Green Valley Rehabilitation Health Center

Inspectors wroteBased on interview and record review it was determined the facility failed to complete a discharge summary, including a recapitulation of the resident's stay and the resident's functional status upon discharge for 3 of 4 sampled residents (#s 2, 3, 5 and 8) reviewed for discharge. This placed residents at risk for an unsafe discharge.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a safe and orderly discharge for 1 of 3 sampled residents (#8) reviewed for discharge. This placed residents at risk for an unsafe and disorderly discharges.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to determine the appropriateness for the self-administration of medication for 4 of 9 sampled residents (#s 5, 10 12, 68, and 108) reviewed for accidents and nutrition. This placed residents at risk for an ineffective medication regimen.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure food temperatures were maintained and to provide palatable food from 1 of 1 facility kitchen and 3 of 5 sampled residents (#s 11, 29 and 57) reviewed for food. This placed residents at risk for food that was not palatable, safe, or appetizing.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were informed of the risks and benefits of psychotropic medications for 1 of 5 sampled residents (#13) reviewed for unnecessary medications. This placed residents at risk for being uninformed about their medications.

Inspectors wroteBased on interview and record review it was determined the facility failed to have a process in place to ensure resident rights to execute an advance directive, provide follow up and obtain copies for the medical record for 3 of 4 sampled residents (#s 10, 30, 108) reviewed for advance directives.

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure residents' health information was kept private for 2 of 2 sampled residents (#s 82 and 105). This placed residents at risk for lack of privacy.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure resident toilets were repaired timely for 1 of 7 sampled residents (#15) reviewed for environment. This placed residents at risk for an unhomelike environment.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to develop and implement comprehensive care plans for 1 of 3 sampled residents (# 92) reviewed for activities. This placed residents at risk for unmet needs.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure appropriate interdisciplinary team members were present for resident care conferences, failed to ensure care plans were updated to reflect current status, and failed to hold care planning meetings for 3 of 6 sampled residents (#s 5, 30, and 71) reviewed for dentures and care planning. This placed residents at risk for lack of care planning participation and unmet care needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to provide a Restorative program for 1 of 1 sampled resident (#55) reviewed for restorative. This placed residents at risk for increased weakness.

Inspectors wroteBased on observation interview and record review it was determined the facility failed to ensure personal hygiene was provided for 1 of 4 sampled residents (#55) reviewed for ADLs. This placed residents at risk for poor hygiene.

Inspectors wroteBased on observation, interview, and record it was determined the facility failed to provide meaningful activities for dependent residents for 1 of 3 sampled residents (#61) reviewed for activities. This placed residents at risk for lack of social interaction and isolation.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure a resident's smoking paraphernalia was stored securely and failed to ensure a resident was evaluated for safety after a fall for 1 of 3 sampled residents (#71) reviewed for smoking and falls. This placed residents at risk for injury.

Inspectors wroteBased on observation, interview and record review the facility failed to effectively manage the resident's pain for 1 of 3 (#66) sampled residents reviewed for pain management. This placed residents at risk for unmanaged pain.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to thoroughly assess a resident with trauma for 1 of 2 sampled residents (#61) reviewed for behaviors. This placed residents at risk for re-traumatization.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide dental services for 1 of 3 sampled residents (#5) reviewed for dental. This placed residents at risk for weight loss and unmet dental needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure consents were obtained prior to administering an influenza vaccine to 2 of 5 sampled residents (#s 9 and 62) reviewed for vaccinations. This put residents at risk for not being informed of their rights.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure consents were obtained prior to administering a COVID-19 vaccine to 2 of 5 sampled residents (#s 9 and 62) reviewed for vaccinations. This put residents at risk for not being informed of their rights.

Inspectors wroteBased on interview and record review, it was determined the facility failed to staff a registered nurse (RN) for eight consecutive hours per day seven days per week for 21 out of 78 days reviewed for staffing. This placed residents at risk for unmet assessment needs.

Inspectors wroteBased on interview and record review, it was determined the facility failed to make prompt efforts in resolving a resident's grievance for 1 of 7 sampled residents (#23) reviewed for misappropriation. This placed residents at risk for unresolved grievances.

Inspectors wroteBased on interview and record review, it was determined the facility failed to report an incident of potential neglect for 1 of 9 sampled residents (#28) reviewed for elopement. This placed residents at risk for accidents.

Inspectors wroteBased on interview and record review, it was determined the facility failed to ensure a resident's environment remained free from accident hazards for 1 of 9 sampled residents (#28) reviewed for accidents. This placed residents at risk for accidents.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident was treated with dignity for 1 of 3 (#1) residents reviewed for dignity. This put residents at risk for a decreased quality of life. Records reveal: Resident 1 was admitted to the facility in 4/2025 with diagnoses including hip fracture and Fibromyalgia (chronic pain illness). An 4/22/25 admission MDS revealed she/he was cognitively intact and required moderate assistance from staff for transfers. On 10/24/25 at 11:54 AM, Resident 1 stated while speaking with Staff 5 (Speech Therapist) about self-transferring for toileting needs she/he was told to only get up with staff assistance and to urinate in the bed when staff were not available. She/He stated the comment was mortifying and caused her/him to feel degraded. On 10/27/25 at 11:45 AM, Staff 5 stated she did not remember Resident 1. [...]

Inspectors wroteBased on record review and interview it was determined the facility failed to ensure a resident's medications were given according to provider orders and a wound was properly monitored for 1 of 5 residents (#1) reviewed for medications and wound care. This put residents at risk for adverse medication reactions, infections, and death. Records reveal: The facility Wound Treatment Management policy revised 4/1/25 stated the effectiveness of wound care treatments would be monitored with ongoing assessments of the wound until healed. Resident 1 was admitted to the facility in 4/2025 with diagnoses including hip fracture and Fibromyalgia (chronic pain illness). An 4/22/25 admission MDS revealed she/he was cognitively intact, had pain daily, and had a surgical wound. [...]

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to assure there was sufficient nursing staff available to provide nursing and related services to meet the residents' needs safely and timely for 2 of 2 units reviewed for staffing. This placed residents at risk for missed or delayed care, missed or late meals, an increase safety risk for falls and aspiration, and a decline in health status.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to follow physician's orders related to oxygen administration for 1 of 3 sampled residents (#8) reviewed for respiratory care. This placed residents at risk for respiratory complications.

Inspectors wroteBased on interview and record review it was determined the facility failed to protect residents' right to be free from physical abuse by staff for 1 of 1 sampled resident (#82) reviewed for abuse. Resident 82 was mistreated by staff resulting in physical injury.

Inspectors wrote4. On 9/11/24 at 12:39 PM Staff 79 (LPN) stated there was an incident in 5/2024 involving Staff 77 (Former NA) who smoked methamphetamine (controlled stimulant medication) in the staff bathroom while working on shift, and continued to finish the shift after it was reported to management. She stated staff reported Staff 77 hallucinated on the unit, and there was a strong chemical smell in the staff bathroom. Review of Staff 77's 5/28/24 time punch record indicated she clocked in at 1:57 PM, clocked out at 5:53 PM, and did not clock in again until 6/1/24. On 9/12/24 at 6:14 PM Staff 78 (CNA) stated she was working evening shift (2:00 PM until 10:00 PM) on 5/28/24 with Staff 77 as her skilled unit hall partner. [...]

Inspectors wrote3. A 9/8/24 at 9:37 AM interview with Staff 7 (CNA) revealed she reported the ICF unit refrigerator was in unsanitary condition, and the sandwiches had no label for expiration date. Staff 7 reported she did not use the food in the unit refrigerator as she was concerned it was expired and unsafe for consumption. On 9/8/24 at 9:46 AM observation of the unit refrigerator revealed eight sandwiches without date labels and one food-soiled and broken refrigerator shelf (previously taped together). An unsanitary sticky wooden corner shelf was food-soiled and holding peanut butter, syrup, bananas and crackers. The floor surrounding the refrigerator was soiled and sticky. An expired orange and a soiled washcloth sat on top of the refrigerator. [...]

Inspectors wroteBased on interview and record review it was determined the facility failed to provide the risk and benefits for the use of an antipsychotic medication to a resident/responsible party prior to administration for 4 of 5 sampled residents (#s 55, 87, 164, and 165) reviewed for medications. This placed resident responsible parties at risk for lack of informed consent.

Inspectors wroteBased on interview and record review it was determined the facility failed to provide a response to Resident Council grievances for 1 of 1 resident group reviewed for grievances. This placed residents at risk for a decline in psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure residents' rooms were clean, in good repair and free of clutter for 5 of 5 sampled residents (#s 2, 62, 71, 98, and 162) reviewed for ADLs and environment. This placed residents at risk for lack of a homelike environment.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide a written grievance, resolution, or communication with a resident or representative for 3 of 17 sampled residents (#s 63, 98 and 162) and 1 of 2 units reviewed for dignity, food, staffing and accidents. This placed residents at risk for unresolved concerns.

Inspectors wroteBased on interview and record review it was determined the facility failed to provide a qualified professional to direct the activities program for 1 of 1 facility reviewed for activities. This placed residents at risk for unmet physical, mental and psychosocial needs.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide sufficient staffing to meet the needs of residents for 1 of 14 sampled residents (#24) and 2 of 2 units (Skilled unit and long-term unit) reviewed for staffing. This placed residents at risk for unmet needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to staff a registered nurse for 8 consecutive hours per day 7 days per week for 7 out of 93 days reviewed for staffing. This placed residents at risk for unmet assessment needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to post accurate and complete staffing information for 6 of 6 days reviewed for staffing. This placed residents at risk for incomplete and inaccurate staffing information.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents understood the meaning of an arbitration agreement (disputes resolved with a neutral party and not in court) for 3 of 3 sampled residents (#s 19, 163 and 262) reviewed for arbitration. This placed residents at risk for being uninformed of their legal rights.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure appropriate use of PPE and failed to follow infection control standards for 2 of 2 units and 1 of 1 laundry room reviewed for infection control. The facility additionally failed to ensure the community use CBG glucometer was properly cleaned and sanitized between resident uses for 1 of 1 sampled resident (#20) reviewed during CBG checks. This placed residents at risk for the spread of infection and placed all residents who required CBG checks at risk for bloodborne illness.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a safe system for a resident's self-administration of medication for 1 of 6 sampled residents (#44) reviewed for accidents. This placed residents at risk for adverse medication reactions.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident was assisted with formulating an advance directive for 1 of 3 sampled residents (#164) reviewed for advance directives. This placed residents at risk for lack of end-of-life choices being honored.

Inspectors wroteBased on interview and record review it was determined the facility failed to notify the physician or resident representative regarding refusals and changes in condition for 3 of 7 sampled residents (#s 55, 86 and 165) reviewed for medications, change of condition and catheter care. This placed residents at risk for delay in treatment.

Inspectors wroteBased on interview and record review it was determined the facility failed to report timely to the State Survey Agency for an allegation of elopement for 1 of 7 sampled residents (#93) reviewed for accidents. This placed residents at risk for elopement.

Inspectors wroteBased on interview and record review it was determined the facility failed to thoroughly investigate an injury for 1 of 9 sampled residents (#82) reviewed for abuse and accidents. This placed residents at risk for neglect of care.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure the Office of the State Long-Term Care Ombudsman was notified of resident hospitalizations for 2 of 2 sampled residents (#s 95 and 262) reviewed for hospitalizations. This placed residents at risk for lack of access to an advocate to inform them of their options and rights.

Inspectors wroteBased on interview and record review it was determined the facility failed to provide a bed hold policy for 2 of 2 sampled residents (#s 95 and 262) reviewed for hospitalization. This placed residents at risk for lack of knowledge related to their right to return to the facility.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to revise care plans related to interventions for personal equipment for 3 of 12 sampled residents (#s 2, 86 and 164) reviewed for ADLs, medications and respiratory care. This placed residents at risk for unmet needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure staff did not falsify documentation for 1 of 1 staff (#20). This placed residents at risk for adverse medication reactions.

Inspectors wroteBased on observation, interview and record it was determined the facility failed to provide care and services to maintain good grooming for 3 of 4 sampled residents (# 62, 86 and 98) reviewed for ADLs. This placed residents at risk for unmet needs.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide meaningful activities for dependent residents for 2 of 2 sampled residents (#s 14 and 54) reviewed for activities. This place residents at risk for lack of social interaction and isolation.

Inspectors wroteBased on interview and record review it was determined the facility failed to follow through on services to maintain hearing for 1 of 2 sampled residents (#86) reviewed for communication and sensory. This placed residents at risk for lack of adequate hearing.

Inspectors wroteBased on observation interview and record review it was determined the facility failed to ensure a pressure ulcer was assessed and provided treatment timely for 1 of 3 sampled residents (#98) reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide adequate catheter and incontinent care for 3 of 15 sampled residents (#s 24, 86 and 164) reviewed for ADLs, accidents and catheter care. This placed residents at risk for unmet incontinent care needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to provide respiratory care and services in accordance with physician orders and standards of practice for 3 of 5 sampled residents (#s 2, 55 and 87) reviewed for respiratory services. This placed residents at risk for unmet respiratory needs.

Inspectors wroteBased on interview and record review the facility failed to provide pain medications as ordered for 1 of 4 sampled residents (#262) reviewed for pain management. This placed residents at risk for uncontrolled pain.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents received proper dialysis care and services after dialysis for 1 of 3 sampled residents (#58) reviewed for personal property. This placed residents at risk for dialysis complications.

Inspectors wroteBased on interview and record review it was determined the facility failed to obtain specialized physician appointments for 1 of 1 sampled resident (#62) reviewed for ADLs. This placed resident at risk for lack of specialized care.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to obtain a resident's medication for 1 of 6 sampled residents (#164) reviewed for medications. This placed residents at risk for increased pain.

Inspectors wroteBased on interview and record review it was determined the facility failed to monitor residents on psychotropic medications for 2 of 5 sampled residents (#s 87 and 164) reviewed for psychotropic medications. This placed residents at risk for receiving unnecessary psychotropic medications.

Inspectors wroteBased on interview and record review it was determined the facility failed to prevent a significant medication error for 1 of 6 sampled resident's (#41) reviewed for unnecessary medications. This placed residents at risk for adverse medication reactions.

Inspectors wroteBased on interview and record review it was determined the facility failed to use the services of a Registered Nurse for at least eight consecutive hours a day, seven days a week for 3 of 39 days reviewed for RN staffing coverage. This placed residents at risk for lack of RN oversight including resident assessment, care and services.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure the Direct Care Staff Daily reports were accurate for 20 of 39 days reviewed for staffing. This placed residents at risk for inaccurate staffing information.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were provided bathing for 3 of 6 sampled residents (#s 1, 4 and 9) reviewed for ADLs. This placed residents at risk for a decline in hygiene.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident's medication was administered as prescribed for 1 of 3 sampled residents (#4) reviewed for incontinent care and failed to ensure call lights were answered timely to address bowel care needs for 1 of 10 sampled (#2) residents reviewed for call lights. This placed residents at risk for ineffective medication regimen and unmet needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure resident oxygen flow rates were documented for 2 of 4 sampled residents (#s 1 and 10) reviewed for respiratory therapy. This placed residents at risk for lack of documented oxygen needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician orders regarding a narcotic pain medication resulting in an excessive dose for 1 of 3 sampled residents (#12) reviewed for medications. This placed residents at risk for adverse medication side effects.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure lab results were reviewed by a physician in a timely manner for 1 of 3 sampled residents (#8) reviewed for UTI. This placed residents at risk for delayed treatment.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a call light was accessible for 1 of 3 sampled residents (#3) reviewed for call lights. This placed residents at risk for incontinence.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure proper flavor and food palatability was maintained for 1 of 1 facility kitchen reviewed for food service and 5 of 8 sampled residents (#s 19, 40, 43, 46 and 399) reviewed for food. This placed residents at risk for food that was not palatable or appetizing.

Inspectors wroteBased on observation, interview and record review it was determine the facility failed to ensure processes were followed to provide a clean and sanitary kitchen for 1 of 1 kitchen. This placed residents at risk for food borne illnesses. 1. On 5/17/23 at 9:12 AM the Dish Machine Log for 5/2023 was reviewed and no temperatures or chemicals were yet recorded for 5/17/23. Staff 11 (Dietary Manager) was observed using the dish machine to wash dishes and was asked to test the chemical level of the low temperature dish machine. Results revealed the sanitizer level was at ten instead of 100 parts per million as required. Staff 4 (Dietary Manager) was called. [...]

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide a homelike dining experience for 1 of 3 dining rooms (main) reviewed for dining, and failed to speak to residents respectfully for 1 of 1 sampled resident (#15) reviewed for dignity. This placed residents at risk for an unhomelike environment and mental anguish.

Inspectors wroteBased on interview and record review it was determined the facility failed to update and involve the resisidents in the care plan for 4 of 16 sampled residents (#s 9, 43, 73, and 102) reviewed for accidents, positioning and care planning. This placed residents at risk for unmet needs.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide sufficient staffing to meet the needs of residents for 3 of 16 sampled residents (#s 15, 19 and 46) and 2 of 4 halls reviewed for staffing. This placed residents at risk for unmet needs.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure the Direct Care Staff Daily Reports (DCSDR) were accurate and posted in a prominent location for 5 of 5 days reviewed for staffing. This placed residents and visitors at risk for lack of staffing information.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to use PPE appropriately for 1 of 4 halls (subacute B) and 1 of 3 dining rooms (main dining room) reviewed for infection control. This placed residents at risk for exposure to infections.

Inspectors wroteBased on interview and record review it was determined the facility failed to notify a resident of a medication change for 1 of 4 sampled residents (#17) reviewed for care planning. This placed residents at risk for lack of notification and participating in treatment decisions.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide call lights residents could activate and ensure residents had comfortable mattresses for 2 of 9 sampled residents (#s 5 and 451) reviewed for accommodation of needs and environment. This placed residents at risk for unmet needs. Findings Include: 1. Resident 451 was admitted to the facility in 5/2023 with diagnoses including central cord syndrome (an incomplete spinal cord injury) and heart failure. A Care Plan revised 5/15/23 revealed Resident 451 required extensive assistence to fully dependent for all care and staff were to ensure Resident 451's call light was within reach. On 5/16/23 at 1:58 PM Resident 451 was observed in bed, her/his call light was placed on her/his stomach approximately two inches from her/his hand. [...]

Inspectors wroteBased on interview and record review it was determined the facility failed to offer and periodically review advance directives for 2 of 4 sampled residents (#s 5 and 251) reviewed for advance directives. This placed residents at risk for unmet needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were informed in writing of advanced beneficiary information for 1 of 3 sampled residents (#454) reviewed for required beneficiary notification. This placed residents at risk for not being informed of financial liabilities.

Inspectors wroteBased on interview and record review it was determined the facility failed to comprehensively assess 2 of 5 sampled residents (#s 19 and 46) reviewed for unnecessary medications. This placed residents at risk for unassessed needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to develop a baseline care plan to meet the immediate care needs for 1 of 5 sampled residents (#251) reviewed for medications. This placed residents at risk for unmet care needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to develop a resident centered activity care plan for 1 of 1 sampled resident (#12) reviewed for activities. This placed residents at risk for lack meaningful activities.

Inspectors wroteBased on interview and record review it was determined the facility failed to provide ADL care for 2 of 9 sampled residents (#s 102 and 400) reviewed for ADL care. This placed residents at risk for unmet care needs.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to develop a meaningful activity program for 1 of 1 sampled resident (#12) reviewed for activities. This placed residents at risk for decreased quality of life.

Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician orders and care plans for 1 of 4 sampled residents (# 73) reviewed for care planning. This placed residents at risk for unmet needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were provided routine eye appointments for 1 of 2 sampled residents (#42) reviewed for communication and sensory needs. This placed residents at risk for worsening vision.

Inspectors wroteBased on interview and record review it was determined the facility failed to provide ROM for 1 of 5 sampled residents (#60) reviewed for mobility. This placed residents at risk for decreased ROM.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to investigate falls and supervise meals per care plan for 2 of 11 sampled residents (#s 84 and 99) reviewed for accidents and nutrition. This placed residents at risk for injury and choking.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure risk and benefits for the use of bed canes were discussed with residents' responsible parties for 1 of 7 sampled residents (#12) reviewed for accidents. This placed residents at risk for injury.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure food preferences were honored for 2 of 8 sampled residents (#s 46 and 400) reviewed for food. This placed residents at risk for lack of food choices.