LONGVIEW, TX - Heritage at Longview Healthcare Center received an immediate jeopardy citation from federal inspectors following a February 2025 investigation that revealed serious failures in pressure wound care management and improper destruction of controlled medications by a staff member who later tested positive for multiple drugs.
Critical Pressure Wound Care Violations Lead to Emergency Citation
Federal inspectors issued an immediate jeopardy citation - the most serious level of violation - after discovering the facility failed to provide adequate treatment and services to prevent and heal pressure ulcers. This designation indicates conditions that pose an immediate threat to resident health and safety.
The investigation revealed systemic failures in the facility's wound care protocols. Inspectors found that staff had not properly identified, staged, or documented pressure wounds according to medical standards. Additionally, the facility failed to implement appropriate prevention measures and treatment plans for residents at risk of developing pressure ulcers.
Pressure ulcers, commonly known as bedsores, develop when sustained pressure reduces blood flow to the skin and underlying tissues. These wounds typically form over bony prominences like the tailbone, hips, and heels in residents who remain in the same position for extended periods. Without proper prevention and treatment, pressure ulcers can progress from superficial skin damage to deep wounds affecting muscle and bone, potentially leading to serious infections, sepsis, and death.
The facility's failures included inadequate completion of Braden Scale assessments, which are standardized tools used to evaluate a resident's risk of developing pressure ulcers. These assessments consider factors such as sensory perception, moisture, activity level, mobility, nutrition, and friction. Healthcare facilities are required to conduct these assessments upon admission and regularly thereafter to identify residents who need enhanced prevention measures.
Medical Standards and Prevention Requirements
Proper pressure ulcer prevention requires a comprehensive approach including regular repositioning every two hours, use of pressure-relieving devices like specialized mattresses and cushions, maintaining adequate nutrition and hydration, and keeping skin clean and dry. When wounds do develop, facilities must accurately stage them according to established medical criteria, document their characteristics including size and appearance, and implement appropriate treatment protocols.
The staging system classifies pressure ulcers from Stage 1 (non-blanchable redness of intact skin) through Stage 4 (full-thickness tissue loss exposing bone, tendon, or muscle). Accurate staging is essential because treatment protocols vary significantly based on wound severity. Misclassification can result in inadequate treatment, delayed healing, and progression to more serious stages.
During the investigation, inspectors found that nursing staff lacked proper training on wound assessment and documentation. The facility's response included comprehensive retraining of all nursing staff on pressure injury prevention, assessment, staging, and treatment protocols. CNA E told inspectors during interviews that wound prevention interventions included "turning and repositioning every 2 hours, elevating legs, changing positions, wedges, pillows to offset pressure points, wheelchair cushions, and movement."
Controlled Substance Destruction Violations
In a separate but equally concerning violation, the facility failed to follow proper procedures for destroying controlled medications belonging to deceased residents. The investigation revealed that significant quantities of powerful narcotics - including 71 hydrocodone tablets, 103 lorazepam tablets, and nearly 95 milliliters of liquid morphine - were improperly destroyed by a licensed vocational nurse.
The medications belonged to three deceased residents who had been receiving hospice care for terminal conditions including liver cancer, lung cancer, and prostate cancer. These controlled substances, which include opioid pain medications and anti-anxiety drugs, are strictly regulated due to their potential for abuse and diversion.
LVN A, who was responsible for the improper destruction, admitted during a phone interview that he "had been passing pills and was tired and frustrated that day, so he decided to lighten his load by destroying the expired residents' medications." He stated he "poured the medications in a cup and then flushed them in the toilet" in a facility bathroom, acknowledging he knew this violated proper procedures.
The incident came to light when the Director of Nursing attempted to retrieve the medications for proper destruction according to facility policy. When she discovered the medications were missing, she contacted LVN A, who initially claimed he had turned them over to administration but later admitted to flushing them down the toilet.
Drug Testing Reveals Additional Concerns
Following the medication destruction incident, facility administrators required LVN A to undergo drug testing. The results showed positive findings for cocaine, opiates, codeine, and hydrocodone. When asked to provide prescriptions justifying these positive results, LVN A never produced any documentation, leading to his termination.
This development raised serious questions about potential drug diversion - the illegal redistribution of legitimately prescribed medications. Healthcare facilities are required to maintain strict controls over controlled substances to prevent theft, misuse, or illegal distribution. The presence of the same types of drugs in the staff member's system that he improperly destroyed represents a significant red flag for investigators.
Proper medication destruction requires supervision by a consultant pharmacist and at least one facility administrator. The destroyed medications must be documented and witnessed by multiple parties to ensure accountability and prevent diversion. The facility's policy clearly stated that nursing staff should submit discontinued medications to the Director of Nursing for proper destruction procedures.
Medical Impact and Industry Standards
These violations represent serious departures from accepted medical and pharmaceutical standards. Pressure ulcer prevention and treatment requires constant vigilance and systematic implementation of evidence-based protocols. Facilities must maintain adequate staffing levels, provide ongoing training, and implement quality assurance measures to ensure compliance.
The medication security failures pose risks both to current residents and the broader community. Controlled substances that enter illegal distribution networks contribute to prescription drug abuse and addiction. Additionally, when facilities cannot account for all controlled medications, it creates uncertainty about whether residents received their prescribed pain management and anxiety medications as ordered.
Additional Issues Identified
Beyond the major violations, inspectors documented other concerns including:
- Incomplete documentation in weekly ulcer assessments and non-pressure wound evaluations - Insufficient notification procedures when new skin issues were identified - Inadequate communication protocols between nursing staff and physicians regarding wound status changes - Missing or incomplete care plan updates for residents with skin integrity issues - Gaps in staff education regarding when wound care failures constitute neglect
The facility implemented extensive corrective measures including comprehensive staff retraining, updated assessment protocols, enhanced documentation requirements, and improved communication procedures. All staff received education on recognizing that failure to properly identify, stage, or treat pressure wounds can constitute neglect under federal regulations.
Federal regulations require nursing homes to provide each resident with the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being. These violations demonstrate how seemingly procedural failures can have serious consequences for vulnerable residents who depend on skilled nursing care for their health and safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Heritage At Longview Healthcare Center from 2025-02-19 including all violations, facility responses, and corrective action plans.
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