therapy and related interventions, and there were no orders for anticoagulant medications in their records. Interviews with facility staff, including the MDS Coordinator, ADON, DON, and Administrator, confirmed that the MDS assessments were marked incorrectly regarding anticoagulant use. The MDS Coordinator acknowledged the error and was unsure how the incorrect information was entered. The facility's policy required the interdisciplinary team to utilize the Resident Assessment Instrument (RAI) for all MDS processes, but this was not followed accurately in these cases.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations.
Failure to Conduct Weekly Skin Assessments
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility did not perform weekly skin assessments for four residents, as required by their care plans and facility policy. Resident #1 did not have skin assessments documented on two occasions, while Residents #2, #3, and #4 missed one weekly assessment each. These lapses in care could lead to skin issues being missed or deteriorating without proper monitoring. Resident #1, a female with dementia and other health conditions, was at moderate risk for impaired skin integrity. Her care plan required weekly skin assessments, but assessments were not documented for two weeks in August 2024. Resident #2, also with dementia and other conditions, was at minimum risk for skin issues but missed one weekly assessment. She had a history of redness and yeast rash under her breasts, which required treatment. Resident #3, severely cognitively impaired, and Resident #4, with bipolar disorder and other diagnoses, also missed one weekly skin assessment each, although they did not have documented skin impairments at the time. The Treatment Nurse, responsible for conducting these assessments, was off work during the week when the assessments were missed. The Director of Nursing (DON) stated that charge nurses were responsible for completing assessments in the Treatment Nurse's absence, but this was not effectively communicated or executed. The facility had recently implemented a new electronic medical record (EMR) system, which was supposed to alert staff when assessments were due, but this system did not prevent the oversight. The lack of documentation and missed assessments were attributed to an oversight and inadequate delegation of responsibilities during the Treatment Nurse's absence.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and understood their health status, care, and treatments, specifically regarding the consent for psychoactive medication therapy. This deficiency was identified for five residents who did not have completed consent forms for their prescribed psychotropic medications. These medications included Duloxetine and Haloperidol for one resident, Depakote for another, Seroquel for a third, Paroxetine for a fourth, and Hydroxyzine and Mirtazapine for the fifth resident. The absence of these consents indicates that the residents or their responsible parties were not informed of the risks and benefits of the medications, nor were they given the opportunity to choose their preferred treatment options. Interviews with facility staff revealed a lack of clarity and responsibility in obtaining these consents. The Director of Nursing (DON) and Licensed Practical Nurse (LPN) both acknowledged that nurses were responsible for obtaining consent for psychotropic medications, which should be done before administering the medication. However, the DON admitted to not knowing the process for monitoring the acquisition of these consents, and the Assistant Director of Nursing (ADON), who was responsible for ensuring consents were obtained, was unavailable due to a family situation. The Administrator (ADM) also stated that consents should be obtained on admission and that verbal consent could be obtained and signed later, but this process was not effectively implemented. The facility's policy on Psychotherapeutic Drug Management, revised in October 2022, clearly states that informed consent must be obtained and documented by the attending physician before administering psychotherapeutic medication, except in emergencies. Despite this policy, the facility failed to adhere to these guidelines, resulting in the administration of psychotropic medications without the necessary informed consent. This oversight could potentially place residents at risk of receiving treatment without being fully aware of the associated risks and benefits.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its written policies and procedures to prevent mistreatment, neglect, and abuse of residents, as evidenced by the lack of criminal history background checks for three staff members (CNA F, CNA G, and the DOR) and the absence of an EMR report for CNA H in their personnel files. These omissions were identified during a personnel file review conducted on July 16, 2024. The facility's Abuse Prevention and Prohibition Program policy, revised in October 2022, mandates the screening and training of employees to protect residents and ensure a standardized methodology for preventing, identifying, investigating, and reporting abuse. However, the facility did not adhere to these requirements, potentially placing residents at risk for an unsafe environment and abuse. Interviews with facility staff revealed a lack of clarity and communication regarding the responsibility for conducting background checks and maintaining personnel files. The HR Payroll, who had been at the facility for four months, stated that she was responsible for background checks and EMR reports but was not informed by the previous HR Payroll about the frequency of these checks. The DON and ADM confirmed that HR was responsible for performing these checks upon hire and annually. The facility's Employee Handbook, dated November 2020, emphasizes the importance of conducting reference checks, criminal background checks, and other background checks to maintain a workforce of high integrity. Despite these policies, the facility's failure to conduct the necessary checks could lead to the employment of individuals with criminal histories or misconduct on their licenses.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the diagnoses of three residents, which could potentially place them at risk of not having their individual needs met. Resident #31, a female with diagnoses of anxiety and depression, was not coded for these conditions on her MDS, despite being prescribed an antianxiety medication. Her care plan indicated a potential for drug-related complications due to anxiolytic medications, yet her MDS did not reflect her mental health diagnoses. Similarly, Resident #33, who had diagnoses of bipolar disorder and depression, was not coded for these conditions on her MDS. She was prescribed antipsychotic, antianxiety, and antidepressant medications, and her care plan noted potential drug-related complications due to psychotropic drug use. However, her MDS did not include her bipolar and depression diagnoses, which are crucial for accurate care planning. Resident #54, diagnosed with depression, also had an inaccurate MDS that did not reflect her condition, despite being prescribed antianxiety and antidepressant medications. Her care plan included interventions for depression, yet her MDS failed to indicate this diagnosis. Interviews with the MDS coordinator and other staff revealed that the inaccuracies were due to another staff member in training completing the MDS assessments without proper oversight, leading to discrepancies between the residents' actual conditions and their documented assessments.
Failure to Conduct Annual CNA Competency Evaluations
Penalty
Summary
The facility failed to conduct annual competency evaluations for five Certified Nurse Assistants (CNAs), identified as CNA J, CNA F, CNA H, CNA K, and CNA G. This deficiency was discovered through a review of personnel files, which revealed that none of these CNAs had a competency evaluation on file. The dates of hire for these CNAs ranged from 2002 to 2017, indicating that the evaluations had been overdue for a significant period. The Director of Nursing (DON) acknowledged that the staffing coordinator was responsible for ensuring these evaluations were completed annually, but this had not been done. During interviews, both the DON and the Administrator (ADM) expressed concerns that without proper training and evaluations, CNAs might not be aware of changes or new processes, potentially leading to inadequate care for residents. The ADM confirmed that the facility lacked a policy for staff development and training, which was corroborated by the absence of such a policy in the employee handbook. The handbook did mention that performance reviews should occur 90 days after hire and annually thereafter, but this procedure was not followed, resulting in the deficiency.
Inadequate Monitoring of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that the drug regimens of several residents were free from unnecessary psychotropic drugs due to inadequate behavior and side effect monitoring. Specifically, Resident #33 did not have side effect monitoring for her prescribed medications, including Seroquel, Buspirone, Venlafaxine, and Remeron, during July 2024. Despite being prescribed these medications for conditions such as depression, bipolar disorder, and anxiety, there was no documentation of behavior or side effect monitoring in her medical records. Resident #35 also experienced a lack of behavior and side effect monitoring for her prescribed medications, Paroxetine and Lorazepam, during the same period. The facility's records did not include orders for monitoring these medications, which are used to treat mood and anxiety disorders. Additionally, Resident #54 was prescribed Depakote for a mood disorder, but there was no documentation of behavior or side effect monitoring for this medication in her records. Furthermore, Resident #69 was prescribed Seroquel and Hydroxyzine without an appropriate diagnosis, and there was no behavior or side effect monitoring documented for these medications. The facility's staff, including the MDS coordinator, LPN, and DON, acknowledged the importance of monitoring and appropriate diagnoses for psychotropic medications but failed to implement these measures effectively. This lack of monitoring and appropriate diagnoses could prevent residents from receiving the intended therapeutic benefits of their medications.
Failure to Document and Administer Vaccinations
Penalty
Summary
The facility failed to ensure that the medical records of 19 out of 74 residents included documentation indicating that the residents received education on influenza and pneumococcal immunizations. Additionally, the facility did not offer or administer the influenza and pneumococcal vaccinations to several residents, including those who were not admitted outside of the influenza season. This lack of action was identified through interviews and record reviews, revealing that the facility's vaccination records were not accurately maintained. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Administrator (ADM) highlighted a lack of awareness and responsibility regarding the vaccination status of residents. The DON and ADM acknowledged the importance of vaccinations in preventing illness and reducing symptoms, yet they were unaware of the vaccination deficiencies. The ADON mentioned that vaccines were offered during the admission process, but there was a need to reach out to families or primary care providers for prior vaccine information. The facility's policies on influenza and pneumococcal disease prevention, revised in 2020, required documentation of vaccination status, which was not adhered to in these cases.
Deficiency in CNA Training Hours
Penalty
Summary
The facility failed to ensure that nurse aides received the required in-service training of no less than 12 hours per year, which is necessary for maintaining their competencies. This deficiency was identified for five staff members, specifically CNAs F, G, H, J, and K, whose training records were reviewed and found lacking. The personnel file review indicated that these CNAs did not have the required training hours documented, despite their varying lengths of employment at the facility. Interviews with facility staff revealed a lack of clarity and responsibility regarding the management of training records. The HR Payroll, who had been at the facility for four months, was responsible for maintaining training records but did not ensure the completion of necessary training. The DON was unaware of the process for keeping employee files up to date and indicated that the staffing coordinator was responsible for CNA training and evaluations. The ADM confirmed that HR was responsible for personnel files and acknowledged the absence of a policy for staff development and training. This lack of training and evaluation could result in CNAs working without the necessary knowledge, potentially placing residents at risk.
Resident Dignity Compromised by Inappropriate Staff Instructions
Penalty
Summary
The facility failed to uphold the resident's right to dignity and respect, as evidenced by an incident involving a resident who was instructed by staff to urinate in her brief. This incident involved a female resident with diagnoses of unspecified dementia, insomnia, and Parkinsonism, who required maximal assistance for toilet use and moderate assistance for other activities of daily living. The resident's care plan included interventions to prevent skin breakdown due to incontinence, yet during a phone call with her family member, the resident was reportedly told by staff to urinate on herself when her call light was not answered. This led to the family member taking the resident home that night. Interviews with other residents and staff revealed that the resident often required assistance and sometimes refused help, but staff generally attempted to assist her. However, there were instances where staff suggested she urinate in her brief if she could not use the bathroom promptly. The Director of Nursing and the Administrator acknowledged that instructing a resident to urinate in their brief was inappropriate and a dignity issue. The facility's admission agreement stated that personal and nursing care would be provided according to the resident's care plan, which was not adhered to in this case.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident, identified as Resident #35, within the required 24-hour timeframe to the state agency. The incident involved a small bruise on the resident's right jaw, which was discovered by a family member during a visit. Despite the facility's policy requiring immediate reporting of such incidents, the bruise was not reported as an injury of unknown origin. The facility's abuse prevention policy mandates that any allegations of abuse, neglect, or injuries of unknown origin be reported immediately, but no later than two hours after forming suspicion. Resident #35, a female with a history of anxiety disorder and dementia, was noted to have cognitive impairments and behavioral symptoms, including rejection of care. The resident's care plan highlighted her risk for bruises due to fragile skin and other factors. On the day of the incident, the resident's bruise was noted by a family member, and the facility staff attributed it to the resident's habit of sleeping with a bed controller and a baby doll, both of which could have caused the bruise. However, the facility did not consider this an injury of unknown origin, and thus, did not report it to the state agency as required. Interviews with the facility's administration revealed a lack of awareness regarding the resident's history of being resistive to care and agitation. The Administrator, who was responsible for investigating and reporting such incidents, acknowledged the importance of reporting injuries of unknown origin to prevent further harm. Despite this, the facility did not report the incident, potentially placing residents at risk for continued abuse and neglect due to inappropriate interventions and failure to report allegations of abuse timely.
Failure to Maintain Clean Wheelchair for Resident
Penalty
Summary
The facility failed to ensure a clean, comfortable, and homelike environment for a resident, specifically regarding the cleanliness of the resident's wheelchair. The resident, an elderly female with Alzheimer's disease, muscle weakness, and mobility issues, was observed using a wheelchair that had a moderate amount of dried substance splattered on the wheels and hair tangled where the wheels and frame connected. This was noted during multiple observations over several days, indicating a lack of regular cleaning and maintenance of the wheelchair. Interviews with facility staff, including a CNA, maintenance supervisor, LPN, DON, and ADM, revealed inconsistencies in the understanding of responsibilities for cleaning and maintaining wheelchairs. While CNAs were generally responsible for wiping down wheelchairs, maintenance was expected to handle more thorough cleaning, such as removing and cleaning the wheels. The staff acknowledged that dirty wheelchairs posed an infection control issue, yet there was a lack of clear protocol or communication to ensure the wheelchairs were kept clean, leading to the observed deficiency.
Failure to Complete Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to complete a baseline care plan for a resident within 48 hours of admission, as required by their policy. The resident, an elderly female with dementia and other behavioral disturbances, was admitted for rehabilitation. Despite being usually understood and having moderately impaired cognition, the resident required various levels of assistance for daily activities. The responsible party for the resident reported not being involved in a care plan meeting or receiving a copy of the baseline care plan. Interviews with facility staff revealed confusion and miscommunication regarding the responsibility for initiating and completing the baseline care plans. The MDS coordinator, DON, and other nursing staff provided conflicting information about who was responsible for the baseline care plans. The DON believed the LVN on admission was responsible, while the MDS coordinator and other staff assumed different roles were involved. The facility's policy indicated that a licensed nurse should initiate the care plan, which should be completed within 48 hours of admission. However, due to the lack of clarity and communication among staff, the baseline care plan for the resident was not completed, potentially placing the resident at risk of not receiving appropriate care.
Deficiencies in Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in addressing their medical, nursing, mental, and psychosocial needs. For one resident, the care plan did not include the use of a positioning bed rail, despite the resident's need for assistance due to left-sided hemiplegia following a cerebral infarction. The resident expressed a desire for a bed rail on the right side for safety and assistance during turning, but this was not documented in the care plan. Interviews with staff revealed a lack of clarity on responsibilities for updating care plans and obtaining necessary orders for bed rails. Another resident, who was a smoker with a history of dementia and nicotine dependence, did not have a smoking care plan or quarterly smoking assessments documented. The resident's care plan also failed to include quarterly elopement risk assessments, despite residing in a secured unit due to a history of wandering and exit-seeking behavior. Staff interviews indicated that smoking and elopement risk assessments were not consistently completed, and there was confusion about who was responsible for these assessments. The facility's policies required comprehensive care plans to address each resident's needs, including the use of bed rails and smoking safety. However, the lack of documentation and adherence to these policies resulted in potential risks to the residents' safety and well-being. The facility's failure to ensure proper care planning and assessment could lead to residents not receiving the necessary care and supervision, increasing the risk of injury or decline in their condition.
Failure to Document Catheter Orders and Care
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent urinary tract infections for a resident with an indwelling urinary catheter. The resident, a female with chronic kidney disease, was admitted to the facility without documented orders for the size and amount of fluid in the bulb of her catheter, nor were there orders for catheter care. This lack of documentation was identified during a survey, and it was noted that the orders were only added to the resident's chart after the surveyor brought it to the attention of the facility staff. Interviews with facility staff, including the Director of Nursing (DON) and Licensed Vocational Nurses (LVNs), revealed that the catheter orders were not present in the system due to a recent change to a new charting system, which the nursing staff had not been fully trained on. The DON acknowledged that the absence of catheter orders could lead to urinary tract infections and sepsis, as the orders were not being monitored. The staff indicated that standard care should be performed with the catheter, and if orders were missing, they would typically contact the physician to obtain them. The facility's policies on catheter care and physician orders were reviewed, highlighting the importance of complete and accurate documentation to prevent infections and ensure clarity of the physician's plan of care. However, the failure to have these orders in place for the resident's catheter care was a significant oversight, potentially placing the resident at risk for complications associated with improper catheter management.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident who required oxygen therapy. Specifically, the nasal cannula and nebulizer mask used by the resident were not stored in bags when not in use, as observed on two separate occasions. This oversight was confirmed by interviews with facility staff, including an LPN and the Director of Nursing (DON), who acknowledged that the equipment should be stored in bags to maintain sanitation and prevent contamination. The resident involved had a medical history of chronic obstructive pulmonary disease and respiratory failure, requiring continuous oxygen therapy and nebulizer treatments. The facility's policy on cleaning and disinfection indicated that respiratory equipment should be free from microorganisms, highlighting the importance of proper storage. The failure to store the nasal cannula and nebulizer mask correctly could lead to contamination and potential respiratory infections for the resident.
Deficiency in Food Handler Certification for Dietary Staff
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and accreditations in the food and nutrition service department, specifically concerning a dietary aide (DA A) who did not possess a food handler's certificate. DA A was hired on November 3, 2023, and was expected to obtain the certificate within two weeks of hire, but failed to do so despite multiple reminders from the Dietary Manager (DM). The DM acknowledged the responsibility, along with Human Resources (HR), to ensure DA A obtained the certificate. However, the certificate was not acquired, and the DM communicated this issue to HR, who also failed to resolve it. Interviews with various staff, including the Dietician, HR, and the Administrator (ADM), revealed a lack of clarity and accountability regarding who was responsible for ensuring the dietary staff had the necessary certifications. The ADM noted that the facility did not have a policy regarding food handler's certificates and attributed the oversight to transitions in management and ownership. The absence of the certificate meant DA A was not trained in proper food safety protocols, potentially affecting all residents who consumed food from the kitchen.
Facility Fails to Maintain Safe Wheelchair Equipment
Penalty
Summary
The facility failed to ensure that all patient care equipment was in safe operating condition, specifically for a resident who used a wheelchair as a mobility device. The resident, who had Alzheimer's disease and other mobility-related diagnoses, was observed self-propelling in a wheelchair with a loose brake handle. This issue was identified during an observation and interview with a CNA, who acknowledged the risk of falls associated with a malfunctioning wheelchair brake. The CNA had not previously noticed the loose brake handle and took steps to notify the maintenance supervisor. The maintenance supervisor confirmed the issue with the wheelchair brake handle and stated that he was responsible for the maintenance of residents' wheelchairs, relying on staff to report any issues. Interviews with other staff, including an LPN and the DON, revealed that while maintenance was responsible for repairs, staff were expected to inspect wheelchairs and report any problems. Despite these expectations, the facility did not provide a policy outlining maintenance responsibilities, even after multiple requests from the surveyor.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 236 citations issued within 25 miles in the last 12 months — including the 16 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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) |
|---|---|---|---|---|
| Heritage At Longview Healthcare Center | 0 mi | ★★★★★ | 1 | 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 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for The Oaks At Longview.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.