Green Valley Care Center

In the surveyor’s words

From the most serious findings on record at Green Valley Care Center, in the surveyor’s own words.

• Actual harm, isolatedF760Aug 21, 2023

  Based on record review and interview, the facility failed to ensure residents were free of significant medication errors which resulted in Resident D being hospitalized for hypoglycemia after receiving an anti-diabetic medication without a diagnosis of diabetes for 1 of 3 resident's whose medication regimens were reviewed. Findings include: The record for Resident D was reviewed on 8/21/23 at 10:00 a.m. The resident did not have any diagnoses related to or including diabetes. The record lacked documentation of any blood sugar monitoring orders or blood glucose levels in the last 12 months prior to 5/11/23. The physician's order, dated 5/11/23 at 5:42 p.m., indicated RN 4 input an order for the resident to have glipizide (anti-diabetic medication) 5 mg (milligrams) daily for diabetes. […]

• No harm, potential for more than minimal, widespreadF812Jan 9, 2026

  Based on observation, record review and interview, the facility failed to ensure kitchen equipment, floors, ceiling vents were clean and in good condition and expired food was disposed of during 3 of 3 kitchen observations. This deficient practice affected 122 of 122 residents who received meals from the kitchen.Findings include:1.During the initial tour of the kitchen with [NAME] 1, on 1/5/26 at 10:00 a.m., the following concerns were observed:There were yellow/brown food particles in the fryer oil with a heavy accumulation of brown food particles on the inside shelf. Cook,1 indicated the fryer was last used the night before.Both stove ovens had cream colored food particles on the inside bottom. […]

• No harm, potential for more than minimal, patternF761Jan 9, 2026

  Based on observation, record review, and interview, the facility failed to ensure proper labeling on 6 of 24 residents receiving insulin during the review of medication storage. (Residents 28, 9, 2, 4, 115 and 23) Findings include: 1. During an observation of the 300 Hall medication cart, on 1/7/26 at 8:41 a.m., the following concerns were identified for Resident 28: a. Resident 28's Lispro (rapid acting insulin) had no pharmacy label with the KwikPen in the medication cart or in the refrigerator. b. Resident 28's Rezvoglar (long-acting insulin) had no pharmacy label with the KwikPen in the medication cart or in the refrigerator. The record for Resident 28 was reviewed on 1/8/26 at 10:08 a.m. […]

• No harm, potential for more than minimal, patternF880Jan 9, 2026

  Based on observation, record review, and interview, the facility failed to ensure proper Personal Protective Equipment (PPE) was applied and the catheter bag drainage valve was kept off of the floor to prevent infection during 2 of 3 observations of care. (Residents 7 and 82) and to ensure glucometers were cleaned per guidelines for infections control when obtaining blood sugar readings for 2 of 2 residents observed. (Residents 32 and 2)Findings include:1. During an observation, on 1/6/26 at 9:38 a.m., Certified Nurse Aide (CNA) 5 entered Resident 7's room to empty the catheter bag, which was full of light-yellow urine and bulging. The urine was visible in the line leading up to the resident. She emptied the bag four to five times before it was empty. […]

• No harm, potential for more than minimal, patternF628Jun 4, 2025

  Based on interview and record review, the facility failed to ensure bed hold polices were provided to residents/resident representatives ( Resident C, Resident D, Resident F and Resident B) discharged to the hospital for 4 of 4 residents reviewed for transfers/discharges. Findings include: 1. The clinical record for Resident C was reviewed on 6/4/25 at 11:31 a.m. The resident's diagnoses included, but were not limited to, paraplegia and neuromuscular dysfunction of the bladder. The progress note, dated 5/26/25 at 1:00 a.m., indicated the resident was very lethargic and the catheter had blood tinged urine in the catheter bag. […]