Average — CMS composite of the measures below.
A standard survey is most likely before 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 Oasis Nursing & Rehab Of Green Valley during CMS and state inspections, most recent first.
A resident with dementia and other medical conditions reported that a CNA was rude during care and intentionally hit them in the eye, later telling multiple staff, including an RN, LPN, and CNA, that they had been assaulted and that their eye hurt. Staff documentation noted a red mark and redness to the resident’s right eye, and the physician was contacted for redness around the eye. Although the facility’s policy required all abuse allegations to be reported to local, state, and federal agencies within specified timeframes, the RN did not notify the Administrator promptly, the Administrator was not aware of the allegation for several days, and the allegation was never reported to the State Agency. The Administrator chose to investigate first and, citing the resident’s history of making allegations and behavioral history, decided the unsubstantiated allegation was not reportable, while the Director of Social Services referenced prior informal guidance suggesting some allegations could be handled internally despite the written reporting policy.
Lack of Signed Informed Consent for Psychotropic Medications: The facility failed to obtain signed informed consent before administering psychotropic medications to two residents. One resident with bipolar disorder received Quetiapine with no documented guardian consent, and another resident with dementia, depression, and bipolar disorder received Sertraline without documented consent before the first dose. The DON stated consent was required and psychotropic medications should not be given without a signed consent form.
Failure to complete a required significant change in status assessment for a hospice resident. A resident with Alzheimer's dementia and protein-calorie malnutrition enrolled in hospice, but the medical record lacked evidence of the required MDS assessment within the RAI timeframe. The MDS Coordinator, DON, and Medical Records Director all confirmed the assessment was not completed, and the MDS Coordinator stated it would have generated a hospice care plan.
A resident with Alzheimer's dementia and protein-calorie malnutrition was admitted to hospice, but the medical record lacked evidence that a hospice care plan was developed after hospice enrollment. The MDS Coordinator confirmed the care plan was not created because the significant change in status assessment was not completed per RAI requirements, and the DON stated no significant change assessment was completed within 14 days of hospice admission.
Failure to provide scheduled showers for a resident who required maximal assistance with bathing. The resident had encephalopathy, malnutrition, pancreatitis, pain, and auditory hallucinations, and the care plan called for bathing support, including sponge baths if a full shower could not be tolerated. Facility records showed the resident was to receive showers twice weekly, but only one shower was documented for the month. CNAs said showers were charted in the resident record and on skin shower sheets, while the RN, DON, and Medical Records Director confirmed the missing documentation and could not locate additional shower sheets.
Failure to Complete Pressure Injury Risk Assessment and Identify New Skin Impairment: A resident with ESRD and osteomyelitis had no documented Braden risk assessment after initial admission, despite the facility using the Braden scale on admission, readmission, and quarterly. The resident’s skin was documented as intact on a facility skin check, but hospital records later showed a new full thickness R foot ulcer and a scabbed wound on the R fifth toe. After readmission, nursing notes documented the wound and IV antibiotics for osteomyelitis, and the DON stated the wound appeared to be facility-acquired and not identified during the last weekly skin check.
A resident with severe cognitive impairment and dementia was able to repeatedly access sugar packets and artificial sweetener from the service area, despite prior staff redirection and a care plan noting wandering and hoarding risk. An LPN reported the resident liked to eat sugar and sometimes ate the packet, and the resident was later observed placing an entire packet into the mouth and chewing it. Surveyors also found broken cabinet locks on the specialty care unit, with cabinets containing large amounts of sugar packets, artificial sweeteners, condiments, and open bottles of liquid hand soap that were supposed to be inaccessible to confused residents.
A facility failed to properly monitor the temperature, dating, and labeling of food stored in residents’ personal refrigerators. Staff gave inconsistent accounts of who was responsible for cleaning, checking temperatures, and discarding expired food, and an LPN found one refrigerator dirty with ice buildup while temperatures in two refrigerators were above the expected range. The DON confirmed the refrigerators needed cleaning and that expired food should have been discarded, and the facility had no specific policy for residents’ personal refrigerators.
Broken cabinet and refrigerator locks were found in the specialty care unit. Surveyors observed two cabinets and a staff refrigerator with broken locks, and CNA1 stated the unit housed 17 residents with dementia and that the contents should be kept secure. On revisit, one cabinet was missing a drawer face and knob, the locks remained broken, and a resident was observed approaching the cabinet before being redirected. Staff reported the issue had been present for nearly a month, but no maintenance work order had been documented in the log.
The facility did not enforce or document its Legionella Water Management Program as required, with no evidence of regular monitoring or review prior to being notified of possible Legionella contamination. Two residents with complex respiratory and cardiac conditions tested positive for Legionella after being transferred to acute care, and the facility could not provide documentation of required water system inspections or control measures before the incident. The water management plan was found to be adequate but had not been periodically reviewed or tailored to the facility, and documentation of compliance only began after external notification.
A resident with intact cognition reported being inappropriately touched on the chest by another resident, who later admitted to the act. The incident was not immediately reported to staff, and the facility's investigation substantiated the abuse. Both residents had behavioral care plans addressing prior concerns, but the event was not prevented or promptly identified, resulting in a deficiency for failure to protect residents from abuse.
A resident with a kidney transplant was given Cialis tablets instead of the prescribed Tacrolimus capsules for several days due to a pharmacy mislabeling error. LPNs administered the medication based on the mislabeled bubble pack without recognizing the form discrepancy, and the error was only discovered after multiple doses when a nurse questioned the medication's appearance. The DON and Consultant Pharmacist confirmed the mislabeling and the failure to identify the error during medication administration.
A facility failed to monitor and document behaviors and side effects for residents on psychoactive medications, affecting six residents with conditions like dementia and psychosis. The issue arose during a transition to a new EHR system, where necessary orders did not migrate, leading to inconsistent documentation. Nurses were instructed to use progress notes instead of the MAR, but this resulted in inadequate monitoring, as acknowledged by the Clinical Care Coordinator.
The facility restricted residents from accessing the front porch area without a chaperone, despite no elopement risk and intact cognition for some. Residents were redirected to a courtyard gazebo, which is also a smoking area, causing dissatisfaction. The facility lacked a policy for this restriction, conflicting with residents' rights to self-determination.
A resident with chronic vision and hearing loss was inaccurately assessed, leading to inadequate care in a LTC facility. Despite being clinically blind and hard of hearing, the resident's MDS assessments documented adequate vision and hearing, resulting in insufficient meal assistance. The LPN and DON confirmed the inaccuracies, and the family reported a lack of accommodations for the resident's health status changes, contributing to weight loss and hospitalization.
The facility failed to conduct PASRR Level 2 evaluations for three residents with psychiatric diagnoses and behavioral issues. One resident exhibited combative behavior and delusions, another showed exit-seeking and inappropriate interactions, and a third displayed delusional behavior. The facility lacked a PASRR policy, and the Social Services Director was unaware of the requirement for PASRR Level 2 evaluations for residents with psychiatric diagnoses.
Two residents using CPAP and BiPAP machines lacked comprehensive care plans in a facility. One resident had no documented care plan for their CPAP machine, while the other had a care plan without interventions for their BiPAP machine. The DON confirmed the absence of necessary care plans and interventions, which are required for individualized care.
A high-risk resident developed a deep tissue injury (DTI) on the left heel due to the facility's failure to implement necessary interventions and conduct regular skin assessments. Despite a care plan outlining preventive measures, the DTI went untreated for weeks, with staff unaware of the condition until the resident complained of pain. The facility's policies for skin monitoring and pressure ulcer care were not followed, leading to a lack of documentation and communication among staff.
A facility failed to provide necessary meal assistance to a blind resident, resulting in significant weight loss and hospitalization. Despite the resident's need for one-on-one feeding assistance due to blindness, this requirement was not communicated or documented, leading to inadequate care. The interdisciplinary team did not address the need for feeding assistance, and the resident's family was not involved in care planning, contributing to the resident's decline and eventual hospitalization for dehydration.
A facility failed to obtain physician orders for a resident's PEG tube care, including bolus feeding and water flushes. The resident, with a history of dementia and dysphagia, was observed with an outdated Glucerna bottle and lacked documented orders for tube care. The LPN and CCC confirmed the absence of necessary orders, despite the resident consuming more than 75% of meals. The facility had transitioned to a new EHR system, but the required orders were not ensured.
A resident with a urinary tract infection had a PICC line inserted for antibiotic therapy, but the facility failed to document care orders for site monitoring, flushes, and dressing changes. The last antibiotic dose was given without follow-up on the stop date or PICC line maintenance. Observations showed improper management, with a gauze pad covering the insertion site, preventing monitoring. The DON confirmed the absence of care orders, and the NP was unaware of the situation, highlighting a risk of infection due to inadequate PICC line care.
The facility failed to obtain physician orders for oxygen administration and monitoring for a resident with respiratory conditions, and for the use of a CPAP machine for another resident. The first resident received oxygen without documented orders or saturation monitoring, while the second resident used a CPAP machine without a physician's order or care plan. Staff confirmed the necessity of these orders to ensure proper respiratory care.
The facility failed to complete annual performance appraisals for four CNAs, risking substandard care. Employees hired between 2021 and 2022 lacked evaluations for multiple years. The HR Coordinator confirmed the absence, and the DON cited miscommunication with a former SDC as a reason. The Administrator was unaware of the issue, despite the appraisal form's importance for feedback and quality care.
The facility failed to ensure proper food storage and handling, with unlabeled and expired items found in storage, and improper meal service practices observed. A refrigerator was also operating above the recommended temperature, posing potential risks to resident safety.
Failure to Timely Report Resident Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse to the State Agency within the required timeframe and in accordance with its own policy. A resident with osteomyelitis, cognitive communication deficit, and dementia without behavioral disturbance reported that a CNA became upset during care, was rude, and intentionally hit the resident in the right eye. The resident stated the eye hurt and that no one checked the eye that day, and also reported the incident to a nurse without receiving a response. The resident later stated they did not feel safe in the facility because the incident could happen again. Documentation shows that on 04/04/2026 the resident reported to an RN that, while being changed, a CNA moved them in a way they did not like, the resident raised their hands and pushed the CNA, and the CNA then hit the resident in the eye. The RN contacted the Acting DON, and a skin assessment documented a red mark under the right eye and redness to the eye. Additional staff statements dated 04/07/2026 from an LPN and a CNA recorded that the resident reported being hit in the face, having their hands held down, and being punched in the right eye, and that the resident’s eye was hurting and they reported being assaulted. Physician notes from the same date documented the physician was called for redness around the right eye and that the resident had been hit but could not recall the incident. The medical record showed the resident reported the alleged abuse to multiple staff members. Despite these reports and documented injuries, there was no documented evidence that the allegation of abuse was reported to the State Agency, and no documentation that the Administrator was notified until 04/07/2026. The Administrator stated the allegation, received on 04/04/2026, was not reported to them until 04/07/2026 and acknowledged that facility policy required all allegations of resident abuse to be reported to local, state, and federal agencies. The Administrator decided to investigate first and, based on the resident’s known behavior, difficulty with staff of certain races, and history of making allegations, determined the allegation was not reportable because it was unsubstantiated. The Acting DON acknowledged that the RN who received the allegation on 04/04/2026 did not notify the Administrator as required. The Director of Social Services reported prior guidance that allegations from residents with a documented history of false allegations could be handled internally and not reported, and was unable to identify any policy requiring all abuse allegations to be reported to the State Agency, despite the written policy specifying immediate reporting within 2 hours or 24 hours depending on the nature of the allegation.
Lack of Signed Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that each resident or the resident’s guardian provided signed evidence of informed consent before psychoactive medication was administered for 2 of 51 sampled residents. Resident 169 was admitted with diagnoses including bipolar disorder and had a guardian appointed to make medical decisions. A physician order dated 09/20/2024 directed Quetiapine 25 mg at bedtime for mood related to bipolar disorder, and the September 2025 MAR showed the resident received Quetiapine every evening of the month with monitoring for side effects such as constipation, blurred vision, and confusion. The record did not contain documented evidence that the guardian gave informed consent for Quetiapine, and the DON verified that consent should have been obtained before the medication was started. Resident 191 was admitted and readmitted with diagnoses including dementia, depression disorder, polyneuropathy, COPD, and bipolar disorder. A physician order dated 09/05/2025 ordered Sertraline HCl 50 mg daily for verbalization of sadness related to major depressive disorder, but the medical record lacked documented evidence that informed consent was obtained before the first administration of Sertraline. Staff stated that if a resident was alert, the resident was asked to sign the medication consent form, and if not alert, the resident’s representative or family member was contacted. The DON stated that before a resident could be placed on a psychotropic medication, consent must be obtained and a signed consent form was required, and that psychotropic medications should not be administered without a signed consent form.
Failure to Complete Required Hospice Significant Change Assessment
Penalty
Summary
The facility failed to complete a significant change in status assessment for a hospice resident after the resident enrolled in hospice care. Resident 200 was admitted with diagnoses including Alzheimer's dementia and protein-calorie malnutrition, and an alert note documented that the resident was admitted to hospice care on 07/24/2025. The medical record did not contain evidence that a significant change in status assessment was completed when the resident entered the hospice program. During record review and interviews on 09/26/2025, the MDS Coordinator confirmed that Resident 200 was admitted to the facility and enrolled in hospice on 07/24/2025, and acknowledged that the required significant change in status assessment was not completed in accordance with RAI requirements. The MDS Coordinator stated the assessment was due within 14 days of hospice enrollment and would generate a hospice care plan. The DON also confirmed that no significant change in status assessment had been completed for the resident, and the Medical Records Director confirmed the same. The RAI Version 3.0 Manual dated October 2023 states that a significant change in status assessment is required when a terminally ill patient enrolls in hospice and must be completed within 14 days of the hospice election.
Failure to Develop Hospice Care Plan After Hospice Enrollment
Penalty
Summary
The facility failed to develop a hospice care plan for Resident 200 after the resident was admitted to hospice care. Resident 200 was admitted with diagnoses including Alzheimer's dementia and protein-calorie malnutrition. An Alert Note dated 07/24/2025 documented that the resident was admitted to hospice, but the medical record lacked evidence that a hospice care plan was developed after hospice enrollment. On 09/26/2025, the MDS Coordinator confirmed that a hospice care plan was not developed when the resident enrolled into hospice because the significant change in status assessment was not completed in accordance with RAI requirements. The DON stated there was no significant change in status assessment completed within 14 days from the resident's admission to hospice and that this may have been the reason a hospice care plan was not developed. The DON also stated hospice care plans typically included a comfort-focused goal and interventions such as pain management, following advanced directives, and coordination between the facility and the hospice provider.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure showers were provided as scheduled for a resident who required assistance with bathing. Resident 202 was admitted with diagnoses including Wernicke's encephalopathy, alcohol-induced chronic pancreatitis, and auditory hallucinations. The resident's care plan documented an ADL self-care performance deficit related to encephalopathy, malnutrition, pancreatitis, and pain, with an intervention to provide a sponge bath when a full bath or shower could not be tolerated. The admission MDS documented that the resident required maximal assistance with showering and bathing. The facility's preferred shower schedule showed the resident's room was to receive showers twice weekly, but the May 2025 ADL documentation reflected only one shower, on 05/13/2025, for the month. During interviews, CNAs stated that showers were scheduled twice a week, documented in the resident's chart, and recorded on skin shower sheets signed by a nurse. The RN and DON reviewed the bathing documentation and confirmed that the lack of documentation appeared to show showers were not completed as assigned, and the Medical Records Director was unable to locate additional May 2025 skin shower sheets for the resident. The facility policy stated that residents unable to carry out ADLs independently would receive appropriate support and assistance with hygiene, including bathing.
Failure to Complete Pressure Injury Risk Assessment and Identify New Skin Impairment
Penalty
Summary
The facility failed to complete a pressure ulcer risk assessment for Resident 12 and failed to identify and address a new skin impairment. Resident 12 was admitted and later readmitted with diagnoses including ESRD and acute osteomyelitis of the ankle and foot. On 09/23/2025, the resident was alert and seated in a wheelchair and reported being hospitalized in July 2025, when ED staff identified a new right foot wound. The resident stated treatment for osteomyelitis with IV antibiotics was resumed after returning to the facility. Record review showed the facility used the Braden scale for pressure injury risk assessment, which was to be completed on admission, readmission, and quarterly, but the medical record lacked evidence of a Braden assessment for Resident 12 since the initial admission in 2023. A skin assessment and nutrition note on 07/02/2025 documented intact skin, but after the resident was transferred to the hospital on 07/05/2025, hospital records documented a full thickness ulcer on the right lateral foot and a scabbed wound on the base of the right fifth toe. After readmission, nursing documentation noted a right foot wound with dressing, and a wound note on 07/10/2025 described the wound measurements and tissue characteristics. The DON reviewed the record and stated the right foot wound appeared to be facility-acquired and not identified during the last weekly skin check.
Unsafe Access to Sugar Packets and Other Items
Penalty
Summary
The facility failed to ensure adequate supervision and a safe environment for a resident with severe cognitive impairment who was able to access and ingest non-food items from the service area. Resident 17 was admitted with diagnoses including unspecified dementia, hyperglycemia, and bipolar disorder, and a BIMS assessment dated 09/15/2025 documented a score of zero. Progress notes documented that the resident had been taking sugar packets from the service area on 09/20/2025 and 09/22/2025, with staff redirecting the resident after the resident rummaged and took sugar packets and became yelling when staff tried to remove them. On 09/25/2025, the resident obtained multiple yellow packets of artificial sweetener from a drawer in the service area. An LPN attempted to remove the packets but was unsuccessful, and stated the resident liked to eat sugar and would sometimes eat the packet. Shortly afterward, the resident placed an entire yellow packet of artificial sweetener into the mouth and began chewing, then pushed past the nurse and walked down the hall. The resident’s care plan documented risk for harm related to wandering throughout the unit and hoarding, and the facility policy stated safety strategies would be implemented immediately if necessary to protect the resident and others from harm.
Personal Refrigerator Food Monitoring and Storage Deficiencies
Penalty
Summary
The facility failed to ensure the temperature, dating, and labeling of food in residents’ personal refrigerators were properly monitored for three sampled residents and one unsampled resident. During observation and interview, a Licensed Practical Nurse stated that Certified Nursing Assistants were responsible for cleaning resident personal refrigerators weekly and on weekends, and that food brought in by family members should be stored no more than 72 hours, dated, and discarded when expired. The LPN observed one resident’s refrigerator and agreed it was dirty with ice buildup in the freezer and needed cleaning. An LPN checked refrigerator temperatures and found one resident’s personal refrigerator at 50 degrees Fahrenheit and another at 42 degrees Fahrenheit. Multiple CNAs gave inconsistent statements about who was responsible for checking refrigerator temperatures, cleaning the refrigerators, dating food, and discarding expired items. Some CNAs stated housekeeping checked temperatures, while others said maintenance did, and several were unsure who was responsible. A housekeeper and the Housekeeping and Laundry Manager also described daily checks and cleaning, but the manager stated temperatures were checked daily without documentation in a logbook. The DON stated all staff were responsible for cleaning resident personal refrigerators and confirmed that food brought in by families must be dated and stored no longer than 72 hours. The DON also confirmed the personal refrigerators for the identified residents needed cleaning and that expired food should have been discarded. The facility had no specific policy related to residents’ personal refrigerators, although it had a policy for foods brought by family/visitors stating perishable foods would be labeled and stored appropriately and discarded on or before the use-by date. The report also noted one resident’s refrigerator was unsecured and unsteady on top of a chest of drawers, creating a safety hazard if the door were pulled forcefully.
Broken Cabinet and Refrigerator Locks in Specialty Care Unit
Penalty
Summary
The facility failed to ensure cabinet and refrigerator locks were in working condition in the specialty care unit. On 09/23/2025, surveyors observed two wooden cabinets and a staff refrigerator with broken locks. The Director of Maintenance turned the locks and confirmed they were broken. CNA1 stated the first cabinet contained food condiments and plastic cutlery, and the second drawer contained three opened bottles of dish soap. CNA1 also stated the specialty care unit housed 17 residents with dementia and that all cabinets and refrigerators were to be kept secure and inaccessible for safety reasons. On 09/25/2025, surveyors returned to the specialty care unit and found the first cabinet missing a drawer face and knob, with a broken lock on the bottom drawer that made contents easily accessible by staff and residents. The locks on the second drawer and the staff refrigerator remained broken. CNA3 stated the cabinet locks had been broken for almost one month and recalled mentioning the issue to maintenance staff, but no maintenance work order had been completed. R200 was observed approaching the cabinet and pulling the handles before being redirected by staff. An LPN stated the locks had been broken for nearly a month and provided the Maintenance Work Request Log binder, which showed no outstanding repair request. Maintenance staff stated requests were to be documented in the maintenance log and confirmed no work requisitions had been received regarding the broken cabinet and locks.
Failure to Enforce Legionella Water Management Program and Document Required Activities
Penalty
Summary
The facility failed to enforce its Legionella Water Management Program (LWMP) as required by its own policy. The LWMP included a checklist of inspection items, frequencies, and documentation requirements, but there was little to no evidence that these activities were performed or recorded prior to notification from the local health department. The Maintenance Director confirmed that while some activities may have been conducted, there was no documentation to support ongoing compliance with the LWMP until after the facility was alerted to possible Legionella contamination. The LWMP itself was found to be adequate for the facility type, but it had not been periodically reviewed, and some of its documentation was not specific to the facility. The deficiency came to light during a complaint investigation after two residents who had been admitted with complex respiratory and cardiac conditions tested positive for Legionella following their transfer to acute care facilities. One resident experienced a significant drop in oxygen saturation and required emergency transfer, while the other was treated for a persistent cough and tested positive for Legionella antigen. The source of the Legionella could not be conclusively determined, but the facility's lack of documented implementation of its water management plan was evident. Interviews with facility leadership, including the Administrator, Maintenance Director, and DON, revealed that the LWMP had not been reviewed or updated except in response to the notification of possible Legionella cases. Water testing and mitigation activities were only documented after the facility was informed of the potential contamination. Prior to this, there was no evidence of regular monitoring, system flushing, or other control measures as outlined in the LWMP.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from abuse when one resident reported that another resident had touched their chest under their shirt without permission. The incident was reported to the Director of Social Services and the Administrator, and the accused resident admitted to the inappropriate contact. The facility's investigation substantiated the allegation of abuse. Prior to the incident, the resident who committed the abuse had a behavioral care plan addressing inappropriate sexual comments, while the resident who reported the abuse had a care plan for making false accusations and having physical altercations. The incident was not immediately reported to staff, as the affected resident only disclosed it to a relative, who also did not inform the facility. Skin assessments conducted during the relevant period noted a rash on the upper left chest of the affected resident, but no complaints of pain or discomfort were documented. The facility's policy requires maintaining an environment free from abuse, neglect, and exploitation. The failure to promptly identify and address the abuse, as well as the delay in reporting, contributed to the deficiency cited in the report.
Medication Administration Error Due to Pharmacy Mislabeling
Penalty
Summary
A resident with end stage renal disease and a history of kidney transplant was admitted and had a physician's order for Tacrolimus 0.5 mg capsule, an anti-rejection medication. However, due to a pharmacy error, a medication bubble pack containing Cialis 5 mg tablets was mislabeled as Tacrolimus and dispensed with the resident's name. Over a period of six days, the resident was administered Cialis instead of the prescribed Tacrolimus. The medical record did not show any order for Cialis for this resident. Licensed Practical Nurses confirmed administering the mislabeled medication, relying on the label and the five rights of medication administration, but failed to notice the discrepancy between the ordered capsule form and the tablet form present in the bubble pack. The error was only identified after several doses when another nurse questioned the form of the medication. The Director of Nursing and Consultant Pharmacist acknowledged the pharmacy's mislabeling and the failure of nursing staff to detect the error before administration, despite facility policies requiring verification of medication form and label against physician orders.
Deficient Monitoring of Psychoactive Medications
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of residents' behaviors and side effects for those receiving psychoactive medications. This deficiency was identified for six residents, each with various diagnoses such as dementia, depression, anxiety, and psychosis. The facility's policy required monitoring for significant negative changes from baseline and ruling out medications as the cause of these changes. However, the medical records for these residents lacked documented evidence of orders to monitor target behaviors and side effects related to the use of psychoactive medications. The deficiency was partly attributed to the facility's transition from one electronic health record (EHR) system to another. During this transition, the necessary orders for monitoring behaviors and side effects did not migrate successfully to the new system. As a result, licensed nurses were instructed to document observations in the progress notes rather than the medication administration record (MAR), leading to inconsistent monitoring and documentation practices. The Clinical Care Coordinator acknowledged the issue and took responsibility for auditing and ensuring the necessary orders were in place. The lack of consistent documentation and monitoring of psychoactive medication side effects was further complicated by the facility's reliance on paper MARs and progress notes during the EHR transition. Nurses were not keen on charting into paper MARs, and the facility was still pending training for entering order sets into the new EHR. This situation resulted in a lack of monitoring documentation essential for the physician and pharmacist during resident drug reviews, as highlighted by the facility's policies on medication monitoring and management.
Facility Restricts Resident Access to Front Porch
Penalty
Summary
The facility failed to honor the residents' right to self-determination by not allowing them to make choices about significant aspects of their lives, specifically regarding their ability to sit outside on the front porch area. This deficiency was observed in one sampled resident and three unsampled residents. Despite having no elopement risk, these residents were restricted from accessing the front porch area without a chaperone, which was not a documented policy of the facility. The residents expressed dissatisfaction with this restriction, comparing the facility to a prison due to the lack of freedom to sit outside without supervision. The report highlights that the facility is located near a minor street with a large, covered portico and a wrap-around porch area with park benches for residents to enjoy. However, residents were instructed to use the gazebo area in the courtyard, which is also the designated smoking area, instead of the front porch. This restriction was enforced by the receptionist, who would redirect residents to the courtyard unless a staff or family member was available to accompany them. The facility's administrator and social services director justified this practice by citing protective oversight and safety concerns, despite the residents' cognitive abilities and low elopement risk. The facility lacked a formal policy requiring residents to have a chaperone to access the front porch area, and the residents' rights document in the admissions packet emphasized their right to self-determination and a dignified existence. The residents' inability to make independent choices about their outdoor activities, despite their cognitive status and elopement assessments, was a significant oversight in respecting their rights and preferences, leading to potential psychosocial distress.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure accurate assessments for a resident, specifically regarding vision, hearing, and functional status impacting activities of daily living. The resident, who was admitted with chronic vision and hearing loss, Parkinson's disease, and weakness, was observed struggling with meal assistance due to these impairments. Despite being clinically blind and hard of hearing, the resident's meal ticket did not indicate the need for assistance, and the staff was not informed of the resident's requirements for one-on-one feeding assistance. The resident's Minimum Data Set (MDS) assessments inaccurately documented adequate vision and hearing, and only required setup or cleanup assistance with eating. However, the resident was clinically blind and required full assistance with meals. The Licensed Practical Nurse (LPN) assigned to the resident confirmed these inaccuracies, noting that the resident had been blind and hard of hearing for some time and was dependent on staff for activities of daily living since the death of their spouse. The MDS Coordinator, responsible for the assessments, admitted to not being aware of the resident's true condition and acknowledged the oversight in the assessments. The Director of Nursing (DON) and a family member corroborated the resident's condition, confirming the resident's blindness and hearing difficulties. The family member expressed concerns about the facility's failure to accommodate the resident's health status changes, which contributed to a significant weight loss and hospitalization. The report highlights the importance of accurate assessments to ensure appropriate care plans and assistance levels for residents.
Failure to Complete PASRR Level 2 Evaluations for Residents with Psychiatric Diagnoses
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASRR) Level 2 evaluation for three residents who displayed behavioral activity or had a psychiatric diagnosis. Resident 99 was admitted with diagnoses including psychosis and bipolar disorder, but the PASRR Level 1 used for admission did not reflect these diagnoses. Observations and nursing progress notes documented Resident 99's combative and aggressive behavior, refusal of medications, and episodes of delusions and confusion, indicating a need for a PASRR Level 2 evaluation. Resident 135 was admitted with diagnoses including bipolar disorder and schizophrenia, but the PASRR Level 1 used for admission only documented dementia and Alzheimer's. The resident exhibited behaviors such as exit-seeking and inappropriate interactions with other residents. The Director of Social Services was unaware that a PASRR Level 2 was required for residents with psychiatric diagnoses and behavioral issues, and the facility lacked a PASRR policy. Resident 72 was readmitted with multiple psychiatric diagnoses, including schizophrenia and dementia with psychotic disturbance. Despite displaying delusional behavior and expressing concerns about an impersonator, there was no documented evidence of a PASRR Level 2 screening. The Social Services Director acknowledged that the PASRR Level 2 process should have been initiated. The facility's policy stated that new or changed behaviors indicating a serious mental disorder should be referred for a PASRR Level 2 evaluation, but this was not done for Resident 72.
Deficiency in Comprehensive Care Plans for Sleep Apnea Devices
Penalty
Summary
The facility failed to ensure comprehensive care plans were created for the management of sleep apnea devices for two residents. Resident 64, who was admitted with diagnoses including an open wound on the lower back and hemiplegia after a cerebral infarction, used a CPAP machine at night to aid breathing. However, there was no documented evidence in the physician and nursing progress notes that the resident was using the CPAP machine, nor was there a comprehensive care plan for its use, care, and maintenance. Similarly, Resident 390, admitted with obstructive sleep apnea and amyotrophic lateral sclerosis, used a BiPAP machine at night. Although the care plan documented the medical diagnosis and the use of the BiPAP machine, it lacked any care interventions, leaving the space allotted for them blank. The Director of Nursing confirmed the absence of care interventions in Resident 390's care plan and the lack of a care plan for Resident 64's CPAP machine, acknowledging that care plans are required to ensure individualized care provisions.
Failure to Provide Adequate Pressure Ulcer Care for High-Risk Resident
Penalty
Summary
The facility failed to provide adequate care for a high-risk resident, identified as R52, who developed a deep tissue injury (DTI) on the left heel. R52 was admitted with multiple diagnoses, including diabetes mellitus and dysphagia, and was assessed as high risk for pressure sores with a Braden Scale score of 10. Despite the care plan outlining necessary interventions such as turning, repositioning, and using pressure-reducing devices, these measures were not consistently implemented. The resident's medical records lacked evidence of regular skin assessments and appropriate treatment for the DTI. On a specific date, R52 complained of heel pain, and an LPN confirmed the presence of a DTI, which appeared to be several weeks old. The wound care treatment nurse noted that the injury had not been previously addressed, and the necessary offloading techniques were not applied. The CNA responsible for R52's care reported observing skin discoloration weeks earlier but did not ensure the information was properly documented or acted upon. The facility's policy required skin assessments twice a week, but records showed only one assessment was completed in September. The facility's failure to adhere to its policies and procedures for skin monitoring and pressure ulcer care resulted in the DTI going untreated for an extended period. The lack of documentation and communication among staff members contributed to the oversight, as the LPN and clinical care coordinator were unaware of the resident's condition until it was too late. This deficiency highlights a breakdown in the facility's processes for identifying and managing pressure injuries in high-risk residents.
Failure to Assist Blind Resident with Meals Leads to Weight Loss and Hospitalization
Penalty
Summary
The facility failed to provide adequate assistance with food and fluids to a resident who was clinically blind, leading to significant weight loss and hospitalization. The resident, who had chronic vision and hearing loss, was observed with an untouched breakfast tray and expressed the need for help with meals due to blindness. Despite the resident's condition, the meal ticket did not reflect the need for full assistance, and the CNA assigned was not informed of the requirement for one-on-one feeding assistance. The interdisciplinary team had discussed the resident's weight loss and added supplements to the diet, but the need for feeding assistance was not addressed. The resident's medical records inaccurately documented adequate vision and hearing, which contributed to the lack of appropriate care. The speech therapy evaluation recommended feeding assistance due to the risk of aspiration and malnutrition, but this was not communicated to the team or reflected in the resident's care plan. The Director of Nursing acknowledged the oversight and confirmed that the resident's significant weight loss was not adequately addressed. The dietary team failed to communicate the resident's needs during weekly meetings, and the resident's family was not involved in care plan discussions. The resident was eventually sent to the hospital for dehydration and weakness, highlighting the facility's failure to provide necessary assistance and hydration.
Failure to Obtain Physician Orders for PEG Tube Care
Penalty
Summary
The facility failed to ensure that physician orders for bolus tube feeding, water flushes, and gastrostomy tube care were obtained for a resident with a PEG tube. The resident, who was admitted with diagnoses including dementia, diabetes mellitus, urinary tract infection, dysphagia, and gastrostomy, was observed with an unopened Glucerna tube feeding bottle labeled with an outdated date. The resident's medical records lacked documented evidence of physician orders for bolus feeding, water flushing, placement verification, and PEG tube site care or monitoring. The LPN and Clinical Care Coordinator confirmed that the bolus feeding was intended only if the resident's meal intake was less than 75%, and the resident was on a soft mechanical diet, consuming more than 75% of meals. However, the necessary physician orders for administering the bolus feeding and managing the PEG tube were not obtained. The facility had transitioned to a new electronic health record system, and the Clinical Care Coordinator was responsible for ensuring the necessary orders were in place, but this was not done. The facility's policy required checking the tube's position before each feeding and medication administration, which was not adhered to in this case.
Deficient PICC Line Management in Resident Care
Penalty
Summary
The facility failed to ensure proper care and management of a peripherally inserted central catheter (PICC) line for a resident, leading to a risk of infection. The resident was admitted with a urinary tract infection and had a PICC line inserted for antibiotic therapy. However, the medical record lacked documented evidence of care orders for the PICC line, such as site monitoring, flushes, and dressing changes, since its insertion. The last dose of the prescribed antibiotic was administered, but there was no follow-up with the physician regarding the stop date for the antibiotic therapy or instructions on whether to maintain or discontinue the PICC line. Observations revealed that the PICC line was not properly managed, with a gauze pad covering the insertion site, which should not have been there, as it prevented nurses from monitoring the site every shift. The Director of Nursing confirmed the absence of care orders and acknowledged that the lack of routine PICC line care placed the resident at risk for another infection. The Nurse Practitioner was unaware of the absence of care orders and indicated that they had not been contacted by the facility regarding the resident's antibiotic therapy, which could have led to further testing and appropriate management of the PICC line.
Failure to Obtain Physician Orders for Respiratory Care
Penalty
Summary
The facility failed to obtain physician orders for the administration and monitoring of oxygen (O2) for Resident 155, who was admitted with diagnoses including pneumonia, respiratory tuberculosis, and dependence on supplemental O2. Observations revealed that Resident 155 was receiving O2 at 5 liters per minute via nasal cannula without documented physician orders or O2 saturation monitoring. A Licensed Practical Nurse confirmed the absence of necessary orders and monitoring, and the Clinical Care Coordinator acknowledged the requirement for such orders to prevent potential risks associated with improper O2 administration. Additionally, the facility did not secure a physician's order for the use of a CPAP machine for Resident 64, who was admitted with conditions including an open wound and hemiplegia after cerebral infarction. Resident 64 self-managed the CPAP machine brought from home, but there was no documented evidence of a physician's order or care plan for its use. The Director of Nursing confirmed that a physician's order was necessary for CPAP use, which would generate a care and maintenance order set in the electronic healthcare records.
Failure to Complete Annual Performance Appraisals for CNAs
Penalty
Summary
The facility failed to complete annual performance appraisals for four certified nursing assistants (CNAs), identified as Employees 6, 7, 9, and 10, which placed residents at risk for receiving substandard quality of care. Employee 6, hired in June 2022, and Employee 7, hired in July 2022, did not have performance evaluations for 2023 and 2024. Employee 9, hired in August 2021, lacked evaluations for 2022, 2023, and 2024, while Employee 10, hired in November 2021, was missing evaluations for 2022 and 2023. The Human Resources (HR) Coordinator confirmed the absence of these evaluations and explained the process involved the Director of Nursing (DON) completing the forms, which were then to be returned to HR. The DON acknowledged responsibility for completing the appraisals, a task previously shared with a former Staff Development Coordinator (SDC). The DON indicated that the forms might not have been completed due to an assumption that the other party had done so. The Administrator was unaware of the missing appraisals and emphasized their importance for discussing areas of improvement and ensuring quality care. The facility's appraisal form, dated 2007, highlighted the significance of these evaluations as feedback tools, with a process in place for managers to gather information and discuss performance with staff prior to filing the completed forms.
Deficiencies in Food Storage and Handling Practices
Penalty
Summary
The facility failed to ensure proper food storage and handling practices, which posed a potential risk to resident safety and health standards. Observations revealed that scrambled egg patties in the walk-in cooler were not labeled or dated, and corn muffin mixes in the dry storage area had expired. Additionally, previously baked pies and scooped ice cream in the freezer were unlabeled and undated. These lapses in labeling and dating could lead to contamination and inadequate storage of food items. During meal service, an uncovered plate of food was mistakenly served to a resident with the incorrect food texture. The plate was returned to the steam table and later served to another resident, contrary to safe food handling practices. The unit one refrigerator was also found to be operating at temperatures above the recommended range, potentially compromising the safety of stored items such as milk, juice, yogurt, and salads. These deficiencies highlight the facility's failure to adhere to professional standards for food storage and handling.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 542 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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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) |
|---|---|---|---|---|
| Green Valley Health And Wellness Suites | 1.1 mi | ★★★★★ | 24 | 0 |
| Coronado Ridge Skilled Nursing & Rehabilitation Ce | 2.4 mi | ★★★★★ | 20 | 0 |
| Advanced Health Care Of Henderson | 2.9 mi | ★★★★★ | 0 | 0 |
| Sage Creek Post-acute | 2.9 mi | ★★★★★ | 9 | 0 |
| Tlc Care Center | 3.2 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Oasis Nursing & Rehab Of Green Valley.
100% money-back within 48 hours.
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.