Health inspection·February 28, 2026

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure treatment was provided, consistent with professional standards of practice, to prevent new pressure injuries from developing for 2 of 4 residents reviewed for pressure injuries (ulcers). (Resident #1, Resident #2)1. The facility failed to complete weekly skin assessments for Resident #1 since 01/27/26. 2. The facility failed to complete quarterly Braden Scale Assessments on Resident #1 and Resident #2. There were no quarterly Braden Scale Assessments for Resident #1 since 06/04/25 and for Resident #2 since 02/08/24.These failures could place residents at risk for developing avoidable pressure injuries and the worsening of existing pressure injuries.1. Record review of a face sheet dated 02/28/26 indicated Resident #1 was [AGE] years old and was initially admitted to the facility on [DATE] with diagnoses of heart failure, muscle weakness, and diabetes. The face sheet indicated Resident #1 had been discharged to an acute care hospital on [DATE]. There was no indication Resident #1 had been re-admitted to the facility.Record review of a quarterly MDS dated [DATE] indicated Resident #1 was understood and usually understood others. The MDS indicated a BIMS score of 02 which indicated severe cognitive impairment. The MDS indicated Resident #1 was at risk of developing pressure ulcers/injuries. The MDS did not indicate any unhealed pressure ulcers/injuries.Record review of the care plan last revised on 10/15/25 indicated Resident #1 was at risk for impairment to skin integrity related to fragile skin, incontinence, impaired mobility, diabetes, and nutritional and hydration risk. There was an intervention to identify and document potential causative factors and eliminate and resolve where possible.Record review of a Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] indicated a score of 21 which indicated Resident #1 was not at risk for pressure injury. The electronic medical record for Resident #1 did not indicate any further assessments from 06/04/25 - 02/28/26.Record review of a Skin Check assessment dated [DATE] indicated Resident #1 had no skin issues. The electronic medical record for Resident #1 did not indicate any further assessments from 01/27/26 - 02/28/26.Record review of an At Risk Skin Assessment Visit by wound care nurse practitioner dated 02/02/26 for Resident #1 indicated, .no new skin abnormalities were observed.no active wounds.Routine skin assessment was performed in a high - risk patient. Patient remains at increased risk due to age, History of Fall.Other Reduced Mobility. Continue skin surveillance at routine intervals. Record review of a Change of Condition Progress note dated 02/25/26 at 1:00 p.m. for Resident #1 indicated, .Resident has small wound on buttock. The note was signed by LVN A.Record review of a Progress Note dated 02/25/26 at 1:59 p.m. for Resident #1 indicated, .Resident has small wound to buttock upon checking aide noticed that stool was dark. Resident appeared to have black tarry stool.EMS (emergency medical services) was called and resident was sent to (hospital). The note was signed by LVN A.Record review of a hospital Wound Care Nurse Note dated 02/26/26 at 1:20 p.m. for Resident #1 indicated the resident had been admitted to the hospital on [DATE] for [NAME] (the passage of black, tarry, foul-smelling stools, indicating upper Residents Affected - Some Page 1 of 3 455684 455684 02/28/2026 Longview Hill Nursing and Rehabilitation Center 3201 N Fourth St Longview, TX 75605

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some gastrointestinal bleeding where blood has been digested). The note indicated, .Patient was seen.for a new consult.Concerns of pressure.on admission. Wound Care consulted on 02/26/26.Patient's Braden Score 14: Moderate risk for pressure injury development.Requires maximum assistance for turning and repositioning.incontinent of stool.Patient is saturated in urine, foley catheter bag is dry.Primary RN notified of this finding.Patient with POA stage 2 pressure injury to the left buttock that measures 1.2 cm x 1 cm, partial thickness loss with pale pink viable wound bed, open wound edges. There is macerated tissue (skin that has become white, wrinkled, soggy, or soft due to prolonged exposure to excessive moisture) noted to the bilateral buttocks concerning for moisture component. There is no edema or periwound erythema (redness of the skin within 4 cm of a wound edge, indicating localized inflammation, infection, or tissue damage), area is not hot to touch, no induration, odor, or fluctuance is present at this time, wound is not cellulitic at this time (there were no signs of infection). There is pale pink intact scar tissue noted to the right buttock, no ulceration.During an observation and interview on 02/28/26 at 10:40 a.m., Resident #1 was a patient at the hospital. She said she could not remember if she was receiving wound care at the nursing facility. Resident #1 said she could not remember if she was being repositioned by staff or if she was kept clean and dry. Unable to observe the resident's wound in the hospital.2. Record review of a face sheet dated 02/28/26 indicated Resident #2 was [AGE] years old and was initially admitted to the facility on [DATE] with diagnoses of diabetes, dementia, and protein-calorie malnutrition (a severe, often life-threatening condition caused by insufficient intake or absorption of protein and energy (calories). Record review of a quarterly MDS dated [DATE] indicated Resident #2 was understood and understood others. The MDS indicated a BIMS score of 04 which indicated severe cognitive impairment. The MDS indicated Resident #2 was at risk of developing pressure ulcers/injuries. The MDS did not indicate any unhealed pressure ulcers/injuries.Record review of the care plan last revised on 11/18/25 indicated Resident #2 had a diagnosis of diabetes and had bowel incontinence related to a cognitive decline.Record review of a Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] indicated a score of 16 indicated Resident #2 was at risk for pressure injury. The electronic medical record for Resident #2 did not indicate any further assessments from 02/08/24- 02/28/26.Record review of a Wound Evaluation and Management Summary by wound care nurse practitioner dated 02/23/26 for Resident #2 indicated a diabetic wound of the right first toe. The evaluation did not indicate any pressure injuries. Record review of a Skin Check dated 02/26/26 for Resident #2 did not indicate any new skin issues.During an interview on 02/28/26 at 11:35 a.m., the DON said the last Braden Scale for Predicting Pressure Sore Risk assessment she could find for Resident #1 was dated 06/04/25. She said the last skin assessment she could find for Resident #1 was dated 01/27/26. She said Braden Scale for Predicting Pressure Sore Risk assessments were to be done quarterly. She said skin assessments were to be done weekly. She said Resident #1 had a previous wound to the left buttock and was prone to getting ulcers in that spot.During an interview on 02/28/26 at 12:18 p.m., LVN A said Resident #1 had a small wound to her buttock. She said it was found just before the resident transferred to the hospital. She said Resident #1 was transferred for having blood in her stool. She said the resident got up out of bed every morning. She said when the resident was in bed, they position her with pillows every two hours. She said the resident was independent in bed mobility and will position herself too. She said the resident would even get herself up. She said the charge nurses were responsible for completing the skin checks. She said she had completed skin checks on Resident #1, but she could not say when was the last time she completed a skin check on the resident. She was not made aware of the current wound until she was getting ready to send the resident out to the hospital.During an interview on 02/28/26 at 455684 Page 2 of 3 455684 02/28/2026 Longview Hill Nursing and Rehabilitation Center 3201 N Fourth St Longview, TX 75605

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 12:28 p.m., the Treatment Nurse said Resident #1 had a history of pressure injuries and shearings (a mechanical force occurring when skin remains stationary (due to friction) while underlying tissue and bone move in the opposite direction, causing blood vessel distortion, tissue damage, and deep pressure injuries) on her left and right buttock. She said the resident had not had any recent wounds until she left for the hospital on [DATE]. She said the nurses were responsible for weekly skin assessments. She said they also did routine skin sweeps. She said the last skin sweep was completed on 02/02/26 and was done with the wound care nurse practitioner. She said Resident #1 had no wounds at that time. She said the resident positions herself in the bed. She said she did observe Resident #1's wound right before she left for the hospital because she was helping the aide clean up the resident. She said the wound was very small. She said it was not even open at that time.During an interview on 02/28/26 at 12:43 p.m., the Administrator said there was a glitch in their electronic charting system and it was not triggering Braden Scale assessments or skin assessments on Resident #1 and that was why they had not been done. He said corporate staff were working to get the system fixed.During an interview on 02/28/26 at 1:37 p.m., the DON said they feel there was a glitch in the electronic charting system since they switched over to the current module and that was why they did not have current skin assessments or a current Braden Scale assessment on Resident #1 and a current Braden Scale assessment for Resident #2. She said she expected residents to have weekly skin assessments and quarterly Braden Scale assessments. She said residents that do not have weekly skin assessments could possibly cause a resident to have skin problems that have not been identified that could lead to pressure injuries or infection. She said Braden Scale assessments not being completed might lead to staff not identifying a risk for skin issues. She said if Braden Scale assessments were not completed, proper interventions might not be initiated and could lead to pressure injuries.During an interview on 02/28/26 at 1:51 p.m., the Administrator said Resident #1's wound was identified by nursing staff just prior to her being transferred to the hospital. He said he understood this was a reoccurring wound. He said they have wound prevention interventions in place for Resident #1. He said he expected skin assessments to be completed based on the generation of the skin schedule. He said if issues were found staff should put appropriate interventions in place. He said it was the same for the Braden Scale assessment. He said not having assessments could lead to skin breakdown. He said the Braden Scale assessment would tell if a resident was at risk or not. He said if a Braden Scall assessment was not completed, interventions might not be put in place to prevent skin breakdown.Record review of a Skin Assessment facility policy dated 04/24/25 indicated, .It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment.A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter.Record review of a Pressure Injury Prevention and Management facility policy dated 08/15/22 indicated, .This facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries.Licensed nurses will conduct a pressure injury risk assessment, on all residents upon admission/re-admission, or whenever the resident's condition changes significantly.Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury.Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment. 455684 Page 3 of 3