Deficiencies (last 3 years)
Deficiencies (over 3 years)
16.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
366% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 13
Date: Aug 26, 2025
Visit Reason
The inspection was conducted to evaluate compliance with resident rights, infection control, care planning, respiratory care, dental services, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, inadequate infection control practices, incomplete and inaccurate care plans, failure to provide timely and appropriate respiratory care, failure to provide dental services and follow-ups, failure to accommodate resident meal preferences, unsafe mechanical lift transfers, failure to provide adequate personal hygiene care, and failure to ensure safe environment and supervision to prevent accidents.
Deficiencies (13)
Failure to treat residents with dignity and respect including privacy during catheter care and proper covering of urinary catheter bags.
Failure to notify physician timely of significant change in resident's condition related to left foot pain.
Failure to provide a safe, clean, and homelike environment including failure to clean resident rooms and change bed linens.
Failure to promptly resolve resident grievances related to late meal service.
Failure to ensure resident was free from physical restraints; seatbelt on wheelchair was used without proper assessment and care planning.
Failure to ensure accurate assessments and care plans reflecting resident diagnoses and needs, including diabetes, bathing preferences, swallowing difficulties, discharge planning, and restraint use.
Failure to provide necessary personal hygiene care including cleaning and trimming of fingernails.
Failure to ensure safe mechanical lift transfers; mechanical lift wheels not locked and legs not in wide position during transfer.
Failure to provide appropriate catheter care including use of catheter securement device and proper cleaning technique.
Failure to provide appropriate respiratory care including oxygen administration at correct settings, proper tracheostomy orders, and proper storage of respiratory equipment.
Failure to assist residents in obtaining routine dental care and follow-up on dental referrals.
Failure to ensure residents receive food that accommodates allergies, intolerances, preferences, and meal choices.
Failure to establish and maintain an infection prevention and control program including urinary catheter bag management, laundry handling, and ice serving practices.
Report Facts
Residents reviewed: 22
Residents affected: 2
Residents affected: 4
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Named in catheter care and privacy deficiencies | |
| CNA G | Named in catheter care and privacy deficiencies | |
| LVN K | Named in catheter care and privacy deficiencies | |
| CNA A | Named in urinary catheter bag and infection control deficiencies | |
| Housekeeper W | Named in homelike environment deficiency | |
| HSK/Laundry Supervisor L | Named in laundry infection control deficiency | |
| CNA R | Named in restraint use deficiency | |
| LVN U | Named in restraint and respiratory care deficiencies | |
| MDS Coordinator B | Named in care planning deficiencies | |
| ADON N | Named in catheter care, respiratory care, and care planning deficiencies | |
| DON | Director of Nursing | Named in multiple deficiencies including catheter care, respiratory care, restraint use, and infection control |
| ADM | Administrator | Named in multiple deficiencies including catheter care, respiratory care, restraint use, and infection control |
| CNA X | Named in personal hygiene deficiency | |
| LVN H | Named in respiratory care and catheter care deficiencies | |
| CNA E | Named in respiratory care deficiency | |
| Director of Therapy T | Named in restraint use deficiency | |
| Social Worker | Named in dental services deficiency | |
| Dietary Manager | Named in meal service deficiency | |
| CNA P | Named in meal service deficiency |
Inspection Report
Complaint Investigation
Census: 12
Deficiencies: 1
Date: Nov 15, 2024
Visit Reason
The inspection was conducted following a complaint regarding a malfunctioning call light system in Resident #1's room, which resulted in delayed staff response after Resident #1 fell out of bed.
Complaint Details
The complaint investigation was triggered by a family member's report that Resident #1 fell and was left on the floor for over 30 minutes without staff responding to the call light. The call light system was found to have a malfunctioning audible alert, and staff were unaware of the call light activation. The complaint was substantiated with observations, interviews, and record reviews confirming the call light malfunction and delayed response.
Findings
The facility failed to ensure Resident #1 had a functioning call light system, which led to a fall incident where staff did not respond timely to call light activation. The call light system's audible notification was not working, and staff were unaware when the call light was activated. Maintenance had repaired part of the system recently, but the audible alert remained nonfunctional.
Deficiencies (1)
Failed to ensure Resident #1 had a functioning call light system, resulting in delayed staff response to call light activation and increased risk of falls.
Report Facts
Residents on hall: 12
Duration on floor: 30
Date of call light repair: Nov 11, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Nurse on duty during the fall incident, unaware of call light activation due to system malfunction |
| CNA B | Certified Nursing Assistant | Assigned to Residents #1 and #2, reported call light audible noise was not working |
| CNA C | Certified Nursing Assistant | Reported call light malfunction and placed maintenance order |
| LVN D | Licensed Vocational Nurse | Night shift nurse who was unaware of call light audible malfunction despite visual indicator |
| Maintenance Director | Repaired shower box component of call light system and monitored system functionality | |
| Administrator | Facility administrator notified of incident and call light system issues | |
| Director of Nurses | Expressed expectation that call light system functioned properly and acknowledged risk of falls |
Inspection Report
Routine
Deficiencies: 2
Date: Jul 10, 2024
Visit Reason
The inspection was conducted to assess compliance with professional standards of care related to respiratory therapy and pharmaceutical services, including medication management and controlled substance handling at Treviso Transitional Care.
Findings
The facility failed to provide appropriate respiratory care by not changing oxygen tubing as ordered for Resident #24, and failed to maintain accurate pharmaceutical records and control of narcotic medications for Resident #42, including discrepancies in narcotic counts and improper documentation.
Deficiencies (2)
Failure to change oxygen tubing weekly for Resident #24 as ordered, placing residents at risk for respiratory infections.
Failure to keep accurate record receipt and control of Resident #42's controlled medication Hydrocodone, including discrepancies in narcotic counts and improper documentation.
Report Facts
Residents reviewed for respiratory care: 8
Residents reviewed for pharmacy services: 4
Hydrocodone tablets received: 30
Hydrocodone tablets destructed: 25
Hydrocodone doses administered: 2
Date of nasal cannula tubing: Jun 17, 2024
Date of survey completion: Jul 10, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ADM | Administrator | Interviewed regarding responsibility for changing nasal cannula and narcotic count procedures. |
| DON | Director of Nursing | Interviewed regarding nursing responsibilities for changing nasal cannula and narcotic count audits. |
| CMA A | Certified Medication Aide | Interviewed about medication count discrepancies and suspension related to narcotic administration. |
| LVN B | Licensed Vocational Nurse | Interviewed about medication count procedures and narcotic handling. |
| ADON | Assistant Director of Nursing | Interviewed about narcotic count discrepancies, pharmacy consultant involvement, and medication destruction. |
Inspection Report
Routine
Deficiencies: 11
Date: Jul 10, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, medication management, and food safety.
Findings
The facility was found deficient in multiple areas including failure to promptly address resident grievances, untimely completion and transmission of resident assessments, inaccurate resident assessments, incomplete and untimely care plan development and revisions, failure to provide appropriate respiratory care, medication management issues including narcotic discrepancies and duplicate medication orders, failure to secure medication carts, and food safety violations related to storage and sanitation.
Deficiencies (11)
Failure to consider and promptly respond to resident group grievances regarding care issues such as beds not being made, snacks not provided, and toilet paper shortages.
Failure to complete resident assessments within required time frames for 3 of 15 residents reviewed.
Failure to electronically complete and transmit Minimum Data Set (MDS) assessments within 14 days for 4 of 32 residents reviewed.
Failure to ensure resident assessments accurately reflected resident status, specifically missing fall history for Resident #13.
Failure to develop and implement comprehensive person-centered care plans addressing all resident needs for Residents #13 and #44.
Failure to review and revise comprehensive care plans by the interdisciplinary team after each assessment for Residents #13 and #44.
Failure to provide appropriate respiratory care by not changing oxygen tubing weekly for Resident #24.
Failure to maintain accurate records of controlled medication receipt and discrepancies for Resident #42's Hydrocodone.
Failure to lock medication cart (400/500 hall cart) during medication administration.
Failure to ensure resident drug regimen was free from unnecessary duplicate medications for Resident #54.
Failure to store, prepare, distribute, and serve food in accordance with professional standards, including storing cardboard boxes on the floor, unclean microwave and beverage table, and unlabeled food items in freezer and cooler.
Report Facts
Residents reviewed for quarterly assessments: 15
Residents reviewed for MDS transmittal: 32
Residents reviewed for accuracy of assessments: 12
Residents reviewed for care plans: 10
Residents reviewed for pharmacy services: 5
Duplicate doses of trazadone administered in June 2024: 16
Duplicate doses of venlafaxine administered in June 2024: 32
Duplicate doses of pantoprazole administered in June 2024: 16
Duplicate doses of metoprolol administered in June 2024: 24
Duplicate doses of MiraLAX administered in June 2024: 16
Duplicate doses of vitamin D3 administered in June 2024: 16
Duplicate doses of trazadone administered in July 2024: 8
Duplicate doses of venlafaxine administered in July 2024: 16
Duplicate doses of pantoprazole administered in July 2024: 8
Duplicate doses of metoprolol administered in July 2024: 15
Duplicate doses of MiraLAX administered in July 2024: 8
Duplicate doses of vitamin D3 administered in July 2024: 8
Weight loss: 36.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN E | Regional Support Nurse / MDS Coordinator | Named in relation to late MDS assessments and efforts to catch up |
| DON | Director of Nursing | Named in relation to MDS assessments, grievance responses, and medication management |
| ADM | Administrator | Named in relation to grievance expectations, MDS and care plan oversight, and medication cart security |
| Housekeeping Supervisor | Named in relation to resident grievance responses and in-service on toilet paper supply | |
| Dietary Manager | Named in relation to resident grievance responses and snack provision | |
| AD | Activity Director | Named in relation to resident council meeting minutes and grievance communication |
| CMA A | Certified Medication Aide | Named in relation to medication count discrepancies |
| LVN B | Licensed Vocational Nurse | Named in relation to medication administration and narcotic count procedures |
| LVN C | Licensed Vocational Nurse | Named in relation to medication cart security |
| MD N | Physician | Named in relation to review of duplicate medications for Resident #54 |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Jan 31, 2024
Visit Reason
The inspection was conducted due to complaints regarding resident abuse, misappropriation of resident property, failure to implement abuse and neglect policies, incomplete care plans, and pharmaceutical service deficiencies.
Complaint Details
The complaint investigation included allegations of verbal abuse by CNA A towards Resident #5, misappropriation of property by CNA E and CNA A involving Residents #3 and #4, failure to conduct criminal background checks on staff RN H and CNA J, failure to implement proper care plans for Resident #6, and medication administration errors for Residents #1 and #2. Substantiated findings led to staff suspensions, terminations, and corrective actions.
Findings
The facility failed to protect residents from verbal abuse by staff, prevent misappropriation of resident property by staff, conduct required criminal background checks on employees, implement comprehensive care plans including proper transfer assistance, and ensure timely administration of medications. Staff were terminated or disciplined as a result of abuse and theft incidents. The facility also failed to notify the Texas Board of Nursing about an employee with stipulations and did not maintain required documentation.
Deficiencies (6)
Failed to ensure residents were free from verbal abuse; Resident #5 was verbally assaulted by CNA A.
Failed to prevent misappropriation of resident property; CNA E stole a $25 gift card and change from Resident #3, and CNA A took Resident #4's box of sodas.
Failed to implement policies and procedures to prevent abuse, neglect, and theft; criminal background checks were not conducted for RN H and CNA J in 2023.
Failed to develop and implement a comprehensive care plan meeting all resident needs; Resident #6 was not provided 2-person assistance during transfers as required.
Failed to provide pharmaceutical services ensuring accurate administration of medications; Resident #1 missed 14 doses of glipizide and omeprazole in January 2024, Resident #2 missed 6 doses of Synthroid in July 2023.
Failed to operate and provide services in compliance with laws and professional standards; failed to notify Texas Board of Nursing of RN H's employment and failed to submit criminal background check prior to employment.
Report Facts
Missed medication doses: 14
Missed medication doses: 6
Residents reviewed for abuse: 24
Residents affected by abuse: 1
Residents affected by misappropriation: 2
Staff reviewed for neglect and abuse policies: 6
Employees with missing criminal background checks: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN H | Registered Nurse | Failed to have criminal background check and notification to Texas Board of Nursing; employed August to October 2023 |
| CNA A | Certified Nursing Assistant | Verbally abused Resident #5 and misappropriated Resident #4's property; suspended and terminated |
| CNA E | Certified Nursing Assistant | Stole $25 gift card and change from Resident #3; terminated |
| CNA D | Certified Nursing Assistant | Failed to provide 2-person assistance during transfers for Resident #6; educated after incidents |
| CMA K | Certified Medication Aide | Unaware of importance of administering glipizide and omeprazole before meals |
| LVN L | Licensed Vocational Nurse | Educated CNA D on 2-person transfers after Resident #6 fall incidents |
| ADM | Administrator | Reported abuse incidents, suspended and terminated staff; responsible for ensuring policies and notifications |
| DON | Director of Nursing | Expected staff to follow care plans and medication administration policies |
| HR | Human Resources | Responsible for pre-employment checks; unable to locate files or background checks for RN H and CNA J |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 15, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report and properly investigate an elopement incident involving Resident #1, including allegations of neglect and inadequate supervision.
Complaint Details
The complaint investigation was substantiated. The facility failed to timely report and investigate the elopement of Resident #1, who was found outside the facility in a hazardous area. Immediate Jeopardy was identified on 11/4/23 and removed on 11/6/23 after the facility implemented corrective actions.
Findings
The facility failed to report the elopement of Resident #1 to the State Agency within required timeframes and did not immediately investigate or protect the resident, resulting in an Immediate Jeopardy (IJ) situation. The resident eloped and was found approximately 150 yards from the facility in a hazardous area. The facility implemented a plan of removal, including staff in-service training, increased supervision, and audits, which led to removal of the IJ but the facility remained out of compliance at a lower severity level.
Deficiencies (3)
Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Failed to ensure allegations of neglect were thoroughly investigated to prevent further elopement and report the results of all investigations to the administrator or designated representative and other officials within 5 working days.
Failed to provide adequate supervision to prevent elopement, resulting in Immediate Jeopardy.
Report Facts
Date of elopement: Oct 8, 2023
Number of residents reviewed for neglect: 4
Number of staff trained in elopement in-service: 23
Duration of Immediate Jeopardy: 2
Frequency of supervision checks: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Resident #1's nurse on the day of the elopement; involved in locating and returning Resident #1. |
| CNA B | Certified Nursing Assistant | CNA caring for Resident #1 on the day of elopement; helped search and located Resident #1 outside. |
| Administrator | Administrator and Abuse Coordinator | Facility Administrator during the incident; acknowledged failure to report elopement timely and failure to investigate. |
| Human Resource Manager | Human Resource Manager | Interviewed regarding awareness of elopement and reporting. |
| Corporate Nurse | Corporate Nurse | Assisted facility after DON termination; aware of elopement but unsure if incident was reported prior to arrival. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 12, 2023
Visit Reason
The inspection was conducted due to complaints regarding Resident #1's delayed hospital transfer and Resident #2 being left unsupervised at the hospital in a hospital gown and brief, causing embarrassment and potential harm.
Complaint Details
The complaint investigation focused on Resident #1's delayed hospital transfer despite worsening condition and Resident #2 being left unsupervised at the hospital in a hospital gown and brief, causing embarrassment and confusion. The family of both residents raised concerns about the facility's handling of these situations.
Findings
The facility failed to ensure Resident #1 was promptly sent to the hospital despite adverse reactions to new medications, resulting in severe health decline and ICU admission. The facility also failed to supervise Resident #2 adequately during transport and hospital admission, leaving her confused and improperly dressed. Multiple staff interviews and record reviews confirmed these failures and the facility's inadequate response.
Deficiencies (2)
Failed to ensure Resident #1 was promptly sent to the hospital despite adverse reactions to new medications, resulting in severe health decline and ICU admission.
Failed to supervise Resident #2 adequately during transport and hospital admission, leaving her confused and improperly dressed.
Report Facts
New medications prescribed: 5
Vomiting days: 3
Sodium level: 121
Oxygen saturation: 50
Blood pressure: 117
Heart rate: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN E | Licensed Vocational Nurse | Named in delayed hospital transfer and failure to properly assess Resident #1 and supervise Resident #2. |
| LVN D | Licensed Vocational Nurse | Named in Resident #2 transport and hospital admission supervision failure. |
| LVN F | Licensed Vocational Nurse | Assisted in assessment of Resident #1 before hospital transfer. |
| CNA A | Certified Nursing Assistant | Reported Resident #1's worsening condition and urged hospital transfer. |
| CNA B | Certified Nursing Assistant | Reported Resident #1's worsening condition and urged hospital transfer. |
| DON | Director of Nursing | Investigated complaints and provided policy information. |
| NP | Nurse Practitioner | Provided clinical input on Resident #1's vomiting and Resident #2's sodium-related confusion. |
| Hospital RN | Registered Nurse | Admitting nurse for Resident #2 at hospital, reported Resident #2 left unsupervised in hospital gown and brief. |
Inspection Report
Routine
Deficiencies: 11
Date: May 18, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, safety, infection control, staff competencies, equipment maintenance, and food service quality at Treviso Transitional Care.
Findings
The facility was found deficient in multiple areas including failure to obtain physician orders upon admission, incomplete and outdated care plans, inadequate personal hygiene and bathing services, unqualified activity director, improper respiratory care equipment maintenance, inadequate infection control practices, failure to maintain safe and functional equipment, and failure to provide palatable and properly heated food.
Deficiencies (11)
Failure to provide physician's orders for resident's immediate care at admission, including use of life vest for Resident #70.
Failure to develop and implement a comprehensive person-centered care plan for Residents #70 and #39, including failure to schedule cardiology appointment and update psychotropic medication orders.
Failure to review and revise Resident #39's care plan to reflect current condition and discontinue psychotropic medication Risperdal.
Failure to provide necessary services to maintain grooming and personal hygiene, including failure to routinely shower Resident #1.
Activity Director not qualified or certified as required by state regulations.
Failure to provide safe and appropriate respiratory care, including dirty oxygen concentrator filter for Resident #37 and improperly stored HHN tubing for Resident #56.
Failure to ensure nurse aides demonstrated competency in hand hygiene and glove changes during incontinent care, specifically CNA L.
Failure to provide residents with food and drink that was palatable, attractive, and at a safe and appetizing temperature, with multiple residents complaining of cold and unpalatable food.
Failure to provide and implement an effective infection prevention and control program, including improper disinfectant use for isolation room, improper linen handling, and failure of staff to perform hand hygiene between glove changes.
Failure to maintain all mechanical, electrical, and patient care equipment in safe operating condition, including wheelchair brakes not functioning and torn wheelchair seat.
Failure to develop, implement, and maintain an effective training program for all staff, including lack of annual restraint and HIV training for Activity Director, Maintenance Supervisor, and Housekeeping Supervisor.
Report Facts
Residents occasionally or frequently incontinent of bladder: 50
Residents occasionally or frequently incontinent of bowel: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA L | Certified Nursing Assistant | Observed failing to perform proper hand hygiene and glove changes during incontinent care for Resident #136. |
| CNA N | Certified Nursing Assistant | Observed handling dirty linen improperly for Resident #70 and failing to perform hand hygiene between glove changes during incontinent care for Resident #45. |
| CNA R | Certified Nursing Assistant | Observed failing to perform hand hygiene between glove changes during incontinent care for Resident #35. |
| LVN G | Unit Manager | Responsible for reviewing new admissions, care plan updates, and competencies. |
| LVN M | Infection Preventionist | Responsible for skills check offs and infection control. |
| LVN O | Charge Nurse | Acknowledged dirty oxygen concentrator filter and cleaning responsibilities. |
| LVN C | Charge Nurse | Expected proper incontinent care and cleaning practices. |
| Interim Administrator | Administrator | Responsible for oversight of training, infection control, and equipment maintenance. |
| Dietary Manager | Dietary Manager | Acknowledged food temperature and quality issues. |
| Corporate Nurse | Corporate Nurse | Provided protocol for oxygen concentrator filter cleaning. |
| Housekeeping District Manager D | Housekeeping District Manager | Responsible for cleaning isolation rooms and disinfectant use. |
| Housekeeping Supervisor | Housekeeping Supervisor | Responsible for ensuring correct disinfectant use. |
| Maintenance Supervisor | Maintenance Supervisor | Responsible for equipment maintenance and repairs. |
| Activity Director | Activity Director | Not certified as required; enrolled in training course. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 16, 2023
Visit Reason
The inspection was conducted as an annual survey of Treviso Transitional Care to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
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