Heritage at Longview: Wound Care Emergency TX
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.
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 19, 2026 · Our methodology
HERITAGE AT LONGVIEW HEALTHCARE CENTER in LONGVIEW, TX was cited for violations during a health inspection on February 19, 2025.
This designation indicates conditions that pose an immediate threat to resident health and safety.
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.