Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Treviso Transitional Care during CMS and state inspections, most recent first.
A resident with a history of falls did not have a functioning call light system, leading to a delayed response when the resident fell out of bed. The call light system in the room was malfunctioning, failing to alert staff at the nurse's station. Despite previous reports of the issue, the problem persisted, and staff were unaware of the malfunction's extent.
The facility failed to address resident grievances in a timely manner, with issues such as unmade beds, lack of snacks, and toilet paper shortages being raised by the Resident Council over several months without prompt resolution. Staff interviews revealed delays in communication and action, contrary to the facility's grievance policy requiring responses within five days.
The facility failed to transmit MDS assessments to CMS within the required 14 days for four residents, potentially affecting payments. Residents with various medical conditions had their assessments completed and transmitted late, with CMS issuing warnings for the delays. Staff interviews revealed challenges in managing the workload, contributing to the deficiency.
The facility failed to meet professional standards for food storage and sanitation. Cardboard boxes were improperly stored on the pantry floor, and there was a lack of cleanliness around kitchen equipment. Additionally, food items in the cooler and freezer were not properly labeled or dated, which could lead to unsanitary conditions and risks for residents. Interviews with the Dietary Manager and Administrator highlighted expectations for cleanliness and proper labeling, but these were not met, potentially risking foodborne illness.
The facility failed to complete quarterly MDS assessments on time for three residents, including those with severe cognitive impairment and multiple health issues. The delay was due to the high volume of assessments and care plans managed by the MDS Coordinator, who was supported by regional staff. The DON and ADM were aware of the issue, which affected both revenue and resident care.
A facility failed to accurately document a resident's fall history in the quarterly MDS assessment. The resident, an 82-year-old female with Parkinson's Disease, dysphagia, and depression, experienced a fall that was not recorded in the MDS. The MDS Coordinator admitted the oversight, highlighting the importance of accurate assessments for care planning. Interviews with staff revealed that the MDS is constructed from various sources and triggers necessary care plan items. The Administrator noted that inaccuracies could have financial implications and affect resident autonomy.
The facility failed to develop comprehensive care plans for two residents, one with Parkinson's Disease and another with significant weight loss. The care plans lacked necessary interventions and updates, potentially affecting resident care. Staffing changes and inadequate meetings contributed to these deficiencies.
The facility failed to update comprehensive care plans for two residents, leading to inaccuracies in their documented care needs. One resident's care plan did not reflect a change in diet, while another's care plan did not account for resolved medical conditions and discontinued treatments. Staff interviews revealed a lack of follow-through in updating care plans after interdisciplinary team meetings.
A resident in an LTC facility received duplicate doses of several medications, including metoprolol and venlafaxine, due to a failure in the facility's medication review process. The issue was identified by a CMA but was not escalated beyond the Unit Manager, leading to continued administration of the duplicate medications. The resident did not show immediate adverse effects, but the potential for harm was recognized by the DON.
A medication cart in the 400/500 hall was left unlocked and unattended by an LVN while administering medication to a resident. The cart contained various medications, including insulin pens and scheduled drugs. Interviews with staff confirmed that medication carts should always be locked when not in use to prevent unauthorized access.
A resident with severe cognitive impairment and multiple diagnoses required oxygen therapy, but the facility failed to change her oxygen tubing weekly as ordered. Observations showed the nasal cannula had not been replaced since a specified date, and interviews confirmed that night nurses were responsible for this task. The facility's failure to follow care plans and physician's orders could place residents at risk of respiratory infections.
A facility failed to maintain accurate records of a resident's controlled medication, Hydrocodone, prescribed for pain management. Discrepancies in medication counts were discovered, leading to an investigation involving the DON and pharmacy consultant. A CMA was suspected of administering medication without documentation, resulting in her suspension. The facility conducted drug tests on staff, which were negative, and implemented new processes to ensure accurate narcotic counts.
Failure to Ensure Functioning Call Light System
Penalty
Summary
The facility failed to ensure that a resident had a functioning call light, which is a critical component for residents to request assistance. This deficiency was identified for a resident who had a history of falls and required substantial assistance with activities of daily living (ADLs). The resident's care plan specifically included the intervention to ensure the call light was within reach and to encourage its use for assistance. However, the call light system in the resident's room was not functioning properly, as it did not make an audible noise at the nurse's station, leading to a delay in response when the resident fell out of bed. On the morning of the incident, the resident fell from his bed and was unable to get back up. Another resident in the room attempted to call for help by pressing the call light button, but no staff responded because the call light system was malfunctioning. The family member of the resident was informed of the fall by another resident and arrived at the facility to find the resident on the floor. The family member reported that the nurses were unaware of the activated call light due to the malfunction, which had been an ongoing issue. Interviews with staff revealed that the malfunctioning call light system had been reported previously, but the issue persisted. The maintenance director had attempted to fix the system by replacing a component in the bathroom, but the problem with the bedroom call light remained unresolved. Staff members were unaware of the malfunction's extent, and the lack of an audible alert at the nurse's station contributed to the delayed response to the resident's fall.
Delayed Response to Resident Grievances
Penalty
Summary
The facility failed to address and document the grievances and recommendations of the resident group in a timely manner, as required by regulations. Over a period of three months, from February to April 2024, the Resident Council raised concerns about various issues, including medicine being left at the bedside, unmade beds, unchanged linens on shower days, lack of snacks, and frequent shortages of toilet paper. Despite these grievances being documented during Resident Council meetings, the facility did not respond or document their responses until May 2024, well beyond the expected timeframe. Interviews with residents and staff revealed ongoing issues with the facility's response to grievances. Residents expressed that their concerns were repeatedly raised during council meetings without receiving timely feedback or resolution. Staff members, including the Housekeeping Supervisor and the Dietary Manager, acknowledged the issues but indicated that resolutions were either delayed or not effectively communicated to the residents. The new DON and ADM, who were not in their positions during the initial grievances, recognized the lack of timely responses and the potential negative impact on residents. The facility's grievance policy, which mandates a response within five working days, was not adhered to, leading to resident dissatisfaction and a sense of being ignored. The Social Service Director, responsible for investigating grievances, did not ensure timely communication of resolutions to the residents. The lack of prompt action and documentation of responses to the grievances contributed to the deficiency identified by the surveyors.
Delayed MDS Transmissions in LTC Facility
Penalty
Summary
The facility failed to ensure that each Minimum Data Set (MDS) was electronically completed and transmitted to the CMS System within 14 days after completion for four residents. This deficiency was identified during interviews and record reviews, which revealed that the MDS assessments for Residents #149, #24, #16, and #5 were not transmitted within the required timeframe. The delay in transmission could potentially affect the timeliness of payments to the facility. Resident #149, an elderly female with diagnoses including stroke and heart failure, had her MDS assessment signed by the MDS Nurse but was not transmitted until three days later. Similarly, Resident #24, who had severe cognitive impairment and required assistance with activities of daily living (ADLs), had her MDS transmitted late. Resident #16, with moderately impaired cognition, and Resident #5, also with moderately impaired cognition, both had their assessments completed and transmitted well beyond the 14-day requirement, with warnings issued by CMS for late submission. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing (DON), highlighted challenges in keeping up with the volume of MDS assessments due to staffing limitations. The MDS Coordinator was responsible for numerous tasks, including reviewing clinical records, completing various MDS types, and coordinating with insurance companies. The DON, who was new to the facility, was unaware of the late submissions but acknowledged the heavy workload of the MDS nurse. The facility's policy indicated that MDS assessments should be transmitted no later than 31 days after completion, but this was not adhered to in these cases.
Deficiencies in Food Storage and Sanitation
Penalty
Summary
The facility failed to adhere to professional standards for food storage, preparation, distribution, and service, as observed in their kitchen. Cardboard boxes containing frying oil were found on the pantry floor, contrary to the facility's policy that requires items to be stored at least six inches above the floor. Additionally, the outside of a microwave and the wall next to a beverage table were observed to have brown buildup and dry brown splashes, respectively, indicating a lack of cleanliness and sanitation. Furthermore, food items in the walk-in cooler and freezer were not properly labeled or dated, with some items being completely unlabeled, which goes against the facility's policy and the FDA's FIFO procedures. Interviews with the Dietary Manager and the Administrator revealed that there was an expectation for all equipment to be clean and for food items to be properly labeled and dated. The Dietary Manager, who was new to the facility, acknowledged that she was working on a cleaning schedule and that the kitchen staff were responsible for maintaining cleanliness and labeling food items. The Administrator confirmed that improper storage and cleanliness could lead to unsanitary conditions and that unlabeled food items could pose a risk of serving expired food or incorrect diets. Despite these expectations, the deficiencies observed during the survey indicate a failure to meet these standards, potentially placing residents at risk of foodborne illness and food contamination.
Delayed MDS Assessments in LTC Facility
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments within the required time frame for three residents. Resident 24, an elderly female with severe cognitive impairment and multiple diagnoses including acute kidney failure and Parkinson's disease, did not have her quarterly MDS submitted until after the due date. Similarly, Resident 16, who has moderately impaired cognition due to a stroke, and Resident 5, who suffers from metabolic encephalopathy and dementia, also had their assessments completed and transmitted late. The delay in completing these assessments was acknowledged by LVN E, who was providing regional support to the facility's MDS Coordinator. LVN E admitted that several MDS assessments were late and attributed this to the challenge of managing the volume of assessments and care plans due each month. The MDS Coordinator, who was responsible for a wide range of duties including completing all MDS assessments and care plans, confirmed that there were delays and that support was being provided to address the backlog. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that they were aware of the issue, with the DON having recently started in her role and the ADM being informed by LVN E. Both acknowledged the importance of timely MDS completion for revenue and resident care. The facility's adherence to RAI and CMS guidelines was noted, but the late submissions were recognized as a deficiency in meeting these standards.
Inaccurate MDS Assessment of Resident's Fall History
Penalty
Summary
The facility failed to ensure that the quarterly Minimum Data Set (MDS) assessment for a resident accurately reflected the resident's history of falls. The resident, an 82-year-old female with diagnoses of Parkinson's Disease, dysphagia, and depression, had a documented fall in her room while attempting to go to the restroom. This incident was not recorded in the MDS assessment, which indicated no falls had occurred since the last assessment. The MDS Coordinator acknowledged the oversight, stating that the fall should have been included in the MDS, as it is crucial for accurate care planning. Interviews with the MDS Coordinator and the Director of Nursing (DON) revealed that the MDS assessment is constructed using various sources, including hospital records and discussions with the resident. The MDS triggers items on the Care Area Assessment (CAA) that are necessary for the care plan. The Administrator expressed that accurate MDS assessments are expected to provide a clear picture of the resident, and inaccuracies could affect the facility financially and impact the resident's autonomy. The facility's policy emphasizes the importance of accurate assessments to maintain or improve residents' medical status and functional abilities.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, which could potentially impact their quality of care and life. Resident #13, an 82-year-old female with Parkinson's Disease, dysphagia, and depression, did not have a care plan addressing her Parkinson's Disease diagnosis and treatment. Despite having a moderate cognitive impairment and requiring assistance with activities of daily living, her care plan lacked specific interventions related to her condition, even though she was prescribed carbidopa-levodopa. Resident #44, a female with diabetes, dementia, and fibromyalgia, experienced significant weight loss of over 15% in 180 days, yet her care plan did not address this issue. Despite being dependent on staff for daily activities and having severe cognitive impairment, her care plan lacked interventions or goals related to her weight loss. The resident was unaware of her weight loss and expressed a desire to reduce her weight to alleviate caregiver burden. Interviews with facility staff revealed that the MDS Coordinator was responsible for creating and updating care plans but had not done so due to recent staffing changes and a lack of regular meetings. The Director of Nursing acknowledged the MDS Coordinator's workload and had arranged for additional nursing support to assist with care plans. The facility's policy emphasized the importance of updating care plans based on comprehensive assessments, but this was not adhered to, leading to deficiencies in resident care.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment. This deficiency was identified for two residents. Resident #13's care plan was not updated to reflect a change in her diet from puree with nectar thickened liquids to puree with honey thickened liquids, despite a physician's order indicating this change. The care plan dated 06/13/2024 still reflected the old diet order, which could lead to inappropriate dietary interventions. Resident #44's care plan was not revised to reflect multiple changes in her medical condition and treatment. Her care plan, dated 05/16/2024, inaccurately indicated that she had an indwelling catheter, was receiving hypnotic medication daily, had a pelvic abscess, used tobacco daily, had a pressure ulcer to her left heel, had a UTI, was on antibiotic therapy, was on anticoagulation therapy, and was on IV therapy. However, records showed that these conditions and treatments had been resolved or discontinued by various dates in 2024. Observations confirmed that Resident #44 no longer had a catheter, pelvic abscess, or pressure ulcer, and was not receiving IV therapy. Interviews with facility staff, including the MDS Coordinator and the DON, revealed that care plans were supposed to be reviewed and revised during care plan meetings with the interdisciplinary team. However, the MDS Coordinator admitted that she did not ensure changes were made to residents' care plans after these meetings. The DON confirmed that the MDS Coordinator was responsible for updating care plans and that they should accurately reflect the resident's current condition to guide care. The facility had a consultant and an assistant to help with care plan updates, but these resources were not effectively utilized to prevent the deficiencies identified.
Duplicate Medication Administration in Resident's Drug Regimen
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, resulting in the administration of duplicate medication therapy. The resident, an 85-year-old female with diagnoses including dementia, COPD, Type 2 diabetes, and vitamin deficiency, received duplicate doses of several medications, including metoprolol, venlafaxine, trazadone, pantoprazole, MiraLAX, and vitamin D3. This was discovered through observation, interview, and record review, revealing that the resident received multiple doses of the same medications over a period of time. The issue arose when a CMA noticed the duplicate orders on the MAR and reported it to the Unit Manager, who instructed her to continue administering the medications as listed. The CMA, trusting the Unit Manager's guidance, continued to administer the medications despite her reservations. The DON was unaware of the duplicate therapy until informed by the surveyor, and the facility's system for checking new orders failed to catch the duplication due to a change in personnel and the timing of the pharmacy consultant's review. Interviews with staff revealed that the duplicate medication administration was not reported beyond the Unit Manager, and the charge nurses were not aware of the issue unless informed by the CMA. The resident did not exhibit any immediate adverse effects from the duplicate therapy, as confirmed by a tele-med exam conducted by the MD. However, the potential for harm was acknowledged by the DON, who stated that duplicate drug therapy could lead to serious health consequences.
Medication Cart Security Breach
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as observed with one of the medication carts for the 400/500 hall. During an observation, LVN B left the medication cart unlocked while administering medication to a resident. The cart was left unattended and out of sight for several minutes, during which time three housekeepers were present in the hallway. LVN B acknowledged that the cart was not locked and admitted that someone could access the medications, which could lead to unauthorized use. Further observations revealed that the medication cart contained various medications, including over-the-counter drugs, insulin pens, and scheduled medications. Interviews with LVN C, the ADON, the ADM, and the DON confirmed that medication carts should always be locked when not in use to prevent unauthorized access. The facility's policy on medication storage, revised in April 2017, mandates that all drugs and biologicals be stored securely and that medication carts should not be left unattended if open.
Failure to Change Oxygen Tubing for Resident
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, specifically by not changing the oxygen tubing as required. Resident #24, a female with severe cognitive impairment and multiple diagnoses including acute kidney failure, Parkinson's disease, and anemia, was dependent on staff for assistance with activities of daily living and required oxygen therapy. The resident's care plan and physician's orders specified that the oxygen tubing should be changed weekly and labeled, but observations revealed that the nasal cannula had not been replaced since 6/17/24, despite the requirement to change it weekly. Interviews with the facility's administration and nursing staff confirmed that the responsibility for changing the nasal cannula lay with the night nurses. Both the administrator and the director of nursing acknowledged that the failure to change the oxygen tubing could place residents at risk of respiratory infections. The deficiency was identified through observations and interviews, highlighting a lapse in following the care plan and physician's orders for Resident #24's respiratory care.
Failure to Maintain Accurate Controlled Medication Records
Penalty
Summary
The facility failed to maintain accurate records of controlled medication for a resident, specifically Hydrocodone, which was prescribed for pain management. The resident, a male with a history of a displaced mid-cervical fracture of the left femur, cervical disc disorder, rheumatoid arthritis, and low back pain, was prescribed Hydrocodone to manage his pain. The medication administration record indicated that the resident received two doses of Hydrocodone, but discrepancies were found in the medication count, leading to concerns about the accuracy of medication administration records. Interviews with facility staff revealed that there was an incident where a Certified Medication Aide (CMA) was off on her counts, and another CMA had to cover the shift. The CMA who was off on counts was suspected of administering medication without proper documentation, leading to her suspension. The Licensed Vocational Nurse (LVN) and Assistant Director of Nursing (ADON) confirmed that there was a discrepancy in the Hydrocodone count, and the facility had to conduct a thorough investigation with the pharmacy consultant to account for the discrepancies. The Director of Nursing (DON) and other staff members were involved in addressing the issue, including conducting drug tests on staff, which returned negative results. The DON implemented new processes to ensure accurate narcotic counts and documentation. Despite these efforts, the initial failure to maintain accurate records of controlled substances posed a risk to the residents' health and well-being, as it could lead to improper administration of medication.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Longview
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Longview Hill Nursing And Rehabilitation Center | 1 mi | — | 13 | 0 |
| Avir At Longview | 1.6 mi | — | 6 | 0 |
| Heritage At Longview Healthcare Center | 1.8 mi | — | 1 | 0 |
| The Oaks At Longview | 1.8 mi | — | 1 | 0 |
| Buckner Westminster Place | 2 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.