Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Green Valley Health And Wellness Suites during CMS and state inspections, most recent first.
Low Sanitizer Concentration in Three-Compartment Sink: The facility failed to ensure dishware was sanitized per policy in the main kitchen three-compartment sink. The quaternary ammonium sanitizer measured about 50-100 ppm, below the Food Service Manager’s stated target range and the facility policy requirement for immersion in a 150-200 ppm solution for at least one minute. The Food Service Manager stated the sink should be tested daily and that utensils and equipment must be washed, rinsed, and sanitized.
Lack of informed consent for psychotropic medication. A resident with depression and an unspecified mood disorder was ordered duloxetine, but the medical record did not show consent was obtained before the first dose. The DON confirmed the missing consent, and an LPN stated consent was required before psychotropic medication administration.
A resident with COPD, pleural effusion, hypothyroidism, and contact isolation status was observed enjoying puzzles but had not attended activities and was unaware of what the facility offered. The medical record lacked an activity care plan with specific interventions and measurable goals, and an Activity Aide and the MDS Director were unaware of who was responsible for completing the plan, which should have been done within 14 days of admission.
A resident with a left patella fracture, metabolic encephalopathy, depression, and mood disorder had a knee brace from PT that was applied by restorative nursing, but the chart lacked a physician order, RNA notes, and a care plan for the brace. Staff reported the resident often refused the brace because of pain and wanted it removed, and the MDS/medical records staff confirmed the missing documentation.
Medication Error Rate Exceeded Allowed Threshold: During a medication pass observation, an LPN omitted two ordered medications, resulting in a 7.14% medication error rate. One resident with atrial fibrillation did not receive ordered azelastine nasal spray, and another resident with sarcopenia, a stage 3 pressure ulcer, and generalized weakness did not receive ordered Lovenox SQ. The LPN later confirmed both orders and stated the medications had been overlooked and omitted.
A resident with multiple diagnoses had several medications and topical products left on the overbed table without a medication self-administration assessment or MD order, and the DON confirmed staff should remove medications from the bedside when observed. In addition, an open multi-dose vial of Tuberculin Diluted Aplisol was found in the med refrigerator after the Unit Manager stated it should have been discarded within 30 days of opening.
QAPI committee meetings did not include the Medical Director as required. Meeting minutes showed repeated absences, and the Administrator confirmed the Medical Director had scheduling conflicts and was not attending at least quarterly. The facility policy required the QAA committee to meet at least monthly and include the Administrator, DON, Medical Director or designee, Infection Control Officer, and a leadership representative.
A resident with a history of congestive heart disease and muscle weakness was not allowed to reenter the facility after returning late from a therapeutic leave, despite expressing a desire to stay. Staff, following direction from the ADON, discharged the resident without providing the required 30-day written notice or notifying the Ombudsman, and the discharge was incorrectly documented as AMA without the resident's signature. Facility leadership later confirmed that proper involuntary discharge procedures were not followed.
The facility did not ensure that resident grievances were investigated or resolved, as required by policy. Multiple complaints, including delayed care, staff rudeness, and missing personal items, were documented in meeting minutes and grievance logs but lacked evidence of investigation or resolution. The DON and Social Worker confirmed that documentation of grievance follow-up was missing, and not all staff had access to the grievance system.
A resident with multiple neurological diagnoses did not receive a scheduled dose of Clonazepam 0.5 mg as ordered, despite the medication being available in the facility's Omnicell system. Documentation cited unavailability and awaiting pharmacy delivery, but staff did not access the medication from the Omnicell or contact the physician for clarification, resulting in the missed administration.
A resident with multiple medical conditions was found with a prescription eye drop medication left unsecured on the bedside table, contrary to physician orders and facility policy. An LPN confirmed the medication should have been stored in the medication cart, and the DON stated that medications are not to be left at the bedside and must be secured.
Staff failed to consistently follow posted infection control precautions for two residents requiring Contact or Enhanced Barrier Precautions. Multiple staff, including CNAs, an LPN, and a housekeeper, entered rooms or provided care without the required PPE, despite clear signage and available supplies. Staff acknowledged the requirements but did not adhere to them, and some expressed confusion about proper PPE use and removal.
A facility failed to implement a person-centered care plan for a resident's PICC line, which was inserted for TPN and antibiotics. The medical records lacked a care plan, and there was a communication breakdown between the MDS department and nursing staff, leading to the oversight.
The facility failed to maintain proper PICC line care for two residents, leading to potential infection and catheter occlusion risks. One resident had a soiled and undated dressing with no physician order for maintenance, while another lacked a saline flushing protocol, resulting in a non-patent line. The facility's policies for PICC line care were not followed, as confirmed by the interim DON and LPNs.
The facility failed to obtain informed consents and monitor behaviors for psychoactive medications for two residents. One resident was prescribed Zoloft without informed consent or monitoring, while another received Hydroxyzine, Seroquel, and Trazodone with undated and unwitnessed verbal consents. The facility's policy for medication management was not followed, leading to deficiencies in monitoring and documentation.
A facility failed to complete an initial PASRR for a resident with depression and anxiety disorder before admission. The resident required 1:1 monitoring due to severe anxiety, and the absence of a PASRR assessment was acknowledged by the Director of Admissions. The last PASRR was from 2008, and the Director of Social Services confirmed that a PASRR level 1 screening should have been conducted to evaluate the resident's mental health needs.
A resident with a spinal injury and overactive bladder was left soiled and wet for several hours despite requesting assistance, leading to a call to 911. The facility failed to provide timely incontinent care, with staff ignoring the resident's pleas and lacking documentation of care provided. Interviews revealed delays in response to call lights and inadequate communication and prioritization of care.
The facility failed to conduct proper nutritional assessments and interventions for residents with significant weight changes. A resident experienced notable weight loss without documented assessments or interventions, while another had missing weight records for two months. A third resident on hospice care had a drastic weight loss that was not immediately verified. The facility did not adhere to its weight monitoring protocols, leading to potential delays in necessary interventions.
A resident with a PICC line was found with a dressing that had not been changed for nearly a month, contrary to the facility's policy of weekly changes. The oversight was confirmed by a nurse, and the resident's medical record lacked documented orders for PICC line care. The Interim DON suggested the omission might be linked to the resident's recent re-admission.
The facility failed to ensure proper dialysis communication and post-treatment assessments for two residents with end-stage renal disease. One resident had incomplete records for 8 days and missing vital signs for 6 days, while another had missing records for 13 days and missing vital signs for 6 days. The interim DON acknowledged the importance of complete records and assessments to ensure residents' safety post-dialysis.
The facility failed to develop baseline care plans for two residents admitted with ileostomies, lacking documentation of care and management interventions. The DON confirmed the absence of these plans, which are required within 48 hours of admission to address immediate care needs. This placed the residents at risk for complications such as stoma infection and skin irritation.
The facility failed to document and execute care orders for the ileostomy care of two residents, leading to a deficiency in their care. One resident was admitted with an ileostomy following a partial colectomy, and another with a history of alcohol abuse and ileostomy creation. Interviews revealed that the facility lacked a designated admission nurse, and the responsibility for entering care orders fell on the admitting nurse. The absence of documented care orders and a specific policy for ileostomy care resulted in inadequate care for the residents.
Low Sanitizer Concentration in Three-Compartment Sink
Penalty
Summary
The facility failed to ensure dishware was sanitized according to facility policy in the three-compartment sink in the main kitchen. On 01/27/2026 at 7:48 AM, the quaternary ammonium sanitizer solution in the three-compartment sink measured approximately 50-100 ppm, which indicated the sanitizer solution was low. On 01/28/2026 at 7:30 AM, the Food Service Manager stated the quaternary ammonium sanitizer solution should be maintained between 200-400 ppm according to most health and food safety standards and manufacturer guidelines, and stated the proper cleaning process included washing, rinsing, and sanitizing all utensils and equipment. The Food Service Manager also stated the three-compartment sink must be tested daily. The facility policy titled Manual Cleaning and Sanitizing with a Three-Compartment sink, dated 10/15/2025, documented immersion for at least one minute in a clean solution of 150-200 ppm of quaternary ammonium at 75 Fahrenheit or hotter.
Lack of Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure informed consent was obtained before administering psychotropic medication for Resident 14, who was admitted with diagnoses including metabolic encephalopathy, depression, and unspecified mood disorder. A physician order dated 01/12/2026 prescribed duloxetine 30 mg twice daily, but the resident's medical record did not contain documented evidence that informed consent was obtained before the first dose was given on 01/12/2026. On 01/28/2026, the DON confirmed the record lacked consent for duloxetine, and on 01/29/2026 an LPN stated that consent for psychotropic medication was required before administration. On 01/30/2026, the DON stated staff were expected to obtain consent for psychotropic medication prior to administration, and the facility policy titled Medication Management, Psychotropic Drugs-Use of, revised 04/17/2025, stated a consent form would be completed for each psychotropic medication prescribed.
Missing Person-Centered Activity Care Plan
Penalty
Summary
The facility failed to ensure a comprehensive person-centered care plan for activities was created for Resident 1, who was admitted with diagnoses including chronic obstructive pulmonary disease, pleural effusion, and hypothyroidism and was on contact isolation. On 01/27/2025 in the morning, Resident 1 was observed enjoying working on puzzles, had not attended activities, and was unaware of what activities the facility offered. The resident’s medical record lacked an activity care plan with specific interventions and measurable goals to promote quality of life. On 01/30/2026 at 9:30 AM, an Activity Aide completed an activity assessment upon admission but was unaware of the staff member responsible for completing the activity care plan. At 9:35 AM, the MDS Director confirmed the resident lacked an activity care plan and stated it should have been completed within 14 days of admission, while also being unaware of who was responsible for completing it.
Missing Physician Order for Knee Brace
Penalty
Summary
The facility failed to obtain a physician order for the use of a knee brace for a resident admitted with metabolic encephalopathy, depression, a displaced transverse fracture of the left patella, and an unspecified mood disorder. On 01/27/2026, the knee brace was observed lying on top of the dresser at the foot of the resident’s bed. The resident had a physician order dated 11/24/2025 for restorative nursing services including passive range of motion to the left lower affected side, non-weight bearing on the left lower side, active range of motion to the upper extremities and unaffected lower right side, at least 6 days per week. The Restorative Nurse Assistant stated the knee brace originally came from physical therapy and was applied by restorative nursing services, and that the resident frequently refused to wear it because of pain and would yell for it to be removed. The resident’s medical record lacked a physician order, RNA notes, and a care plan for the knee brace. The Medical Records Director confirmed the record lacked documentation of RNA services provided and a physician order for the knee brace, and the Unit Manager confirmed the resident required a physician order for the knee brace. The facility policy on Physician Orders stated orders are maintained for the resident’s immediate care, including routine care orders to maintain or improve functional abilities, and the Restorative Nursing policy stated restorative interventions are included in the plan of care and documented.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5 percent. During a medication administration pass observation on 01/29/2026, surveyors observed 28 opportunities and identified 2 medication errors, resulting in a 7.14% error rate. The facility’s Medication Management Program policy, revised 01/15/2025, stated that authorized staff members administer medications according to accepted standards of practice and in compliance with regulatory requirements. Resident 74 was admitted with diagnoses including displaced fracture of the lateral condyle of the left femur, unspecified protein calorie malnutrition, and atrial fibrillation. During the morning medication pass, the LPN prepared and administered the resident’s scheduled medications, but Azelastine spray 137 mcg, ordered as two nasal sprays once daily at 8:00 AM, was not administered as ordered. Resident 86 was admitted with diagnoses including sarcopenia, a stage 3 pressure ulcer of the right buttock, and generalized muscle weakness. During the morning medication pass, the LPN prepared and administered the resident’s scheduled medications, but Lovenox 40 mg SQ once daily at 8:00 AM was not administered as ordered. The LPN later confirmed both physician orders and stated the medications had been overlooked and omitted.
Unsecured bedside medications and expired multi-dose vial found in storage
Penalty
Summary
Medications were left unsecured at the bedside of a resident admitted with diagnoses including recurrent dislocation of the right hip, acute osteomyelitis of the right femur, and fibromyalgia. During observations, the resident had a 10-ounce spray bottle of 91% isopropyl alcohol, a spray bottle of hydrogen peroxide, and a 10-ounce bottle of Mylanta on the overbed table, and later had a 10-ounce spray bottle of 91% isopropyl alcohol, a 10-ounce bottle of Mylanta, and a tube of Neosporin on top of the overbed table. The resident stated the isopropyl alcohol and Neosporin were used for skin scrapes and the Mylanta was used as needed for heartburn. The medical record did not contain a medication self-administration assessment or physician's order for the isopropyl alcohol, Mylanta, or Neosporin. The DON confirmed that CNAs and nurses should remove medications from the resident's bedside when observed and that bedside medication storage requires a self-administration assessment and physician order. An open 1 mL multi-dose vial of Tuberculin Diluted Aplisol dated 11/27/22025 was found in the medication refrigerator during a tour of the second-floor medication storage room. The Unit Manager stated the medication should have been discarded within 30 days of opening. The facility policy for medication storage stated outdated, contaminated, or deteriorated medications, and those in containers that are cracked, soiled, or without secure closures, are to be immediately removed from stock and disposed of according to medication destruction procedures.
QAPI Committee Lacked Required Medical Director Participation
Penalty
Summary
The facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee included the Medical Director. Quality Assessment and Assurance meeting minutes documented that the Medical Director did not attend meetings on 01/16/2025, 03/27/2025, 04/25/2025, 05/22/2025, 06/24/2025, 08/28/2025, 10/16/2025, and 01/15/2026. On 01/30/2026 at 11:30 AM, the Administrator confirmed the Medical Director had not been attending the QAPI meetings and stated the Medical Director had scheduling conflicts and did not attend the meetings at least quarterly. The facility policy titled Leadership Framework, revised 12/03/2019, stated the QAA committee team would meet at least monthly and include, at a minimum, the Administrator, DON, Medical Director or Designee, Infection Control Officer, and an individual in a leadership role.
Failure to Follow Involuntary Discharge Procedures for Resident Returning from Therapeutic Leave
Penalty
Summary
The facility failed to ensure that a resident was not involuntarily discharged without a valid reason and without following required procedures. The resident, who had diagnoses including congestive heart disease and muscle weakness, was admitted for long-term care and had a physician order allowing therapeutic leave for up to four hours at a time. On the date of the incident, the resident left the facility on a pass and returned late, after which staff, under the direction of the Assistant Director of Nursing (ADON), did not allow the resident to reenter the facility. The resident was given their belongings and told they could not stay due to repeated violations of the four-hour pass rule, despite the resident expressing a desire to remain at the facility. Documentation showed that the discharge was recorded as 'against medical advice' (AMA), but the resident did not sign the AMA form, and the form itself lacked a diagnosis. Staff notes indicated that the resident was unhappy with being discharged and did not want to leave. Interviews with facility staff, including the ADON, DON, and Case Manager, revealed that the facility had an ongoing issue with the resident returning late from passes, but there was no written policy supporting automatic AMA discharge for exceeding the pass time. The DON and Administrator acknowledged that the required 30-day written notice of involuntary discharge and notification to the Long-Term Care Ombudsman were not provided to the resident. The facility's actions were based on verbal warnings and frustration with the resident's non-compliance, rather than adherence to established discharge procedures. The resident was not provided with the opportunity to appeal the discharge or receive proper notification, and the discharge was not supported by a physician order or a documented safe discharge plan. The facility's failure to follow its own policies and regulatory requirements resulted in the resident being involuntarily discharged without due process.
Failure to Investigate and Resolve Resident Grievances
Penalty
Summary
The facility failed to ensure that resident grievances were properly investigated and that determinations or resolutions were provided to residents. Interviews and document reviews revealed that issues raised during Resident Council Meetings were not consistently entered into the grievance program, and there was no documentation of investigations or resolutions for the grievances. The Social Worker stated that not all new staff had access to the computer system to input investigations and resolutions, resulting in a lack of follow-up on reported concerns. The Director of Nursing confirmed the absence of documentation for grievance investigations and resolutions, despite being able to provide meeting agendas where related topics were discussed. Resident Council Meeting Minutes and grievance logs from January through March documented multiple unresolved issues, including staff not performing rounds every two hours, staff being rude or sleeping during shifts, delayed medication administration, call lights not being answered for extended periods, and personal items being taken from residents' rooms. The facility was unable to provide evidence of steps taken to investigate these grievances, summaries of findings, confirmation of grievances, or corrective actions taken, as required by their own grievance policy.
Failure to Administer Medication per Physician Order
Penalty
Summary
A deficiency occurred when a resident with diagnoses including Friedreich ataxia and functional quadriplegia did not receive Clonazepam 0.5 mg as ordered by the physician. The medication was scheduled to be administered twice daily at 8:00 AM and 8:00 PM, but was not given at the scheduled 8:00 PM dose. Documentation on the Medication Administration Record indicated the medication was not administered due to it being unavailable, with a note that the facility was awaiting delivery from the pharmacy for a new admission. Further investigation revealed that the facility had an Omnicell automated medication dispensing system stocked with Clonazepam 0.5 mg, with six tablets available at the time. Staff confirmed that the medication could have been accessed from the Omnicell after verifying the order with the pharmacy, but this was not done. The Director of Nursing confirmed that the medication had not been administered and that staff would have needed to contact the physician for clarification due to the late delivery, but this step was not taken.
Medication Not Secured in Locked Storage
Penalty
Summary
A deficiency occurred when a prescription medication, Latanoprost 0.005% eye drops, was found unsecured on a resident's bedside table. The medication was intended to be administered at bedtime as per a physician's order. The resident, who had diagnoses including cellulitis of the right lower limb, type 2 diabetes mellitus with hyperglycemia, and difficulty walking, reported that the nurse had left the medication at the bedside the previous night. This was confirmed by an LPN the following morning, who acknowledged the medication should have been stored in the medication cart due to its specific administration schedule and safety concerns. Further, the Director of Nursing confirmed that facility policy requires all medications to be secured in locked compartments and not left at the bedside. The facility's policy, revised recently, mandates that all drugs and biologicals be stored in locked compartments under proper conditions. The failure to secure the medication as required by policy and regulation led to the deficiency identified during the survey.
Failure to Adhere to Infection Control Precautions for Residents on Contact and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain proper infection control practices for two residents who required either Contact Precautions or Enhanced Barrier Precautions. In one instance, a certified nurse assistant entered a resident's room with gloves but without a gown, despite signage indicating both were required, and then exited the room carrying a meal tray. The same resident's room was later entered by a licensed practical nurse and another certified nurse assistant without any gloves or gown, and a housekeeper was observed mopping in the room without a gown, even though the posted sign specified the need for both gloves and gown. All staff acknowledged the signage and the requirements but did not adhere to them, despite the availability of personal protective equipment (PPE) outside the room. For another resident on Enhanced Barrier Precautions, staff were observed providing care without the required PPE. One certified nurse assistant was at the room threshold with gloves but no gown, and another was inside the room without gloves or gown, both having removed their PPE after care activities but before leaving the room. Staff expressed confusion about when and where PPE should be worn or removed, particularly during resident transport. The infection prevention nurse confirmed that staff were educated on infection control and that the expectation was for staff to follow the posted signage, which was specific to each resident's needs. Facility policy required clear signage and periodic monitoring of infection control procedures.
Failure to Implement Person-Centered Care Plan for PICC Line
Penalty
Summary
The facility failed to implement a person-centered care plan for the utilization and maintenance of a PICC line for one resident. This resident was admitted with diagnoses including dysphagia, dementia, protein-calorie malnutrition, and failure to thrive. A PICC line was inserted for total parenteral nutrition and antibiotics administration, with specific physician orders for its use. However, the medical records lacked evidence of a formulated care plan for the PICC line's utilization and maintenance. The interim DON confirmed that no care plan had been formulated when the PICC line was inserted. The responsibility for care plan formulation was unclear, with the MDS department expected to create the plan if the PICC line was inserted post-admission, and licensed nurses responsible if the resident was admitted with a PICC line. The Director of MDS was unaware of the PICC line insertion due to a lack of communication and did not perform routine visual assessments. The facility's policy required the development of a baseline and comprehensive care plan for each resident, which was not adhered to in this case.
Deficient PICC Line Care and Maintenance
Penalty
Summary
The facility failed to ensure proper maintenance and care of a peripherally inserted central catheter (PICC) line for two residents, leading to potential risks of infection and catheter occlusion. Resident 1, who was admitted with diagnoses including diabetes mellitus and chronic hepatitis, had a PICC line in the right upper arm with a dressing that was undated, peeling, and soiled with dried blood-like residues. There was no documented evidence of a physician order for the maintenance of the dressing changes, and the dressing had not been changed since the PICC line was inserted. The interim Director of Nursing confirmed that the dressing should have been changed weekly, and the absence of a physician's order meant that licensed nurses were not prompted to complete the task. Resident 2, admitted with conditions such as dysphagia, dementia, and protein-calorie malnutrition, had a PICC line inserted for total parenteral nutrition (TPN) and antibiotics. However, there was no documented evidence of a physician order for the PICC line saline flushing protocol, which is essential to ensure patency. The PICC line was not patent or flushing, leading to the need for a replacement. Licensed Practical Nurses confirmed that a flushing protocol should have been in place, and the absence of such an order meant that the licensed nurses were not prompted to perform the necessary flushing. The facility's policies required licensed nurses to perform procedures related to PICC line care, including dressing changes and obtaining and transcribing physician orders. However, these protocols were not followed, as evidenced by the lack of orders and documentation for both residents. The interim Director of Nursing acknowledged the deficiencies and confirmed that the necessary orders were not obtained or implemented, leading to the potential for infection and catheter occlusion.
Failure to Obtain Informed Consents and Monitor Psychoactive Medications
Penalty
Summary
The facility failed to obtain informed consents, monitor behaviors, and document non-pharmacological interventions for the use of psychoactive medications for two residents. Resident 46 was admitted with diagnoses including schizoaffective disorder, insomnia, and depression. A physician order was given for Zoloft to be administered for depression, but there was no evidence of a physician order to monitor behavior or side effects, nor was there an informed consent obtained prior to the use of Zoloft. The interim Director of Nursing (DON) acknowledged that informed consent should have been obtained and that the facility's process for monitoring behaviors and side effects was not followed. Resident 38 was admitted with diagnoses including psychotic disorder with delusions, anxiety disorder, and schizophrenia. The resident was prescribed Hydroxyzine, Seroquel, and Trazodone, but informed consents were obtained verbally via telephone and were undated and unwitnessed. The DON explained that verbal consents required documentation and signatures from two licensed nurses as witnesses, which were not present. Additionally, there was no monitoring of the effectiveness of the medications. The facility's policy required obtaining physician orders and consent forms for each prescribed psychotropic medication, as well as monitoring and documenting the resident's response to the medication, which was not completed for Resident 38.
Failure to Complete PASRR Prior to Resident Admission
Penalty
Summary
The facility failed to ensure an initial Preadmission Screening and Resident Review (PASRR) was completed prior to the admission of a resident with diagnoses including depression and anxiety disorder. The resident was admitted with a history of psychiatric issues, requiring 1:1 monitoring due to severe anxiety behavior. Despite the presence of a Level of Care (LOC) assessment dated 07/08/2022, there was no documented evidence of a PASRR assessment in the resident's medical record. The Director of Admissions acknowledged the absence of a PASRR assessment and noted that the last completed assessment was from 2008, which was not retrievable due to a system upgrade. The Director of Social Services confirmed that the resident should have undergone a PASRR level 1 screening to evaluate any related diagnoses from the previous hospitalization. The resident exhibited behavioral issues during the hospital stay, and a newer PASRR could have identified any new mental illness diagnosis, potentially altering the determination or recommendations for care. The facility's policy requires all applicants to a Medicaid-certified nursing facility to be evaluated for mental illness or intellectual disability prior to admission, but this was not adhered to in this case.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide incontinent care to a dependent resident, identified as Resident 229, who was left soiled and wet despite requesting assistance. The resident, who was admitted with diagnoses including overactive bladder and a spinal injury, was totally dependent on assistance for care. On December 12, 2024, the resident experienced a bladder spasm and urinated in bed, pressing the call light for help. However, no assistance arrived for several hours, and staff were observed ignoring the resident's repeated pleas for help. The resident eventually called the facility operator and later 911 when no staff responded, leading to police involvement. The medical record lacked documented evidence of incontinent care being provided on December 12 and 13, 2024. Interviews with the interim Director of Nursing, a Licensed Practical Nurse, and a Certified Nursing Assistant revealed that there were delays in responding to the resident's call light and a lack of communication and prioritization in providing care. The staff were expected to provide care within 5-10 minutes of a call light being activated, but this did not occur. The CNA assigned to the resident on the day of admission confirmed that bowel and bladder care was not provided during their shift and was left for the night shift, which also failed to provide the necessary care. The Administrator confirmed that the delays in response and care were unacceptable, although no intentional neglect was observed. The facility's policy on Activities of Daily Living required staff to develop and implement interventions based on the resident's assessed needs and preferences, which was not adhered to in this case.
Failure to Monitor and Address Significant Weight Changes
Penalty
Summary
The facility failed to ensure proper nutritional assessments and interventions for residents experiencing significant weight changes. Resident 14, who was at risk for malnutrition, experienced a notable weight loss from 160 lbs. to 129.3 lbs. over several months without a documented nutritional assessment or intervention. The Director of Dietary Services and the Registered Dietitian confirmed that weight monitoring protocols were not followed, as weights were not documented for July, and no re-weighs were conducted after the weight loss was identified in August. Additionally, the interim Director of Nursing acknowledged the lack of a nutritional assessment during this period. Resident 16 also experienced lapses in weight monitoring, with no weights recorded for July and November. The Registered Dietitian and the Director of Nursing confirmed the absence of documentation for these months, indicating a failure to adhere to the facility's policy of obtaining and documenting weights as scheduled. This oversight in weight monitoring could have delayed necessary interventions for maintaining the resident's health. Resident 39, who was on hospice care, experienced a significant weight loss from 411.2 lbs. to 151.8 lbs. in December, which was not immediately re-weighed to verify accuracy. The Registered Dietitian noted the drastic weight change and requested a re-weigh, which was eventually conducted, confirming the weight loss. The interim Director of Nursing acknowledged that the resident's weight was not taken in November, contrary to the physician's order for monthly weights. The facility's policy required re-weighing in the presence of licensed personnel if a significant weight change was observed, which was not initially followed.
Failure in PICC Line Maintenance for a Resident
Penalty
Summary
The facility failed to ensure proper care and maintenance of a peripherally inserted central catheter (PICC) line for a resident, identified as Resident 35. The resident was observed with a PICC line dressing dated nearly a month prior, indicating it had not been changed according to the facility's policy, which requires weekly dressing changes. A registered nurse confirmed the oversight and acknowledged that the dressing should have been changed and documented in the medication and administration record (MAR). The resident's medical record lacked documented orders for the care and maintenance of the PICC line, which was confirmed by the Interim Director of Nursing. Resident 35 was admitted with diagnoses including hemiplegia and cellulitis of the abdominal wall. The resident's family member reported that no intravenous antibiotics or fluids had been administered for over a month. The Interim Director of Nursing suggested that the missing orders might have been due to the resident's recent re-admission. The facility's policy, revised in May 2023, outlines that licensed nurses are responsible for assessing and performing dressing care of a PICC line, including labeling the dressing with the date of the procedure or the next due date for a change.
Incomplete Dialysis Communication and Assessment
Penalty
Summary
The facility failed to ensure proper dialysis communication and post-treatment assessments for two residents, leading to a deficiency in care. Resident 5, diagnosed with end-stage renal disease and generalized anxiety, attended dialysis treatments 24 times. However, the Hemodialysis Communication Record was incomplete, with 8 days missing records, 6 days missing return vital signs and/or dialysis site information, and 2 days where the resident refused treatment. This lack of documentation could impair continuity of care and prevent the identification of adverse reactions post-dialysis. Similarly, Resident 8, with diagnoses including end-stage renal disease and heart failure, attended dialysis treatments on 20 occasions. The communication record was missing for 13 days, and 6 days lacked return vital signs and/or dialysis site observations. Additionally, one day was missing information from the dialysis center. The interim DON acknowledged the importance of complete communication records and post-dialysis assessments, as per the facility's policy, to ensure residents are not experiencing latent effects of dialysis and to check for bleeding at access sites.
Failure to Develop Baseline Care Plans for Ileostomy Management
Penalty
Summary
The facility failed to develop a baseline care plan for two residents who were admitted with ileostomies, which are surgical openings created by bringing the end of the small intestine to the skin's surface. This deficiency was identified through interviews, record reviews, and document reviews. Resident 1 was admitted with diagnoses including malignant neoplasm of the endometrium and an ileostomy following a partial colectomy. Similarly, Resident 3 was admitted with a history of alcohol abuse and an ileostomy creation. Both residents' medical records lacked documentation of a baseline care plan addressing the care and management of their ileostomies. The Director of Nursing confirmed the absence of baseline care plans for the residents' ileostomies, acknowledging that the admitting nurse was responsible for initiating such plans to address immediate care needs. The Director of Clinical Services also emphasized the importance of including ileostomy care in the baseline care plan, as it is an immediate care need. The facility's policy requires a baseline care plan to be developed within 48 hours of admission to guide staff in providing necessary treatment and care. The lack of a baseline care plan for the ileostomies placed the residents at risk for complications such as stoma infection, skin irritation, and discomfort.
Failure to Document Ileostomy Care Orders for Two Residents
Penalty
Summary
The facility failed to ensure that care orders were entered and executed for the ileostomy care of two residents. Resident 1 was admitted with diagnoses including malignant neoplasm of the endometrium and an ileostomy, following a partial colectomy. Despite the need for specific care, the medical record for Resident 1 lacked documented evidence that care orders for the ileostomy were transcribed and carried out. Similarly, Resident 3, who was admitted with a history of alcohol abuse and an ileostomy creation, also had no documented care orders for their ileostomy in the medical record. Interviews with facility staff, including the Director of Nursing (DON), a wound nurse, and a Licensed Practical Nurse (LPN), revealed that the facility did not have a designated admission nurse, and the responsibility for entering care orders fell on the admitting nurse. The DON confirmed the absence of care orders for the ileostomies of both residents and acknowledged the lack of a specific policy for ileostomy care. The facility's practice was to follow professional standards for ostomy care, which include monitoring, emptying, and replacing the ostomy appliance as needed. However, these standards were not documented in the residents' care plans, leading to a deficiency in providing necessary care for the residents' ileostomies.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 538 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Henderson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oasis Nursing & Rehab Of Green Valley | 1.1 mi | ★★★★★ | 20 | 0 |
| Sage Creek Post-acute | 1.9 mi | ★★★★★ | 9 | 0 |
| Advanced Health Care Of Henderson | 2.5 mi | ★★★★★ | 0 | 0 |
| Coronado Ridge Skilled Nursing & Rehabilitation Ce | 2.6 mi | ★★★★★ | 20 | 0 |
| Tlc Care Center | 4.2 mi | ★★★★★ | 6 | 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 July 2026) and official state health department websites.