Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 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.
Expired, discontinued, and damaged meds were found on medication carts, including a resident’s taped Tylenol with codeine blister pack, another resident’s damaged Lyrica blister, and a deceased resident’s expired Bactroban cream. Staff stated controlled meds with broken blister seals should not be taped and discontinued narcotics should be removed from the cart, but the survey found these items still stored on the carts along with other expired meds.
Surveyors found unsecured and improperly labeled medications on resident med carts, including an eye drop bottle left at a resident’s bedside and multiple opened insulin pens without opening dates; one open insulin pen also lacked a patient label. Records showed the involved residents had diabetes orders for the insulins, and staff stated nurses were responsible for ensuring insulin pens were labeled and dated and that the resident was not supposed to keep medication at bedside.
Late Comprehensive MDS Assessment: A resident admitted with seizures, morbid obesity, pain, and anxiety disorder did not have a Comprehensive MDS completed within the required 14-day timeframe. The MDS/PPS Nurse stated the delay occurred because she was on vacation when the assessment was due, and she did not believe the late completion posed a risk because care was still provided.
A resident with anxiety, depression, schizoaffective disorder, and moderate cognitive impairment had an inaccurate PASRR Level I screening that stated she had no evidence of MI. The MDS Coordinator acknowledged the screening was wrong and said the required LTC portal form was not completed, while the MDS/PPS Nurse stated the resident had dementia that would override PASRR even though her primary admission diagnosis was not dementia.
Incomplete Baseline Care Plan for Newly Admitted Resident: A resident admitted with seizures, morbid obesity, pain, and anxiety disorder did not have a complete baseline care plan within 48 hours of admission. The Interim Plan of Care, used by the facility as the baseline care plan, was signed as completed by an LVN but omitted required items such as initial goals, physician orders, dietary orders, therapy services, social services, and PASARR recommendations. The LVN stated she was told all sections were not necessary unless the resident needed increased care in that area, and the DON was unsure of the required timeframe and content.
Inaccurate care plan did not reflect PASRR status. A resident with moderate cognitive impairment and diagnoses including anxiety, depression, and schizoaffective disorder had a care plan that stated PASRR specialized services were needed, even though the PASRR Level 1 screening showed no evidence of mental illness. The MDS/PPS Nurse acknowledged the resident never received PASRR services and that the comprehensive care plan was inaccurate.
A resident with chronic respiratory failure and an order for continuous O2 at 2 L/min via nasal cannula was observed in a wheelchair with an empty portable O2 tank while the cannula was dragging on the floor. The resident said she needed the tank replaced because she was supposed to be on continuous oxygen. The PCA said she was taking the resident to the nurse for a replacement tank and did not notice the cannula on the floor, and an LVN and the DON confirmed the continuous O2 order and that residents should always have access to oxygen.
Infection Control Failure With Hallway Hydration Cart: A family member used a metal ice scoop at a hallway hydration cart to get ice for herself and a resident, then touched the scoop on the inside of two personal cups. The family member said she had done this since the resident’s admission and had not been told staff needed to obtain the ice. The ADM stated residents and visitors were not supposed to use the cart, that it was for staff use, and that the facility had no specific policy for hydration carts.
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.
Expired, Discontinued, and Damaged Medications Left on Medication Carts
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of medications for three residents on two medication carts. During record review, Resident #4 had a discontinued order for Tylenol with codeine #3 tablet 300-30 mg, and Resident #99 had an active order for Lyrica 300 mg capsule twice daily for pain. Resident #200’s record showed a discontinued order for Bactroban Cream 2% for a facial rash, and the resident was discharged as deceased. The facility policy stated that discontinued, outdated, or deteriorated drugs were not to be used and were to be returned to the dispensing pharmacy or destroyed. On observation of the 200 hall medication carts, Resident #99’s Lyrica capsule had a damaged blister bubble with the capsule still inside. On the 200 hall nurses cart, Resident #4’s Tylenol with codeine blister pack had two broken seals that were taped, and Resident #200’s expired Bactroban Cream 2% remained on the cart. Staff interviews showed that nurses and medication aides were responsible for checking blister packs during shift change narcotic counts, removing discontinued narcotics from the cart, and discarding broken controlled-medication blisters rather than taping them. The DON stated discontinued narcotics were to be removed from the cart and secured until the consultant pharmacist disposed of them, and that broken controlled-medication blister packs should not be taped. Additional cart review found an expired opened hemorrhoid cream on the 400 hall nurses’ medication cart and an expired Argiment supplement on the same cart. Staff interviewed stated they were responsible for ensuring medications were within date and that discontinued or damaged medications were removed from the carts. The observations and interviews documented that expired, discontinued, and damaged medications remained stored on medication carts, including controlled medications with broken blister seals and taped packaging.
Unsecured and Undated Medications on Resident Carts
Penalty
Summary
The facility failed to secure and properly label drugs and biologicals used in the facility in accordance with accepted professional principles. During observation, interview, and record review, surveyors found unsecured and improperly stored medications on the 100 and 200 hall nurses’ medication carts, including insulin pens and an eye drop bottle. The report identified five residents whose medications were involved: Resident #33, Resident #10, Resident #13, Resident #122, and Resident #19. Resident #33’s Naphcon A eye drops were observed on the bedside table rather than secured in the medication cart. Record review showed Resident #33 had a BIMS score of 10, indicating moderate cognitive impairment, and the care plan and physician orders did not include self-administration of medications or an order for Naphcon A. During interview, Resident #33 stated he self-administered his eye drops. Staff stated they were not aware the eye drops were in the room and that the resident was not supposed to have medication at bedside. The DON stated the bottle should have been secured and stored in the facility’s medication cart. On the 100 hall medication cart, surveyors observed opened insulin pens and one open Lyumjev pen without a patient label or opening date. Resident #10’s Fiasp FlexTouch, Resident #13’s Humalog Mix 75/25, Resident #122’s Lantus SoloStar, and Resident #19’s insulin degludec were all found opened with no opening dates. The Lyumjev pen had no patient label and no opening date. Record review showed each resident had active diabetes-related physician orders for these insulins. Staff stated nurses were responsible for checking that insulin pens and vials had patient labels and open dates, and that opened insulin expires after 28 days. The DON stated all insulin pens and vials should be labeled and dated, and that expired, discontinued, or discharged residents’ medications should be removed from the medication cart.
Late Comprehensive MDS Assessment
Penalty
Summary
The facility failed to complete a Comprehensive MDS Assessment for Resident #124 within 14 calendar days after admission and also failed to ensure the assessment was completed at least once every 12 months. Resident #124 was a [AGE]-year-old male admitted to the facility with diagnoses including seizures, morbid obesity due to excess calories, pain, and anxiety disorder. His Face Sheet was dated 03/12/26, and his MDS Assessment was dated 02/20/26 but was completed on 03/02/26, which was 17 days after admission. During an interview on 03/11/26 at 10:25 AM, the MDS/PPS Nurse stated the assessment was not completed within the required timeframe because she was on vacation when it was due. She also stated she did not believe MDS Assessments completed outside the required timeframe posed a risk to residents because necessary care was still provided. The facility’s Electronic Transmission of the MDS policy stated that all MDS assessments, including admission and annual assessments, would be completed and electronically encoded into the facility’s MDS system and transmitted to the State database in accordance with current OBRA regulations, but the policy did not specify the timeframe for completion.
Incorrect PASRR Screening for Resident With Mental Health Diagnoses
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not coordinated to the maximum extent practicable to avoid duplicative testing and effort for one of six residents reviewed. Resident #16 had an MDS assessment showing a BIMS score of 12, indicating moderate cognitive impairment, and diagnoses that included anxiety disorder, depression, and schizoaffective disorder. Her care plan reflected use of antipsychotic, antianxiety, and antidepressant medications to treat those conditions. Despite this history, the resident’s PASRR Level I screening dated 10/21/2025 after re-admission stated that she did not have evidence of a mental illness. During interview, the MDS Coordinator acknowledged the PASRR screening was incorrect and stated it had been completed by the hospital. She reported that if an incoming screening was incorrectly filled out, she was supposed to complete form 1012 and submit it through the Long-Term Care Portal, but that form was not completed for Resident #16. The MDS Coordinator also stated the resident was not at risk because she did not qualify for PASRR due to not having an intellectual disability and because she received psychiatric and mental health services through a contracted mental health provider. The MDS/PPS Nurse stated the resident had dementia that would override her and make her ineligible for PASRR services, but also stated the resident’s primary diagnosis on admission was urinary tract infection, not dementia. The facility PASRR policy stated that if Alzheimer/dementia is not the primary diagnosis and there is a MI diagnosis, a PASRR evaluation is needed.
Incomplete Baseline Care Plan for Newly Admitted Resident
Penalty
Summary
The facility failed to develop and implement a baseline care plan for Resident #124 within 48 hours of admission. Resident #124 was a male admitted with diagnoses including seizures, morbid obesity due to excess calories, pain, and anxiety disorder. Review of his Interim Plan of Care, identified by the facility as the baseline care plan, showed it was signed by LVN A as completed on 02/13/26, but it did not include required areas such as initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, or PASARR recommendations. During interview, LVN A stated she completed the Interim Plan of Care for Resident #124 and said baseline care plans were to be completed on the day of admission. She stated she did not complete all sections because she had been told it was not necessary unless the resident required increased care in that area. The DON confirmed the Interim Plan of Care was the baseline care plan and stated she was not sure of the required timeframe or the areas that had to be included. The facility policy stated a baseline care plan was to be developed within 48 hours of admission and include review of the healthcare practitioner’s orders and the resident’s immediate care needs, including initial goals, physician orders, dietary orders, therapy services, social services, and PASARR recommendations if applicable.
Inaccurate care plan did not reflect PASRR status
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #16 that was consistent with resident rights and included measurable objectives and timeframes to meet the resident’s medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. Resident #16’s MDS assessment reflected an [AGE]-year-old female admitted to the facility on [DATE] with a BIMS score of 12, indicating moderate cognitive impairment, and diagnoses including Anxiety Disorder, Depression, and Schizoaffective Disorder. Record review of the resident’s comprehensive care plan dated 11/28/2026 showed that it identified PASRR assessment needs for specialized services and stated that specialized services would be provided to maintain the highest level of function. However, the PASRR Level 1 Screening dated 10/21/2025 reflected that the resident did not have evidence of a mental illness. In interview, the MDS/PPS Nurse stated she completed the comprehensive care plan and acknowledged that Resident #16 never received PASRR services and that the comprehensive care plan was inaccurate.
Failure to Maintain Continuous Oxygen and Proper Cannula Handling
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for a resident who had a physician order for continuous oxygen at 2 liters per minute via nasal cannula. The resident’s record showed a history of acute and chronic respiratory failure with hypercapnia and dependence on supplemental oxygen, and the care plan identified altered respiratory status and difficulty breathing. During an observation, the resident was being pushed in a wheelchair by a personal care attendant with a portable oxygen tank on the back of the wheelchair, but the oxygen level indicator showed the tank was empty, and the nasal cannula was dragging on the floor while the resident was in the hallway in view of other staff. The resident stated she was supposed to be on continuous oxygen and needed the tank replaced. The personal care attendant stated she was taking the resident to the nurse to replace the empty tank and did not know the cannula was dragging on the floor until it was pointed out. An LVN confirmed the resident had an order for continuous oxygen therapy and that the portable tank was empty, and the DON stated residents with continuous oxygen orders should always have access to oxygen. The facility’s oxygen administration policy stated that the nasal cannula is held in place by an elastic band around the resident’s head.
Infection Control Failure With Hallway Hydration Cart
Penalty
Summary
Provide and implement an infection prevention and control program was cited after observation, interview, and record review showed the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The deficiency involved one hydration cart observed in the hallway, where a family member of Resident #49 used a metal ice scoop to obtain ice and then poured the ice into two personal cups, touching the scoop on the insides of each cup. Resident #49's face sheet dated 03/12/26 showed he was a [AGE]-year-old male admitted on [DATE] with diagnoses including closed fracture with routine healing and pneumonia. During interview, the family member stated she frequently used the hydration cart to obtain ice for herself and Resident #49 and had done so since his admission, and she had not been told that staff needed to obtain the ice to maintain proper infection control protocols. The Administrator stated residents and visitors were not supposed to use the hydration cart located in the hallway, that it was meant for staff use, and that the facility did not have a specific policy and procedure related to hydration carts. The facility's Policies and Practices - Infection Control policy dated 07/2014 stated the facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections.
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.
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 1,141 citations issued within 25 miles in the last 12 months — including the 32 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 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 | ★★★★★ | 2 | 0 |
| Avir At Kennedale | 3.9 mi | ★★★★★ | 7 | 0 |
| Town Hall Estates - Arlington, Inc. | 4.2 mi | ★★★★★ | 2 | 1 |
| Arbrook Plaza | 4.7 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Green Oaks Nursing & Rehabilitation.
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 August 2026) and official state health department websites.