Oasis Nursing & Rehab of Green Valley

Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure 1 of 50 residents (Resident 205) with a Full Code status was provided basic life support (BLS) after being found unresponsive. Facility staff did not initiate cardiopulmonary resuscitation (CPR) as required. This deficient practice deprived the R205 of required life saving measures, specifically CPR, which may have potentially increased the resident's chance of recovery and survival.

Inspectors wroteBased on interview, record review and document review, the facility failed to use the correct technique when applying a mechanical lift sling for 1 of 50 residents (Resident 102) who requires care in pairs. This deficient practice constituted past non-compliance, existing from 05/22/2026 to 05/26/2026. The facility returned to compliance on 05/26/2026 prior to the start of the current survey, after implementing corrective actions including staff termination, disciplinary actions, removal of incorrect sling sizes, and 100% staff competency retraining. This deficient practice had the potential to increase serious body harm and risk of injury to the resident. Findngs include:Resident 102, (R102) was readmitted on [DATE] with diagnoses including fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing. [...]

Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure an accurate process was implemented for receiving, documenting, and safeguarding resident personal funds for 1 of 50 sampled residents (Resident 56). The deficient practice had the potential to result in inaccurate accounting of resident funds, financial loss, and the inability to verify funds entrusted to the facility.

Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure an allegation of abuse was reported to the State Agency within the required timeframe for 1 of 3 sampled residents (Resident 1). The deficient practice had the potential to delay reporting of alleged abuse and place the resident at risk for continued abuse.

Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure each resident or resident's guardian provided signed evidence of informed consent prior to the administration of a psychoactive medication, for 2 of 51 sampled residents (Residents 169 and 191). The deficient practice had the potential to put residents at risk of using psychoactive medication without understanding the risks and benefits of the medication.

Inspectors wroteBased on interview, record review and document review, the facility failed to ensure a significant change in status assessment was completed for a hospice resident for 1 of 3 closed record sampled residents (Resident 200). The deficient practice had the potential for a hospice plan of care to not be generated.

Inspectors wroteBased on interview, record review and document review, the facility failed to develop a hospice care plan for 1 of 3 closed record sampled residents (Resident 200). The deficient practice had the potential to place the resident at risk for receiving inadequate hospice care.

Inspectors wroteBased on interview, record review and document review, the facility failed to ensure showers were provided as scheduled for a resident who required assistance with bathing for 1 of 51 sampled residents (Resident 202). The deficient practice had the potential to result in poor hygiene, increased risk for skin breakdown and negatively affect resident's dignity and psychosocial well-being.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure 1) a risk assessment for pressure ulcer development was completed and 2) a new skin impairment was identified and addressed for 1 of 51 sampled residents (Resident 12). The deficient practice had the potential to place the resident at risk for new or worsening pressure ulcers.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure adequate supervision and a safe environment to prevent a resident with cognitive impairment from accessing and ingesting non-food items for 1 of 51 sampled residents (Resident 17). The deficient practice had the potential to result in choking, gastrointestinal upset or other adverse health outcomes.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the temperature, dating, and labeling of food in residents' personal refrigerators were properly monitored for 3 of 51 sampled residents (Resident 1, 2 and 136) and one unsampled resident (Resident 125). The deficient practice had the potential to lead to foodborne illness.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure cabinet and refrigerator locks were in working condition in the specialty care unit. The deficient practice had the potential to pose a safety risk to residents with dementia who resided in the unit.

Inspectors wroteBased on interview and record review, the facility failed to ensure the water management plan was enforced.

Inspectors wroteBased on interview, record review and document review, the facility failed to ensure a resident was kept safe from abuse for 1 of 5 sampled residents (Resident 4). The deficient practice had the potential for the resident to experience emotional distress and physical harm.

Inspectors wroteBased on interviews, record review, and document review, the facility failed to ensure the wrong medication was not administered to a resident for 1 of 5 sampled residents (Resident 3). The deficient practice placed the resident at risk for kidney transplant complications.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure the residents' behavior was monitored and documented for residents receiving psychoactive medications for 6 of 25 sampled residents (Residents 44, 102, 5, 161, 4, and 99). This deficient practice could have increased the risk of adverse side effects, ineffective medication management, missed signs of worsening conditions, and compromised resident safety.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure residents have a right to make choices about aspects of their life in the facility which are significant to the resident for 1 of 35 sampled residents and 3 unsampled residents (Residents #126, 14, 118 and 41). The failure to accommodate the residents' preferences and choices had the potential risk to cause psychosocial distress to the residents.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure assessments were accurate, specifically for vision, hearing, and functional status impacting activities of daily living for 1 of 35 sampled residents (Resident 96). The deficient practice potentially deprived the resident of a person-centered plan of care ensuring the resident received adequate level of assistance with care needs.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to complete a Preadmission Screening and Resident Review (PASRR) Level 2 evaluation for displayed behavioral activity or diagnosis for 3 of 35 sampled residents (Resident 99, 135, and 72). The deficient practice had the potential to place residents at risk of not being evaluated for appropriate determination of necessary behavioral health services.

Inspectors wroteBased on observation, interview, record and document review, the facility failed to ensure comprehensive care plans were created for the management of sleep apnea devices for 2 of 35 sampled residents (Resident 64 and 390). The deficient practice had a potential for staff not to provide person centered care for a resident.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure a deep tissue injury in a high risk resident was treated, and appropriate interventions were implemented and the weekly skin assessment was completed as scheduled for 1 of 25 sampled residents (R52). This deficient practice had the potential to lead to worsening of the pressure injury, increased risk of infection, delayed healing, further tissue damage, and a higher likelihood of complications such as sepsis or hospitalization.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure a resident who was clinically blind was provided assistance with food and fluids for 1 of 35 sampled residents (Resident 96). The deficient practice potentially contributed to the resident's significant weight loss and hospitalization. The resident was sent to the hospital on [DATE] due to poor oral intake and weakness and on 09/27/2024 due to dehydration.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure the physician orders for bolus tube feeding, water flushes, and gastrostomy tube care were obtained for 1 of 35 sampled residents (Resident 52). This deficient practice had the potential to result in improper nutrition, dehydration, increased risk of infection, gastrointestinal complications, delayed healing, and potential hospital readmission.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure care orders were obtained, transcribed and carried out for a peripherally inserted central catheter (PICC) line for 1 of 35 sampled residents (Resident 96). The deficient practice placed the resident at risk for infection.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure physician orders were obtained for the use of Oxygen (O2) and monitoring of O2 saturation for 1 of 35 sampled residents (Resident 155), and for the use of a CPAP machine (a device used to treat sleep-related breathing disorders, such as sleep apnea, by keeping the airways open during sleep) for 1 of 35 sampled residents (Resident 64). This deficient practice could have led to potential adverse health outcomes, including inadequate oxygenation and compromised respiratory management. Resident 155 (R155) R155 was admitted on [DATE], with diagnoses including pneumonia, respiratory tuberculosis, acute and chronic respiratory and dependence of supplemental O2. The Observation Report dated 08/28/2024, documented R155 had O2 flowing via nasal cannula and had experienced shortness of breath. [...]

Inspectors wroteBased on interview, record review and document review, the facility failed to ensure annual performance appraisals were completed for 4 out of 10 sampled employees (Employees 6, 7, 9 and 10). The deficient practice placed the residents at risk for receiving substandard quality of care from certified nursing assistants (CNAs).

Inspectors wroteBased on observation, document review and interview, the facility failed to ensure stored foods were labeled and dated, food items were discarded prior to the expiration date, nourishment refrigerators were keeping the proper temperature, and safe food handling was occurring during meal service. This deficient practice posed a potential risk to safety and health standards which could lead to contamination, inadequate storage, and place residents at risk of foodborne illness.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a dining room was not overcrowded with residents and staff members for 1 of 4 dining rooms. The deficiency practice placed the residents and staff in uncomfortable environment and at risk for accidents.

Inspectors wroteBased on observation, interview, record review, and document review the facility failed to ensure an assessment was completed for the self-administration of medication for 2 of 35 sampled residents (R417 and R69). The deficient practice had the potential to have adverse medication side effects detrimental to the safety of the residents of the facility.

Inspectors wroteBased on observation, interview, record review and document review the facility failed to ensure a comprehensive care plan was completed on splint application for the management of contractures for one of 35 sampled residents (Resident #81). The failure of the development of a resident centered care plan inhibited consistent care of the resident throughout the different care disciplines.

Inspectors wroteResident 134 (R134) R134 was admitted on [DATE], with medical diagnoses to include a history of falling and diabetes mellitus type II. On 06/14/2023 at 09:29 AM, R134 complained their knee was not working correctly and requested to be seen by a physician. On 06/14/2023 at 10:04 AM, Licensed Practical Nurse 1 (LPN1) was informed R134 requested to be seen by a physician for their knee. LPN1 advised this was the first time hearing of any knee/leg concern for R134 and would follow up on the matter. On 6/16/2023 at 11:16 AM, Licensed Practical Nurse 2 (LPN2) verbalized were not aware of any recent complaints regarding R134 knee/leg. LPN2 reviewed electronic medical records and confirmed R134 had a right knee x-ray completed on 05/31/2023, with no findings, and there was documentation that a physician was recently paged for R134's knee but contact was pending. [...]

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure application and documentation of a splint application for two of 35 sampled residents (Resident #81 and #39). The failure of application of splints could increase resident's contractures leading to decrease mobility and increase of pain during movements.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to follow physician orders for peripherally inserted central catheter (PICC) dressing changes and flushes, for 1 of 35 sampled residents (Resident #217) and failed to obtain orders for PICC line care that included flushing, dressing changes and monitoring for signs of infection or complications, for 1 of 35 sampled residents (Resident #40). This deficient practice placed the residents at risk of complications including but not limited to catheter dislodgement, insertion site infection, phlebitis, and blood infection.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure a physician order for Lidocaine patch pain medication was clarified, and the manufacturer's instructions for administration were followed as directed for 1 of 35 sampled residents (Resident 167). This deficient practice could potentially lead to inadequate pain management, compromised therapeutic outcomes, increased discomfort, adverse reactions, undermine the overall effectiveness of the medication, hinder the resident's recovery process, and affect physical and psychosocial health.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failure to ensure hemodialysis access catheter was assessed for patency for 1 of 35 sampled residents (R135). The deficient practice placed the resident at risk of complications of the AV fistula such as stenosis (abnormal narrowing of a blood vessel) that could cause problems with the quality of the hemodialysis treatment, persistent bleeding following punction and pain. Resident #135 (R135) R135 was admitted on [DATE], with diagnoses including end stage renal disease. On 06/15/2023 at 8:13 AM, it was observed R135 had a failed arteriovenous (AV) fistula ( a connection created between an artery and a vein used as access to perform hemodialysis) at the left upper arm. [...]

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure the Nicotine patch was timely delivered and available as ordered following the resident's admission for 1 of 35 sampled residents (Resident 167). This deficient practice could potentially lead to negative health outcomes, hinder smoking cessation efforts, compromise overall well-being and quality of life, increase nicotine cravings, exacerbate withdrawal symptoms, impede the resident's progress towards a smoke-free lifestyle and adversely affect their physical health.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure (1) an open med cart was not left unattended for 1 of 6 med carts, (2) medication was not left at bedside (R69 and R127), and (3) monitoring of temperature for medication refrigerator and room was completed, and medical supplies for residents were properly disposed.