Below 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 Valley Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
Medication Given Outside Ordered BP Parameters: A resident with HTN had Metoprolol Succinate ER ordered with hold parameters for low SBP or HR, but the MAR showed the med was given on multiple occasions when SBP was below the ordered threshold. The med aide stated she gave the dose outside parameters and should have held it and notified the nurse; the LVN said he was not notified, and the DON stated meds should be held and the physician notified when parameters are not met.
A resident with HTN, DVT, and GERD had an admission/comprehensive MDS assessment completed late because the SW was behind on her sections and the MDS Nurse could not finish until after her part was done. The DON said she was not aware the assessment was incomplete, and the Administrator stated the facility did not have an MDS policy and used the RAI manual.
Unlocked Treatment Cart Left Unattended: A treatment cart was observed unlocked and unattended, with drawers open and medication and wound care supplies easily accessible. An LVN said the cart belonged to the wound care nurse, who was not at work, and the ADON and DON stated the cart should be locked when not in use. The facility policy stated compartments containing drugs and biologicals are locked when not in use.
A resident with significant physical and cognitive impairments, who required a mechanical lift and two-person assistance for transfers per physician orders, was manually transferred by a CNA with help from a family member. This improper transfer resulted in a shoulder dislocation and humeral neck fracture, as the required equipment and staffing were not used in accordance with the care plan and facility policy.
Multiple resident rooms and air conditioning units were found with significant dirt, dust, and stains, including unclean vents, stained bathroom fixtures, and dirty mini fridges. Housekeeping and maintenance staff acknowledged that cleaning had not been thorough, despite facility policy requiring daily cleaning to ensure a sanitary environment.
Surveyors found that the facility failed to maintain proper food storage, preparation, and equipment sanitation standards. The kitchen's ice machine and scoop holder had visible stains, cooking equipment was dirty, and food items were not properly labeled or dated. Additionally, a tea dispenser was left uncovered, and several food storage policies were not followed, as confirmed by staff interviews.
Staff failed to maintain the confidentiality of resident medical information by leaving documents and medication packaging containing personal health details unattended and visible on carts in hallways and at the nurses' station. These items included names, diagnoses, medication details, and other sensitive information, and were left without supervision, making them accessible to unauthorized individuals.
Surveyors found that several residents requiring oxygen therapy did not receive care consistent with professional standards, including improper storage of nasal cannulas, an empty humidifier bottle, and missing "Oxygen In Use" signage. Staff interviews confirmed these lapses, and facility policy required these safety measures to be in place.
Staff failed to follow infection control protocols, including proper hand hygiene, glove changes, and use of gowns during incontinent care, medication administration via feeding tube, and wound care for several residents with significant medical needs and on enhanced barrier precautions. These lapses were observed among a CNA, an LVN, and a wound care nurse, despite facility policies requiring these practices.
Two residents identified as high fall risk were provided with fall prevention equipment—a scoop mattress and bolster pads—without the required physician orders. Both residents were totally dependent for ADLs and had diagnoses including dementia and unsteadiness. The absence of physician orders for this equipment was confirmed by an LVN and the DON during interviews and record reviews.
Two residents with severe cognitive impairment and high dependence on staff were found without accessible call lights in their rooms, as required by their care plans and facility policy. Staff interviews confirmed that call lights are essential for requesting assistance, but in both cases, staff failed to ensure the devices were within reach after providing care or medication.
A CNA failed to follow proper perineal care technique by wiping from back to front during incontinent care for a resident with a history of UTI and severe cognitive impairment. This action was inconsistent with the resident's care plan and facility policy, which require front-to-back cleaning to prevent infection.
Two residents with g-tubes did not have tube placement or gastric residual checked before medications were administered by an LVN, despite physician orders and care plans requiring these steps. The LVN acknowledged forgetting to perform the checks, and facility leadership confirmed that these procedures are expected as part of enteral feeding management.
A resident with a history of peripheral artery disease (PAD) was not provided with adequate care and monitoring by the facility. Despite known risks, the facility failed to conduct regular skin assessments and did not implement a comprehensive care plan addressing the resident's PAD. This oversight led to the resident being transferred to the hospital with significant skin issues, including gangrenous toes, highlighting a lack of communication and documentation among staff.
A resident with a history of metabolic encephalopathy, acute kidney failure, E. coli infection, and type 2 diabetes developed a deep tissue pressure injury due to the facility's failure to perform consistent skin assessments and implement necessary interventions. Despite being at risk for pressure ulcers, the facility did not adequately monitor or document the resident's skin condition, leading to a diagnosis of a deep tissue pressure injury and ischemic eschar upon hospital transfer. Staff interviews revealed a lack of communication and adherence to the facility's pressure ulcer prevention policies.
A facility failed to create comprehensive care plans for a resident, neglecting to address risks of altered skin integrity and peripheral artery disease (PAD). The resident, with multiple diagnoses and requiring substantial assistance, lacked a care plan focusing on impaired skin integrity or pressure injury prevention. Staff interviews revealed confusion over care plan responsibilities, and there were no orders for pressure-relieving devices for the resident's heels. This oversight could negatively impact the resident's quality of life and care.
The facility failed to maintain respiratory equipment according to professional standards for three residents requiring respiratory therapy. Observations showed undated nasal cannulas and improperly stored nebulizer masks, potentially leading to respiratory infections. Residents with dementia and respiratory conditions were affected, and staff interviews revealed inconsistencies in following protocols for equipment maintenance.
Two residents with feeding tubes were found with unlabeled enteral feeding formula and water bags, and improperly stored piston syringes, posing risks of contamination and infection. Despite care plans requiring specific feeding interventions, nursing staff failed to adhere to protocols due to oversight and workload.
A resident with paraplegia and stage 4 pressure ulcers exhibited altered mental status and hallucinations for over 22 hours without timely notification to the physician or responsible party. Despite staff observations of the resident's deteriorating condition, including hallucinations and sweating, there was a lack of documentation and communication, leading to a diagnosis of severe sepsis at a hospital.
A resident with complex medical conditions experienced a decline in well-being due to the facility's failure to monitor and report changes in bowel movements and mental status. Despite being at risk for constipation, the resident did not receive prescribed PRN medication, and significant symptoms were not communicated to the provider, resulting in hospitalization for severe sepsis and fecal impaction.
A resident with complex medical conditions was not promptly notified to the physician about STAT lab results, leading to hospitalization for severe sepsis and chronic constipation. Despite being at risk for constipation due to medications, the facility failed to administer MiraLax or document interventions. Staff interviews revealed communication lapses, and the physician was not informed of the lab results timely, placing the resident at high risk for complications.
Medication Given Outside Ordered BP Parameters
Penalty
Summary
Resident #1, a cognitively intact female with a diagnosis of hypertension, had a physician order for Metoprolol Succinate ER 50 mg once daily with instructions to hold the medication for SBP less than 110 or HR less than 60 and not to crush it. Review of the MAR showed that the medication was administered outside of those parameters on 04/27/26, 04/28/26, and 04/29/26, with documented SBP readings of 101, 108, and 108 respectively. The care plan directed staff to give antihypertensive medications as ordered and to monitor for side effects such as orthostatic hypotension and increased heart rate. The medication aide stated she administered the medication outside of parameters on those three dates and said she was supposed to hold the blood pressure medication when the blood pressure was below parameters and notify the nurse. The LVN stated medication aides pass routine medications and that if a blood pressure reading was outside of parameters, it should be rechecked and the nurse notified if still outside parameters; he also stated he was not notified of any out-of-parameter blood pressures for Resident #1. The DON stated she was not aware of blood pressure medications being administered outside of parameters and expected the nurse to notify the physician, hold the medication, and indicate the hold on the MAR. The facility policy stated medications are administered according to prescriber orders.
Late Admission MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive admission assessment within 14 calendar days for Resident #1. Review of the resident’s MDS assessment showed she was a [AGE]-year-old female admitted to the facility with diagnoses including HTN, DVT, and GERD. Her BIMS score was 15, indicating she was cognitively intact. The MDS summary screen in the Electronic Health Record showed an ARD date of 04/10/26 and completion on 04/21/26, which was 11 days after the ARD date. During interviews, the DON stated she was not aware the MDS was incomplete and late and said the MDS Nurse was responsible for MDSs. The MDS Nurse stated she had worked at the facility for about 12 years and knew the SW had been behind on her sections of the MDS, but she completed her part on 04/17/26 and the MDS could not be completed until 04/21/26. The Administrator stated the facility did not have a policy on MDS and used the RAI manual. The RAI manual excerpt reviewed reflected that the 14th calendar day of admission is admission date plus 13 calendar days.
Unlocked Treatment Cart Left Unattended
Penalty
Summary
The facility failed to ensure treatment cart #1 was stored securely when it was left unlocked and unattended on 05/04/26. During an observation at 8:50 AM, treatment cart #1 was found unlocked with no staff within eyesight, and all drawers could be opened so that medication and supplies such as needles, gauze, and ointments were easily accessible. In an interview at 8:54 AM, an LVN stated the cart belonged to the wound care nurse, who was not at work. At 8:55 AM, the ADON locked the cart and stated it was expected to be locked when not in use and that the nurse who last used it was responsible for locking it, though she did not know who had used it last. Later interviews with the ADON and DON confirmed that the cart should be locked when not in use and that any staff member could lock it if found unlocked. The facility policy titled Storage of Medications dated 06/24/2025 stated that compartments containing drugs and biologicals are locked when not in use.
Failure to Follow Transfer Protocols Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a resident, who had multiple medical conditions including hemiplegia, hemiparesis, muscle weakness, and was dependent on staff for all activities of daily living, was transferred without the required mechanical lift and two-person assistance. The resident's care plan and physician orders specified that transfers must be performed using a mechanical lift with two staff members due to her inability to bear weight and significant physical debility. Despite these clear directives, a CNA manually transferred the resident with the assistance of a family member, rather than using the mechanical lift as ordered. During the manual transfer, the CNA bear-hugged the resident and, while holding her up, a popping sound was heard from the resident's right arm. The resident immediately expressed severe pain, and subsequent assessment and hospital evaluation revealed an anterior shoulder dislocation and a right humeral neck fracture. Interviews with staff and the resident's representative confirmed that the transfer was performed by a single CNA without the mechanical lift, and that the family had previously requested that the lift not be used. The CNA admitted to having transferred the resident manually on prior occasions, despite knowing the care plan and physician orders required the use of a mechanical lift with two staff. Facility policy required strict adherence to physician orders for transfers, including the use of mechanical lifts for non-weight-bearing residents, and mandated that staff not deviate from these orders even if requested by residents or their families. The incident was reported by staff, and it was acknowledged by the DON and other staff members that the CNA's actions were not in compliance with established protocols and orders. The failure to follow the prescribed transfer method directly resulted in a significant injury to the resident.
Failure to Maintain Clean and Sanitary Resident Rooms and Air Conditioning Units
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents in 13 out of 16 rooms on the 100 hall, as well as the air conditioning unit on the same hall. Observations revealed that multiple resident rooms had significant cleanliness issues, including thick black and brown dirt along and between air conditioning vents, thick white substances between vents, and thick dust on air filters. Additional findings included brownish stains on bathroom sink faucets, brown stains along the edges and corners of bathroom floors and door frames, stained bed frames, and dirty mini fridges. Some rooms also had thick dirt in the corners of the floors and stained picture frames and toilets. Interviews with housekeeping staff and supervisors confirmed that staff were responsible for cleaning all areas of the resident rooms, including bathrooms, air conditioning units, and mini fridges. However, the staff acknowledged the observed deficiencies and stated that cleaning had not been thorough. The maintenance director confirmed responsibility for cleaning the inside of air conditioning units and air filters, stating that these were supposed to be cleaned monthly, but the observed conditions indicated this was not being done adequately. The facility's policy on resident room cleaning emphasized the importance of daily cleaning to maintain a sanitary environment and prevent odors. Despite this policy, the observed conditions and staff interviews demonstrated a lack of adherence to cleaning protocols, resulting in unclean and unsanitary living conditions for residents in the affected rooms.
Deficient Food Storage, Preparation, and Equipment Sanitation
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding food storage, preparation, and equipment cleanliness. The ice machine and its scoop holder had visible brown stains, indicating they were not thoroughly cleaned. Cooking equipment, including a large bread toaster, microwave, and toaster oven, showed significant buildup of dirt and dried food stains both inside and outside. Two baking pans were also heavily stained with food residue. Additionally, a tea dispenser containing tea was left uncovered, exposing it to potential air-borne contaminants. Further observations revealed that food items in the refrigerator, such as a container of pears and a glass container of milk, were not labeled or dated after being opened. Several large cans of fruit salad and beans in dry storage were also not dated with the month, day, and year of receipt. Interviews with the Dietary Manager and Administrator confirmed awareness of these issues, and facility policies reviewed required proper cleaning, sanitization, and labeling of food items, which were not followed as observed.
Failure to Protect Resident Privacy and Confidentiality of Medical Information
Penalty
Summary
Multiple instances were observed where staff failed to maintain the privacy and confidentiality of residents' personal and medical information. In one case, a piece of paper containing a resident's name, room number, and details about skin tears sustained during a fall was left unattended on top of a documentation cart in the hallway, visible to unauthorized individuals. The staff member present acknowledged that such information should not be left exposed and was unsure who was responsible for leaving it there. In another instance, a medication aide left a plastic medication packaging on top of a medication cart, which included a resident's name, medication details, prescription number, dosage, frequency, physician's order, diagnosis, and pharmacy name. The cart was unattended and facing the hallway, making the information accessible to anyone passing by. The aide admitted to leaving the packaging and recognized that it should not have been left exposed. Additional observations included a piece of paper with a resident's name and blood pressure left on a cart at the nurses' station, and a blister pack top with a resident's information left on a medication cart, both unattended and visible in the hallway. Staff interviews confirmed that these actions were contrary to facility policy and expectations regarding the confidentiality of resident information.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to five residents who required oxygen therapy, as evidenced by multiple deficiencies in the handling and administration of respiratory equipment. Observations revealed that several residents' nasal cannulas were not properly stored when not in use. Specifically, nasal cannulas were found coiled around oxygen tanks or attached to wheelchairs without being bagged, with the prongs exposed and touching surfaces. This was observed for multiple residents, and staff interviews confirmed that the cannulas should have been bagged to prevent respiratory infection, but this was not done during routine rounds. Additionally, the facility did not ensure that a humidifier bottle attached to an oxygen concentrator for one resident contained water. The humidifier bottle was observed to be empty while the resident was receiving oxygen therapy. Staff acknowledged that they had not checked the water level during their rounds, despite the purpose of the humidifier being to moisten the air and prevent irritation to the nasal passages. The facility also failed to display an "Oxygen In Use" sign outside the room of a resident receiving oxygen therapy. Staff interviews indicated that such signage is required to alert staff and visitors to the presence of oxygen and the associated fire hazards. Review of facility policies confirmed the requirements for proper storage of nasal cannulas, maintenance of humidifier water levels, and the posting of oxygen use signage, but these procedures were not followed as observed during the survey.
Failure to Adhere to Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple staff members not adhering to established protocols during resident care. Certified Nursing Assistant (CNA) F did not perform hand hygiene before donning gloves, between glove changes, or after providing incontinent care to a female resident with a history of urinary tract infection and severe cognitive impairment. During the care process, the CNA changed gloves without sanitizing hands and handled soiled items before touching clean briefs and padding, further neglecting to wash hands after completing care. Licensed Vocational Nurse (LVN) C did not wear a gown while administering medications via gastrostomy tube to two residents who were on enhanced barrier precautions, as indicated by signage and care plans. Both residents had severe cognitive impairment and required feeding tubes for nutrition. Despite facility policy requiring the use of gloves and gowns during high-contact care for residents with indwelling medical devices, the LVN proceeded with medication administration without donning a gown. The Wound Care Nurse (WCN) J also failed to wear a gown while performing wound care on a male resident with a diabetic foot ulcer who was on enhanced barrier precautions. During the dressing change, the nurse touched the outside edge of the resident's foot and did not change gloves before handling the new dressing. These actions were inconsistent with facility policies on hand hygiene, glove use, and enhanced barrier precautions, as confirmed by staff interviews and policy reviews.
Failure to Obtain Physician Orders for Fall Prevention Equipment
Penalty
Summary
The facility failed to ensure that two residents' environments were free from accident hazards by not obtaining physician orders for safety equipment used for fall prevention. One resident, who was totally dependent for assistance with transfers, toileting, and bathing and had diagnoses including unsteadiness on feet, dementia, and muscle weakness, was observed with bolster pads on her bed. Review of her records showed no physician orders for the bolster pads, despite her care plan identifying her as high risk for falls and requiring a safe environment. Another resident, also totally dependent for assistance and with similar diagnoses including a history of falls and dementia, was observed with a scoop mattress on her bed. Record review indicated there were no physician orders for the scoop mattress, even though her care plan also identified her as high risk for falls. Interviews with the LVN and DON confirmed that both residents had equipment in use without the required physician orders, and that such equipment could restrict movement and potentially act as a restraint.
Failure to Ensure Accessible Call Lights for Dependent Residents
Penalty
Summary
The facility failed to ensure that the call light systems in the rooms of two residents were accessible, as required by their care plans and facility policy. Both residents had severe cognitive impairments and were dependent on staff for activities such as transfer, toileting, dressing, and personal hygiene. Observations revealed that one resident's call light was found on the floor at the foot of the bed while she was in her wheelchair, and she was unaware of its location. In the other case, the call light was observed on the floor, coiled around an IV stand, while the resident was in bed and unable to communicate its location. Interviews with staff confirmed that call lights are essential for residents to request assistance, and that staff are responsible for ensuring call lights are within reach before leaving the room. In both cases, staff acknowledged that they had not ensured the call lights were accessible after providing care or administering medication. The facility's policy requires that each resident be provided with a means to call staff for assistance from their bed and other locations, but this was not followed in these instances. The deficiency was identified through direct observation, interviews with the residents and staff, and review of medical records and care plans. The lack of accessible call lights for these residents, both of whom were at risk for falls and dependent on staff, constituted a failure to reasonably accommodate their needs and preferences as outlined in their care plans and the facility's own policies.
Improper Perineal Care Technique During Incontinent Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to provide appropriate incontinent care to a female resident with a history of urinary tract infection and severe cognitive impairment. During an observed episode of care, the CNA cleaned the resident's perineal area and then proceeded to clean the resident's bottom by wiping from back to front multiple times, contrary to established infection control procedures. The CNA later acknowledged that the correct technique is to wipe from front to back to prevent urinary tract infections, but was unaware of her error during the care episode. The resident involved was always incontinent of bowel and bladder, as documented in her comprehensive assessment and care plan, which specified cleaning the perineal area with each episode of incontinence. Facility policy also outlined the correct procedure for perineal care, emphasizing the importance of wiping from the base of the labia towards and over the buttocks to prevent infection. Interviews with facility leadership confirmed that the expectation was for staff to follow these procedures to avoid cross-contamination and infection.
Failure to Verify G-Tube Placement and Residual Before Medication Administration
Penalty
Summary
Two residents with gastrostomy tubes (g-tubes) were not provided appropriate treatment and services to prevent complications of enteral feeding. Both residents had physician orders and care plans requiring verification of g-tube placement and checking for gastric residual prior to medication administration. On the observed date, an LVN prepared and administered medications via g-tube to both residents without performing these required checks. For the first resident, who had severe cognitive impairment and dysphagia, the LVN prepared the medication, dissolved it in water, and administered it through the g-tube after flushing, but did not verify tube placement or check for residual as ordered. The resident's care plan and physician orders specifically required these steps to be performed every shift. The second resident, who was unable to complete a cognitive interview and had a diagnosis of gastrostomy status, also received medications via g-tube from the same LVN without verification of tube placement or checking for residual, despite similar orders and care plan interventions. During interviews, the LVN acknowledged forgetting to perform the required checks and described the correct procedure, while the DON and ADON confirmed that staff are expected to verify g-tube placement and check residual before administering medications. The facility's policy also required confirmation of tube placement and checking gastric residual volume as part of enteral nutrition management.
Failure to Monitor and Manage Peripheral Artery Disease
Penalty
Summary
The facility failed to provide resident-centered care and services in accordance with professional standards of practice for a resident with a history of peripheral artery disease (PAD). The resident, a 78-year-old female with multiple comorbidities including metabolic encephalopathy, acute kidney failure, and type 2 diabetes mellitus, was admitted to the facility without a comprehensive care plan addressing her risk for skin integrity issues and PAD management. Despite the resident's known history of PAD, the facility did not implement preventative treatment orders or adequately monitor for signs and symptoms of PAD, such as diminished pedal pulses and skin discoloration. The facility's failure to conduct regular and thorough skin assessments contributed to the oversight of the resident's deteriorating condition. Weekly skin checks were not consistently performed, and when they were, they failed to identify significant changes in the resident's skin condition. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's skin issues, with several staff members unaware of the resident's PAD history and the associated risks. The resident's care plan did not reflect any focus on impaired skin integrity or PAD management, and interventions such as turning and repositioning were not effectively implemented. As a result of these deficiencies, the resident was transferred to the emergency department with mottled legs, abrasions on the toes, and absent distal pulses, eventually leading to a diagnosis of gangrenous skin of the toes. The facility's inadequate monitoring and documentation of the resident's condition placed her at unnecessary risk of serious complications, including infection and tissue necrosis. The lack of a coordinated approach to the resident's care and the failure to adhere to professional standards of practice were significant factors in the resident's adverse health outcomes.
Failure to Prevent Pressure Ulcers and Inadequate Skin Care
Penalty
Summary
The facility failed to ensure that a resident did not develop pressure ulcers unless clinically unavoidable and did not provide care and services consistent with professional standards to promote healing and prevent new pressure ulcers. The resident, a 78-year-old female with a history of metabolic encephalopathy, acute kidney failure, E. coli infection, and type 2 diabetes, was admitted to the facility with redness on the buttocks. Despite being at risk for pressure ulcers, the facility did not perform the required weekly skin assessments consistently, and the care plan did not reflect a focus on impaired skin integrity or risk of developing pressure injuries. The facility's inaction included failing to identify early signs of pressure injuries and implement interventions to prevent deep tissue pressure injuries in the sacral region. The resident was transferred to the hospital, where a deep tissue pressure injury and ischemic eschar were diagnosed. The facility's records showed inconsistencies in documenting skin assessments and interventions, with several staff members unaware of the resident's skin issues. The facility's policy required regular skin assessments and interventions, but these were not adequately followed. Interviews with staff revealed a lack of communication and coordination in monitoring and addressing the resident's skin condition. The wound care nurse and other staff members were not informed of the resident's skin issues, and there was a failure to document and notify appropriate personnel about changes in the resident's skin condition. The facility's failure to adhere to its policies and procedures for pressure ulcer prevention placed the resident at risk for complications, as evidenced by the hospital's findings upon the resident's transfer.
Failure to Develop Comprehensive Care Plans for Resident
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for a resident, which included measurable objectives and timeframes to address the resident's medical, nursing, mental, and psychosocial needs. Specifically, the facility did not create a care plan to address the risk of or actual altered skin integrity for the resident, who was admitted with a history of altered skin integrity. Additionally, the facility did not develop a care plan for the resident's peripheral artery disease (PAD), despite the resident's admission paperwork indicating a history of PAD. The resident, a 78-year-old female, was admitted to the facility with multiple diagnoses, including metabolic encephalopathy, acute kidney failure, E. coli infection, and type 2 diabetes mellitus. The resident required substantial assistance with activities of daily living and was always incontinent of bowel and bladder. Despite being at risk for developing pressure ulcers, the resident's care plan did not reflect a focus on impaired skin integrity or the risk of developing pressure injuries. The care plan goals were limited to preventing skin breakdown due to incontinence and maintaining intact skin related to fragile skin, without addressing the resident's specific needs for pressure injury prevention. Interviews with facility staff revealed a lack of clarity and responsibility regarding the development and updating of care plans. The Director of Nursing (DON) and other staff members were unaware of the deficiencies in the care plan, and there was no evidence of orders for pressure-relieving devices for the resident's heels. The facility's policy required care plans to include measurable objectives and timeframes, but this was not reflected in the resident's care plan. The failure to develop a comprehensive care plan could negatively impact the resident's quality of life and the quality of care received.
Failure to Maintain Respiratory Equipment
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for three residents who required respiratory therapy. Observations revealed that the nasal cannulas (NC) for two residents were not changed and dated according to facility policy. Additionally, a registered nurse failed to change, date, and properly store the NC tubing and nebulizer mask for another resident. These lapses in care could potentially lead to respiratory infections and poor air quality for the residents. Resident #4, a female with a history of dementia and congestive heart failure, was observed with an undated humidifier water bottle and improperly stored nebulizer equipment. Her medical records indicated she was severely cognitively impaired and dependent on staff for all activities of daily living (ADLs). Despite having orders for regular oxygen therapy and nebulizer treatments, the equipment was not maintained according to the prescribed schedule, as evidenced by the undated and improperly stored items. Resident #5, who has dementia, asthma, and COPD, was observed with an undated NC and a nebulizer mask that was not stored in a bag. Her care plan included interventions for her respiratory conditions, but the equipment was not managed as required. Similarly, Resident #6, with a diagnosis of dementia and chronic respiratory failure, was found with undated NC tubing and a concentrator bottle. Interviews with staff revealed inconsistencies in following the facility's protocol for changing and dating respiratory equipment, contributing to the deficiencies noted.
Failure to Label and Store Enteral Feeding Supplies
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for two residents who were reviewed for feeding tubes. Specifically, the nursing staff did not label the enteral feeding formula and water bags with the date and time of administration for both residents. Additionally, the piston syringes used for flushing the feeding tubes were not stored in containers or dated, which could lead to potential risks such as tube obstruction and decreased hydration. Resident #3, a female with Huntington disease and dysphagia, was observed with an unlabeled enteral feeding formula bag and water bag. The piston syringe was found lying in a clear container without a date. The resident's care plan required PEG feeding and water flushes as ordered, but the lack of labeling and proper storage of the feeding supplies indicated a failure to adhere to these interventions. The resident was severely cognitively impaired and dependent on staff for care, highlighting the importance of staff compliance with feeding protocols. Resident #7, a female with multiple diagnoses including coronary artery disease and Barrett's esophagus, was also found with an unlabeled enteral feeding system. The piston syringe was improperly stored on a towel in a bedpan, and the feeding formula and water bags were not dated. Despite being cognitively intact, the resident was totally dependent on staff for activities of daily living. Interviews with nursing staff revealed that the failure to label and store the feeding supplies properly was due to oversight and workload, which could result in contamination and infection risks.
Failure to Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to immediately consult with a resident's physician and notify the resident's representative when there was a significant change in the resident's condition. This deficiency was identified for a resident who showed signs of altered mental status for at least 22 hours and was later diagnosed with severe sepsis at a local hospital. The resident, a male with paraplegia, osteomyelitis, and polyneuropathy, was admitted with stage 4 pressure ulcers and required IV medication and isolation for infectious disease. Despite these conditions, the facility did not document or report the resident's change in mental status to the physician or responsible party in a timely manner. Observations and interviews revealed that the resident exhibited symptoms such as hallucinations, yelling, and sweating, which were indicative of a significant change in condition. These symptoms were noted by various staff members, including CNAs and nurses, over a period of time. However, there was a lack of communication and documentation regarding these changes. The resident's hallucinations and altered mental status were reported by CNAs to an LVN, but the LVN did not document the assessment or notify the physician. The resident's condition continued to deteriorate, leading to a diagnosis of severe sepsis at the hospital. Interviews with staff members highlighted inconsistencies in the reporting and assessment of the resident's condition. Some staff members reported the resident's hallucinations and changes in condition, while others did not observe or document these changes. The facility's policy required that any significant change in a resident's condition be reported to the physician and family, but this was not adhered to in this case. The failure to promptly notify the physician and responsible party of the resident's altered mental status and potential infection risk resulted in a delay in appropriate medical intervention.
Removal Plan
- CCS in-serviced Administrator and DON on change of condition policy and procedure to include comprehensive assessments and notification of Physician/NP. In-service covered when to notify the Physician/NP for a change of condition, discussed what categories fall under change of condition, the process for notification of Physician/NP, escalation of the communication process if the Physician/NP cannot be reached, and examples of significant changes. Competency was verified via quiz.
- Administrator and DON initiated in-services with the licensed nurses on change of condition policy and procedure to include comprehensive assessments and notification of Physician/NP. In-services covered when to notify the Physician/NP for a change of condition, discussed what categories fall under change of condition, the process for notification of Physician/NP, escalation of the communication process if the Physician/NP cannot be reached, and examples of significant changes. Competency was verified via quiz. Nursing staff will not be allowed to work until In-servicing has been completed.
- An audit was conducted by DON/Designee to identify other residents with potential change of condition. Via direct observation, staff interviews, and record review, no other residents were identified as having a change of condition. Medical Director was notified.
- In order to monitor current residents for potential risk, DON and CCS will monitor residents for change of condition for 30 days on all residents via Triage Log. The purpose of this log is to monitor residents with acute changes in condition. DON compliance will be monitored weekly by CCS for 90 days. Thereafter, QA will monitor quarterly up to a year for compliance of change of condition, quality of care and abuse and neglect. If any issues are identified, the physician will be contacted for further medical management and family/POA of the same. The facility QA Committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns are noted, will continue to monitor as per routine facility QA Committee.
Failure to Monitor and Report Resident's Condition Leads to Hospitalization
Penalty
Summary
The facility failed to provide necessary care and services to a resident, leading to a significant decline in their physical and mental well-being. The resident, a 78-year-old male with complex medical conditions including paraplegia, osteomyelitis, and polyneuropathy, was admitted to the facility and was cognitively intact. Despite being at risk for constipation due to medications like Duloxetine and Tramadol, the facility did not administer the prescribed PRN medication MiraLax for constipation. The resident's bowel movements were not adequately monitored or documented, and significant changes in his condition, such as hallucinations and elevated heart rate, were not reported to the provider. The facility also failed to notify the provider of the resident's last known bowel movement and did not report significant abnormalities in bowel sounds as required by the care plan. The resident was admitted to the hospital with severe sepsis, chronic constipation, and fecal impaction after exhibiting altered mental status and other symptoms. The facility's staff, including nurses and CNAs, did not effectively communicate or document the resident's condition changes, leading to a delay in appropriate medical intervention. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's condition. The DON stated that changes in condition should be reported, but staff failed to do so. The MD was not informed of critical lab results or the resident's symptoms, which could have indicated severe complications. The facility's policies on bowel disorders and change of condition notifications were not followed, contributing to the resident's decline and subsequent hospitalization.
Removal Plan
- CCS inserviced DON on the prompt or timely review of laboratory results, lab policy and procedure to include the lab tracking system, lab orders, receiving lab results, and proper follow up and notifications. An inservice was initiated on the proper documentation of resident bowel function and reporting any important changes to the nurse. Competency was verified via quiz.
- DON/designee initiated inservices with the licensed nurses on prompt or timely review of laboratory results, lab policy and procedure to include the lab tracking system, lab orders, receiving lab results, and proper follow up and notifications. Competency was verified via quiz. Nursing staff will not be allowed to work until inservicing has been completed.
- An inservice was initiated on the proper documentation of resident bowel function and reporting any important changes to the nurse. Competency was verified via quiz. Nursing staff will not be allowed to work until inservicing has been completed.
- DON/designee initiated inservices with the CNAs/MA s on proper documentation of resident bowel function and reporting any important changes to the nurse. Competency was verified via quiz.
- An audit of the 24-hour report and laboratory findings was conducted by DON/Designee to ensure Physician/NP has been notified timely.
- An audit of BM documentation was completed by DON/designee.
- Medical Director was notified.
- In order to monitor current residents for potential risk, DON, and CCS will monitor residents for change of condition and physician/np notification for all residents via Triage Log. The purpose of this log is to monitor residents with acute changes in condition and to ensure timely notification of Physician/NP. DON compliance will be monitored weekly by CCS. Thereafter, QA will monitor quarterly for compliance of physician notification. The facility QA Committee will meet weekly to review compliance with the plan of action. If no further concerns are noted, will continue to monitor as per routine facility QA Committee.
Failure to Notify Physician of Lab Results Leads to Resident Hospitalization
Penalty
Summary
The facility failed to promptly notify the physician of laboratory results for a resident, leading to a significant deficiency. The resident, a 78-year-old male with complex medical conditions including paraplegia, osteomyelitis, and polyneuropathy, was admitted to the facility. He was on medications such as Duloxetine and Tramadol, which have constipation as a common side effect. Despite being at risk for constipation and sepsis, the facility did not administer MiraLax as needed for constipation, nor did they document any interventions for constipation relief or notify the provider of the resident's condition. On a specific day, the resident exhibited altered mental status, hallucinations, and other symptoms indicative of a serious condition. STAT lab results were ordered and received, showing abnormal values, but the facility failed to notify the physician promptly. The resident was later admitted to the hospital with severe sepsis and chronic constipation, where a CT scan revealed a large rectal stool ball and colonic stool burden, indicating fecal impaction. Interviews with staff revealed a lack of communication and documentation regarding the resident's bowel movements and changes in condition. The Director of Nursing (DON) and other staff members were not informed of the resident's constipation or other symptoms, and the physician was not notified of the STAT lab results in a timely manner. This oversight placed the resident at high risk for serious complications, including sepsis.
Removal Plan
- CCS inserviced DON on the prompt or timely review of laboratory results, lab policy and procedure to include the lab tracking system, lab orders, receiving lab results, and proper follow up and notifications. An inservice was initiated on the proper documentation of resident bowel function and reporting any important changes to the nurse. Competency was verified via quiz.
- DON/designee initiated inservices with the licensed nurses on prompt or timely review of laboratory results, lab policy and procedure to include the lab tracking system, lab orders, receiving lab results, and proper follow up and notifications. Competency was verified via quiz. Nursing staff will not be allowed to work until inservicing has been completed.
- An inservice was initiated on the proper documentation of resident bowel function and reporting any important changes to the nurse. Competency was verified via quiz. Nursing staff will not be allowed to work until inservicing has been completed.
- DON/designee initiated inservices with the CNAs/MA s on proper documentation of resident bowel function and reporting any important changes to the nurse. Competency was verified via quiz. Nursing staff will not be allowed to work until inservicing has been completed.
- An audit of the 24-hour report and laboratory findings was conducted by DON/Designee to ensure Physician/NP has been notified timely.
- An audit of BM documentation was completed by DON/designee.
- Medical Director was notified.
- In order to monitor current residents for potential risk, DON, and CCS will monitor residents for change of condition and physician/np notification for all residents via Triage Log. The purpose of this log is to monitor residents with acute changes in condition and to ensure timely notification of Physician/NP. DON compliance will be monitored weekly by CCS. Thereafter, QA will monitor quarterly for compliance of physician notification. The facility QA Committee will meet weekly to review compliance with the plan of action. If no further concerns are noted, will continue to monitor as per routine facility QA Committee.
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 1,073 citations issued within 25 miles in the last 12 months — including the 43 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 Fort Worth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| North Pointe Nursing And Rehabilitation | 0.9 mi | ★★★★★ | 1 | 1 |
| Avir At North Richland Hills | 2.1 mi | ★★★★★ | 5 | 0 |
| Heritage House At Keller Rehab & Nursing | 2.9 mi | ★★★★★ | 7 | 1 |
| Oakmont Guest Care Center | 3.5 mi | ★★★★★ | 2 | 1 |
| Glenview Wellness & Rehabilitation | 3.6 mi | ★★★★★ | 18 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Green Valley Healthcare And Rehabilitation Center.
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.