Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Oaks Nursing & Rehabilitation during CMS and state inspections, most recent first.
A resident with chronic knee pain was using a cold therapy unit for pain management without a documented physician order or inclusion in the care plan. Staff were unclear about responsibility for monitoring the device, and the DON was unaware of who had ordered it or how long it had been in use. Facility policy required all treatment orders to be documented, but this was not followed, resulting in incomplete records for the resident's pain management.
A facility failed to manage a resident's PICC line properly, as the dressing was not changed for 19 days, and there were no orders for dressing changes or flushes. The resident, who was receiving IV antibiotics, did not show signs of infection, but staff interviews revealed a lack of awareness and training on PICC line care protocols. The DON acknowledged the oversight and initiated staff education on documenting PICC line care orders.
A breach of medical record privacy occurred when a nurse mistakenly included another resident's medication, containing personal information, in the discharge medications of a resident. The error was discovered by the family member of the discharged resident. The facility's policy emphasizes the importance of protecting residents' personal information.
A resident was discharged with another resident's medication due to a failure in following the facility's medication reconciliation policy. The error involved a Methocarbamol Blister Pack being sent home with the wrong resident. The RN involved verified medications but did not catch the mistake, and the DON acknowledged the error likely occurred due to the proximity of medications. The facility's policy required proper verification and reconciliation, which was not followed.
The facility's kitchen failed to meet food safety standards, with issues including improper refrigerator temperatures, inadequate labeling of food items, and cross-contamination risks during meal service. The standby refrigerator was in defrost mode without proper temperature monitoring, and food items in both the walk-in refrigerator and dry storage lacked use-by dates. Additionally, a staff member used the same utensil for different foods, increasing the risk of cross-contamination.
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper technique during IV administration to a resident on enhanced barrier precautions. The LVN did not wear a gown, allowed the IV port to contact the resident's skin, and improperly disposed of the syringe. Additionally, the facility did not implement a water management program per its policy, lacking documentation and oversight.
A facility failed to date a resident's peripheral IV dressing, which is crucial for infection control and adherence to professional standards. The resident, with multiple health conditions, had an undated IV that had not been used since the previous week. Staff interviews revealed a lack of compliance with the facility's policy requiring IV dressings to be dated, posing a risk of cross-contamination and infection.
A facility failed to secure a Nurses' Treatment Cart and allowed a resident to have unauthorized medications at their bedside. The cart was found unlocked and unattended, containing various medications. A resident had medications brought by family without staff knowledge, posing a risk of unauthorized access. The facility's policy on medication security was not followed.
A facility failed to develop a comprehensive care plan for a resident with multiple medical conditions, including acute respiratory failure and chronic viral hepatitis C. The care plan was incomplete, lacking details on the resident's diagnoses and care needs. Interviews with staff revealed that the MDS Coordinator was behind on care plan completions, and both the DON and Administrator stressed the importance of timely care plans. The facility's policy mandates care plans be developed within seven days of assessment, which was not followed.
The facility failed to follow the prescribed menu, leading to discrepancies between meal tickets and what was served. Residents reported receiving incorrect meals, including items they were allergic to, and staff interviews revealed issues with menu management and communication. The facility's policy did not adequately address how to handle meal substitutions, resulting in repeated inaccuracies and potential nutritional risks for residents.
Failure to Obtain Physician Order for Cold Therapy Device Used in Pain Management
Penalty
Summary
The facility failed to ensure that pain management was properly provided to a resident who required it, specifically by not obtaining a physician's signed and dated order for the use of a cold therapy unit (ICTU) that was being used to manage the resident's knee pain. The resident, a female with a history of chronic left knee pain, osteoarthritis, and multiple other medical conditions, was admitted with ongoing pain and had been using the ICTU since admission. Despite the use of this device for pain control, there was no corresponding physician order documented in the resident's clinical record, nor was the use of the ICTU reflected in the care plan or active physician orders. Observations and interviews revealed that the resident had the ICTU in place on her knee, and staff were unclear about who was responsible for monitoring and maintaining the device. The medication aide stated that nurses and CNAs were responsible for the equipment, but deferred to the nurse for follow-up. The nurse on duty admitted to not checking the ICTU for ice water and was unsure who had ordered the device, suggesting it may have come from the hospital. The CNA reported not being responsible for the ICTU and was unfamiliar with its operation. The DON confirmed that nurses were responsible for obtaining and transcribing physician orders and that nurse managers should ensure all orders are accurate, but was unaware of who had ordered the ICTU or how long it had been in use. Facility policy required that all treatment orders specify the treatment, frequency, and duration, and that a current list of orders be maintained in the clinical record. The lack of a physician order for the ICTU, as well as the absence of documentation in the care plan, resulted in insufficient information regarding the resident's treatment and pain management regimen. This deficiency was identified through observation, interview, and record review, and was supported by the facility's own policies and product information for the cold therapy unit.
Failure in PICC Line Management and Documentation
Penalty
Summary
The facility failed to ensure the timely and appropriate administration of intravenous (IV) fluids for a resident, specifically in the management of a Peripherally Inserted Central Catheter (PICC) line. The dressing on the PICC line of a resident was not changed for 19 days, contrary to the facility's policy of changing it every 5-7 days. Additionally, there were no physician orders for PICC line care, including dressing changes and flushes, which are essential to prevent infections and maintain the line's patency. The resident involved was a male with multiple medical conditions, including chronic osteomyelitis, deep vein thrombosis, hypertension, and diabetes. He was receiving IV antibiotics through the PICC line for his osteomyelitis. Despite the absence of documented dressing changes and flushes, the resident did not exhibit signs of infection at the PICC line site, and his inflammatory markers had improved according to recent blood work. Interviews with nursing staff revealed a lack of awareness and training regarding the facility's PICC line care protocols. Nurses reported not changing the dressing due to the absence of specific orders and acknowledged the risk of infection from not adhering to the dressing change schedule. The Director of Nursing (DON) confirmed the oversight and began educating staff on the importance of having orders for PICC line care documented in the electronic medical record upon a resident's admission.
Breach of Medical Record Privacy During Resident Discharge
Penalty
Summary
The facility failed to maintain the privacy of medical records for one resident, identified as Resident #2, during the discharge process of another resident, identified as Resident #1. On the day of Resident #1's discharge, a nurse, RN B, mistakenly included Resident #2's Methocarbamol Blister Pack, which contained personal identifying information such as name and date of birth, in the medications given to Resident #1 and her family member (FM). This error was discovered when the FM arrived home and found the medication belonging to Resident #2. Interviews conducted with the involved parties revealed that RN B had collected all of Resident #1's medications and compared them to a printed Medication Summary to ensure accuracy. However, RN B was unsure how Resident #2's medication was included in the discharge. The Director of Nursing (DON) suggested that the mistake might have occurred because Resident #2's medication was stored directly behind Resident #1's medication. Despite RN B's efforts to verify the medications with the FM, the error was not caught until after the discharge. The facility's policy on resident rights and confidentiality emphasizes the importance of protecting residents' personal information. RN B had previously signed a Confidentiality and Non-Disclosure Agreement, acknowledging the responsibility to protect confidential records. The incident highlights a breach in the facility's procedures for maintaining the privacy and confidentiality of residents' medical information during the discharge process.
Medication Reconciliation Error During Resident Discharge
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate reconciliation of medications for a resident upon discharge. Specifically, a Licensed Vocational Nurse (LVN) did not follow the facility's policy for reconciling unused medications when a resident was discharged home. This resulted in the resident receiving another resident's medication, Methocarbamol, which was not prescribed to her. The resident involved was an elderly female with multiple diagnoses, including acute kidney failure, paroxysmal atrial fibrillation, chronic obstructive pulmonary disease, dysphagia, transient ischemic attack, and cerebral infarction. Upon discharge, her family member received her medications, but also mistakenly received a Methocarbamol Blister Pack belonging to another resident. This error was discovered when the family member arrived home and identified the medication as belonging to a different resident. Interviews with the nursing staff revealed that the error occurred because the Methocarbamol Blister Pack was mistakenly included with the discharged resident's medications. The Registered Nurse (RN) involved in the discharge process stated that he had verified the medications against a printed summary but was unsure how the error occurred. The Director of Nursing (DON) acknowledged that the medication was likely pulled by mistake due to its proximity to the discharged resident's medications. The facility's policy required the charge nurse to verify and reconcile medications, which was not adequately followed in this instance.
Food Safety and Storage Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food safety in its kitchen, as observed during a survey. The standby refrigerator was found to be in defrost cycle mode without an internal thermometer to monitor the temperature, which was later recorded at 49°F, exceeding the safe limit of 41°F. This poses a risk for bacterial growth in stored food items, such as prepared fruit cups. Additionally, the Dietary Manager was unaware of the frequency of the defrost cycle, which could lead to unsafe food storage conditions. In the walk-in refrigerator, several food items, including sliced cheese, cream cheese, and mustard, were not labeled with use-by dates, only delivery dates. This lack of proper labeling could result in the use of expired or unsafe food. Similarly, in the dry storage area, open packages of pancake mix, spaghetti noodles, and toasted oats were not sealed properly and lacked use-by dates. Multiple dented canned goods were also observed, which could compromise the safety of the food due to potential contamination. During meal service, uncovered food items were observed on the steam tray table, and cross-contamination risks were identified when a staff member used the same serving utensil for different food items. The facility's policy requires separate utensils for each food item to prevent cross-contamination, but this was not followed. The Dietary Manager acknowledged the risk of cross-contamination and the importance of using separate utensils, as well as the need for proper labeling and storage of food items to ensure safety.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper technique during the administration of intravenous medication to a resident on enhanced barrier precautions. The resident, a male with a primary diagnosis of metabolic encephalopathy, was at risk for infection due to indwelling medical devices. During an observation, an LVN was seen cleaning the resident's IV port with an alcohol wipe but then allowed the port to come into contact with the resident's skin, which was not sterile. The LVN also failed to wear a gown as required by the enhanced barrier precautions and placed the used syringe on the bedside table instead of disposing of it properly, increasing the risk of cross-contamination. Additionally, the facility did not implement a water management program as per its policy. The Administrator acknowledged that the current Maintenance Director was new and that another company was supposed to manage the water, but no documentation was provided to confirm that a water management program was developed or implemented. This lack of documentation and oversight could potentially place residents at risk of exposure to waterborne pathogens, as the facility's policy on water management was not being followed.
Failure to Date IV Dressing Leads to Infection Control Lapse
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of intravenous (IV) fluids for a resident, specifically Resident #68, by not adhering to professional standards of practice and physician orders. The deficiency was identified when it was observed that Resident #68's peripheral IV dressing was not dated with the insertion date. This oversight was discovered during an observation and interview with the resident, who was unable to recall the exact date of IV insertion and mentioned that the IV had not been used since the previous week. The resident's care plan did not address the peripheral IV, which is a critical component of their care given their medical conditions, including dementia, malnutrition, and diabetes. Interviews with facility staff, including an LVN, RN, ADON, and DON, revealed a lack of adherence to the facility's policy on peripheral IV catheter insertion, which requires the dressing to be dated. The staff acknowledged the importance of dating the IV dressing to monitor for infection and ensure timely dressing changes. The failure to date the IV dressing could lead to cross-contamination and infections, as the facility's policy mandates that IVs be checked daily for infection and the dressing changed every 72 hours. The deficiency highlights a lapse in infection control practices and communication among the nursing staff regarding the management of IVs.
Medication Storage and Security Deficiency
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, as required by State and Federal laws. During an observation, a Nurses' Treatment Cart was found unattended and unlocked outside the women's bathroom. The cart contained over-the-counter and prescription topical medications, as well as wound care supplies. RN C, who was responsible for the cart, was unaware of who left it unlocked. The Director of Nursing (DON) confirmed that all medication carts should be secured when not in use. Additionally, the facility did not ensure that medications were not left at the bedside for a resident. The resident, who had a diagnosis of unspecified dementia and other health conditions, was found with a bottle of AZO Dual Protection Urinary & Vaginal Support and Biofreeze Roll-On gel on their over-bed table. The resident's family had brought these medications without the staff's knowledge. The Licensed Vocational Nurse (LVN) was unaware of these medications and confirmed that the resident did not have orders to self-medicate. The facility's policy required medication carts to be locked when not in use and medications to be stored securely. However, the policy was not followed, leading to the potential risk of unauthorized access to medications. The DON and Administrator were informed of the situation, acknowledging the potential negative outcomes if a confused resident accessed the medications.
Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which is a requirement to meet the resident's medical, nursing, and mental and psychosocial needs. The deficiency was identified for a resident who was admitted with multiple diagnoses, including acute respiratory failure, chronic viral hepatitis C, morbid obesity, depression, obstructive sleep apnea, and other conditions. The resident's admission record indicated a need for assistance with daily activities and a risk of developing pressure ulcers, yet the care plan only noted the resident's lack of activity involvement without addressing other critical care areas. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing (DON), revealed that the comprehensive care plan for the resident was overdue and incomplete. The MDS Coordinator admitted to being behind on care plan completions and acknowledged that the care plan should have included the resident's diagnoses, medication regimen, and other care needs. The DON and the facility Administrator both emphasized the importance of timely and comprehensive care plans to ensure appropriate care delivery. The facility's policy requires that comprehensive care plans be developed within seven days of completing the resident's comprehensive assessment, which was not adhered to in this case.
Menu Adherence and Meal Ticket Discrepancies
Penalty
Summary
The facility failed to adhere to the prescribed menu for its residents, as observed during a survey on 05/07/2024. Specifically, the menu was not followed for the dinner meal, and discrepancies were noted between what was served and what was listed on the meal tickets. For instance, Anonymous #2 did not receive milk, a health shake, or a roll as indicated on their meal ticket. This inconsistency was not an isolated incident, as multiple residents reported receiving meals that did not match their meal tickets, which could potentially lead to nutritional deficiencies and a decrease in quality of life. Interviews with residents and staff revealed ongoing issues with meal ticket accuracy and menu adherence. Residents expressed dissatisfaction with the repetitive nature of alternate meals and the serving of items they were allergic to, despite allergies being noted on meal tickets. Staff interviews indicated a lack of communication and coordination between the kitchen and nursing staff, with meal tickets often reflecting outdated menus. The District Dietary Manager admitted to errors in menu management, including failing to update meal tickets to reflect current menus, which contributed to the discrepancies observed. The facility's policy on resident food preferences did not adequately address how substitutions should be communicated or ensure that meal tickets matched the meals served. This lack of clarity and oversight led to repeated instances where residents did not receive the correct meals, as evidenced by grievances and resident council minutes highlighting inaccurate menus. The failure to follow the menu and update meal tickets as required posed a risk to residents' nutritional status and overall quality of life.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Arlington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Immanuel's Healthcare | 3.4 mi | ★★★★★ | 3 | 0 |
| Village Creek Nursing & Rehabilitation | 3.5 mi | ★★★★★ | 11 | 0 |
| Avir At Kennedale | 3.9 mi | ★★★★★ | 25 | 2 |
| Town Hall Estates Arlington, Inc. | 4.2 mi | ★★★★★ | 1 | 1 |
| Arbrook Plaza | 4.7 mi | ★★★★★ | 12 | 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.