Treviso Transitional Care

In the surveyor’s words

From the most serious findings on record at Treviso Transitional Care, in the surveyor’s own words.

• Immediate jeopardy, patternF580Oct 12, 2023

  Based on observation, interview, and record review the facility failed to immediately consult with the resident physician when there was a significant change in the resident physical condition for 1 of 6 residents reviewed for change in condition. (Resident #1) The facility failed to notify the physician when Resident #1 experienced nausea and vomiting for 3 days after receiving new medications. Resident #1 was prescribed 5 different medications on 9/27/23 and 4 of them had side effects of nausea and vomiting. Resident #1 received the medications on 9/27/23. She vomited on 9/28/23, 9/29/23 and 9/30/23 and nurses noted in the clinical record no adverse reactions to medications. On 10/1/23 Resident #1 was sent to the ER with decreased blood pressure, decreased heart rate, and oxygen levels. […]

• Immediate jeopardy, patternF684Oct 12, 2023

  Based on observation, interview, and record review the facility failed to ensure a resident received the treatment and care in accordance with professional standards of practice for 1 of 5 residents reviewed for quality of care.(Resident #1), in that: The facility failed to ensure Resident #1 was not having adverse reactions to new medication. Resident #1 was prescribed 5 different medications on 9/27/23 and 4 of them had side effects of nausea and vomiting. Resident #1 received the medications on 9/27/23. She vomited on 9/28/23, 9/29/23 and 9/30/23 and nurses noted in the clinical record no adverse reactions to medications. […]

• Immediate jeopardy, patternF725Jan 7, 2021

  Based on observation, interview, and record review, the facility failed to provide sufficient nursing staff to provide nursing services to assure resident safety and maintain the highest practicable physical, mental and psychosocial well-being determined by resident assessments and plans of care and considering the number, acuity and [DIAGNOSES REDACTED]. (Resident #s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, and 19) The facility did not provide sufficient nursing personnel on the COVID-19 unit to: * Provide wound care according to physician's orders [REDACTED]. […]

• Immediate jeopardy, isolatedF610Nov 15, 2023

  Based on interviews and record review the facility failed to ensure allegations of neglect were thoroughly investigated to prevent further elopement and report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency within 5 working days of the incident and if the alleged violation is verified appropriate corrective action must be taken for 1 (Resident #1) of 4 residents reviewed for neglect. The facility failed to immediately investigate, protect the resident, and report allegations of neglect when: Resident #1 eloped from the facility for an unknown amount of time and was found down the street approximately 150 yards from the facility by law enforcement. […]

• Immediate jeopardy, isolatedF689Nov 15, 2023

  Based on interviews, and record review the facility failed to provide adequate supervision to prevent elopement for 1 of 3 residents (Resident #1) reviewed for accidents, hazards, and supervision in that: Resident #1 eloped from the facility for an unknown amount of time and was found approximately 150 yards away from the facility by a neighboring facility and law enforcement. She had crossed a street and was in a 30 mile per hour area. An Immediate Jeopardy (IJ) was identified on 11/4/23 at 7:25 p.m. […]