Heritage at Longview Healthcare Center

Inspectors wroteBased on interview and record review, it was determined the facility failed to coordinate the PASRR assessment for specialized services for 1 of 1 resident (Resident #1) reviewed for resident assessment, in that:The facility failed to submit a NFSS request for nursing facility specialized services in the LTC Online Portal for Resident #1's customized manual wheelchair (CMWC) by a specific deadline of 9/12/2025. This failure could place residents with intellectual and developmental disabilities at risk for a decline in physical, mental, psychosocial well-being and quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure food stored in the kitchen was labeled and dated on 06/30/25 and 07/01/25. 2. The facility failed to ensure cookware stored near the dishwasher area were free of carbon build up on 06/30/25. 3. The facility failed to ensure the apple juice, cranberry juice, and thickened water, connected to the drink dispenser were dated on 06/30/25. 4. The facility failed to ensure a large bin with small, beige grain, stored underneath a preparation table was labeled on 06/30/25. 5. The facility failed to ensure a floor drain near the walk-in refrigerator was free of rust and drainage. 6. [...]

Inspectors wroteBased on observation, interviews and records reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to ensure the comprehensive care plan described the services and interventions to be used to attain and maintain the resident's practicable physical, mental, and psychosocial well-being for 3 of 15 residents reviewed for care plans (Resident #49, Resident #55, and Resident #119). 1. The facility failed to ensure Resident #49's fall mat was added as an intervention to her fall care plan. The facility failed to ensure Resident #49's fall mat was in place when she was in the bed on 07/01/25. The facility failed to ensure Resident #49's call light was within reach per her care plan intervention on 06/30/25 and 07/01/25. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 3 of 3 residents (Resident #13, Resident #23 and Resident #118) reviewed for medication storage. 1. The facility failed to securely store over the counter medications (hydrogen peroxide) for Resident #13.2. The facility failed to ensure the Treatment Nurse securely locked the treatment cart while providing care to Resident #23 on 7/1/2025 from 10:04 AM-10:48 AM. 3. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an effective pest control program so the facility was free of pests and rodents for 1 of 1 facilities reviewed for the environment. The facility failed to maintain an effective pest control program to ensure the facility was free of flies. This failure could place residents at risk for an unsanitary environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 3 of 15 residents (Resident #29, Resident #114, and Resident #117) reviewed for resident rights. 1. The facility failed to ensure Resident #29 was assisted with eating in a dignified manner on 06/30/2025. 2. The facility failed to ensure on 06/30/25, Resident #114 did not have to wait from 10:34 a.m. until 11:05 a.m., to be provided incontinence care. 3. The facility failed to ensure on 07/01/25, Resident #117 was provided incontinence care when requested. Resident #117 reported to the ADON and MA G she needed to be changed. These failures could place residents at risk for decreased quality of life, quality of care, and self-esteem.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from chemical restraints (the use of medication to restrict a person's movement or behavior) that were not required to treat the residents' medical symptoms for 2 of 5 residents (Resident #114 and Resident #49) reviewed for unnecessary medications. The facility failed to ensure Resident #114 had an appropriate diagnosis related to use of Escitalopram (anti-depressant medication; is used to treat depression and generalized anxiety disorder). The facility failed to ensure Resident #114 had an appropriate diagnosis related to use of Trazodone (anti-depressant medication; is used to treat major depressive disorder). The facility failed to ensure Resident #49 had an appropriate diagnosis related to use of Buspirone (anti-anxiety medication; [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment, including injuries of unknown source were reported by staff immediately or not later than 24 hours for 2 of 2 residents reviewed for abuse and neglect. The facility failed to report verbal altercation between Resident #45 and Resident #53 during week of 6/23/2025. This failure could place residents at risk for abuse and neglect.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care and failed to provide a copy of the summary of the baseline care plan for 1 (Resident #117) of 5 residents reviewed for baseline care plans. The facility failed to ensure Resident #117's baseline care plan include dialysis dependence (is a life-sustaining medical treatment that cleans the blood when the kidneys are unable to do so due to kidney failure). The facility failed to ensure Resident #117's baseline care plan include her diabetes mellitus (is a chronic condition where the body either doesn't produce enough insulin or can't properly use the insulin it produces, leading to high blood sugar levels) diagnosis. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, personal and oral hygiene for 1 of 15 residents (Resident #49) reviewed for ADL (activities of daily living) care. The facility failed to ensure Resident #49 received her scheduled bed baths on 06/10/25, 06/14/25, 06/17/25, 06/24/25, 06/26/25, and 06/28/25. This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in feelings of poor self-esteem, decrease socialization and skin breakdown.

Inspectors wroteBased on observations, interviews, and records review, the facility failed to ensure the facility provided care and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new pressure ulcers/injuries from developing for 1 (Resident #23) of 5 residents reviewed for pressure ulcers/injuries.1. The facility failed to perform complete and accurate wound care per Physician orders for Resident # 23's right ischium (a paired bone forming the lower and back part of the hip bone) on 7/1/2025 at 10:04 AM.2. The facility failed to ensure Resident #23's air mattress was dialed to the correct weight of 154.2 pounds. This failure could affect residents with skin injures and wounds and could place the residents at risk for worsening of pressure ulcers.

Inspectors wroteBased observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infection and to restore continence to the extent possible for 1 of 2 residents (Resident #114) reviewed for catheter care. 1. The facility failed to ensure Resident #114 had an order for his indwelling catheter (a flexible tube inserted into the bladder to drain urine). 2. The facility failed to ensure Resident #114's indwelling catheter was care planned. 3. The facility failed to ensure Resident #114's catheter bag (connected to the indwelling catheter and collects urine) was not touching the floor on 07/01/25. These failures could place residents at risk of not receiving continuity of catheter care and urinary tract infection (is a bacterial infection that affects any part of the urinary system).

Inspectors wroteBased on interview and record review the facility failed to ensure residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Resident #117) reviewed for dialysis services. 1. The facility failed to ensure the pre-dialysis assessments were completed and documented on Resident #117's dialysis communication forms on 06/25/23. 2. The facility failed to ensure the post-dialysis assessments were completed and documented on Resident #117's dialysis communication forms on 06/23/25 and 06/25/23. These failures could place residents at risk for complications and not receiving proper care and treatment to meet their needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the medication error rate of five percent or greater. The facility had a medication error rate of 6.06%, based on two errors out of 33 opportunities, which involved 2 of 5 residents (Resident #116 and Resident #118) and 1 of 2 staff reviewed for medication administration. 1. The facility failed to administer Resident # 116's correct dose of Famotidine 40 mg 1 tablet by mouth daily for gastric reflux (occurs when stomach acid flows back into the esophagus) on 7/1/2025 at 7:46 AM. 2. The facility failed to administer Resident #118's correct dose of Pepcid (Famotidine) 20 mg 2 tablets to be administered two times daily related to gastro-esophageal reflux disease without esophagitis (occurs when stomach acid flows back into the esophagus) on 7/1/2025 at 7:34 AM. [...]

Inspectors wroteBased on interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 15 residents (Resident #49) reviewed for infection control. The facility failed to ensure Resident #49 was placed on contact isolation (implemented to prevent the spread of germs that are transmitted through direct or indirect contact with a person or objects they have touched) after her urinalysis with culture and sensitivity (UA examines urine for physical and chemical characteristics, while C&S identifies any bacterial infection and determines its sensitivity to antibiotics), dated 6/12/25, resulted on 06/16/25 with ESBL E. Coli. [...]

Inspectors wroteBased on interviews 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 3 Residents (Resident #1) reviewed for pressure injuries. The facility failed to implement interventions to prevent Resident #1 from developing a facility acquired unstageable pressure ulcer. The facility failed to identify and treat an unstageable pressure ulcer to Resident #1's sacral area. The facility failed to identify residents who are at risk for pressure ulcer development. An IJ was identified on 2/18/2025 at 3:49 PM. The IJ template was provided to the facility on 2/18/2025 at 3:49 PM. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications for 3 of 5 residents (Resident #3, Resident #4 and Resident #5) and reviewed for pharmacy services. The facility failed to remove discontinued controlled medications from the medication cart for Resident #3, Resident #4 and Resident #5 who had expired. The facility failed to ensure proper destruction of 71 Hydrocodone 10/325mg, 103 Lorazepam 1mg, 17 Lorazepam 0.5mg, and 94.75ml Morphine Sulfate 100mg/5ml that were controlled medications for Resident #3, Resident #4 and Resident #5 who had expired. [...]

Inspectors wroteBased on interview and record review, the facility failed to consult with the physician when the resident experienced a change in condition for one (Resident #1) of three residents reviewed for a change of condition. The facility failed to notify the responsible party or family of a change in condition for Resident #1 after finding a new wound on her buttocks on 7/22/2024. This failure could affect residents by placing them at risk for a delay in medical treatment, worsening in condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 1 of 3 residents (Residents #2) reviewed for care plans. The facility failed to implement Resident #2's care plan by not changing the dressing to her diabetic ulcer on the left second toe daily. On 2/12/2025 Resident #2's dressing was dated for 2/9/2025. This failure could place residents at risk of not receiving appropriate care and interventions to meet their current needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice, pain management services for 1 of 16 residents reviewed for pain. (Resident #203) 1. The facility failed to effectively manage Resident #203's pain. 2. The facility failed to ensure Resident #203's low air loss mattress was plugged in, functioning, and fully inflated to prevent pain. 3. The facility failed to ensure LVN B notified Resident #203's physician after a family member requested a medication change to manage his pain related to muscle spasms. These failures could result in residents experiencing unnecessary pain and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards in 1 of 1 kitchen reviewed for food service safety. The facility failed to repair a leaking roof that caused rainwater to drip from the range hood and nearby ceiling tiles. This failure could place residents at risk of foodborne illness and food contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living the necessary services to maintain personal hygiene for 2 of 16 residents reviewed for ADLs. (Resident #25 and Resident #43) The facility failed to provide scheduled baths/showers to Resident #25 and Resident #43. This failure could place residents who required assistance from staff for ADL's at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 16 residents reviewed for infection control. (Resident #34 and Resident #203). 1. The facility failed to ensure a sign was posted on Resident #34 and Resident #203's doors to indicate they were on Enhanced Barrier Precautions (interventions to prevent spread of infection in high-risk residents) and what personal protective equipment was required to enter the residents' rooms. 2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure assessments accurately reflected the status for 1 of 16 residents reviewed for assessments. (Resident #26). The facility failed to complete an accurate resident assessment for Resident #26 indicating the resident had an inaccurate diagnosis of bipolar. This failure could place residents at risk of not having individual needs met and a decreased quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 1 of 16 residents reviewed for care plans. (Resident #12) The facility failed to develop a person-centered PASRR care plan for Resident #12 to meet medical, nursing, mental and psychosocial needs. The failures could place residents at risk of not having individual needs met, a decreased quality of life, and cause residents not to receive needed services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 1 of 8 residents (Resident #11) reviewed for respiratory care. The facility failed to ensure Resident #11's oxygen concentrator filter was free of gray fuzz and dust-like particles. These failures could place residents requiring respiratory care at risk for respiratory infections or complications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biologicals were stored in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 16 residents. (Resident #27) The facility failed to ensure Lantiseptic skin protectant 50% cream was properly stored and locked in accordance with currently accepted professional standards. This failure could place residents at risk for adverse effects and reduced therapeutic effects of medication and supplies.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 1 of 10 residents reviewed for care plans. (Resident #24) 1. The facility failed to initiate intervention for a fall mate on the comprehensive person-centered care plan for Resident #24 by not including intervention for a fall mat. 2. The facility failed to develop a person-centered Hospice care plan for Resident #24 to meet medical, nursing, mental and psychosocial needs. These failures could place residents at risk of not having individual needs met, a decreased quality of life, and cause residents not to receive needed services.

Inspectors wroteBased on interview and record review the facility failed to review and revise the person-centered care plan to reflect the current condition for 1 of 7 (Resident #42) residents reviewed for care plan revisions. The facility failed to ensure Resident #42's care plan was updated to reflect he was receiving end of life hospice care. This deficient practice could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Resident #48) reviewed for respiratory care and services. The facility failed to administer oxygen at 3.5 liters per minute via nasal cannula as prescribed by the physician for Resident #48. This failure could place residents at risk for developing respiratory complications.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 20 residents (Resident # 18) reviewed for dialysis. The facility failed to ensure Resident #18 had a physician order for dialysis. This failure could place residents at risk for not receiving appropriate care and treatment services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #17) reviewed for infection control practices. CNA B during incontinent care failed to perform hand hygiene prior to exiting Resident #17's room to obtain more gloves and exiting Resident #17's room after incontinent care for a pillowcase. These failures could place residents and staff at risk for cross contamination and the spread of infection.