Green Valley Healthcare and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, patternF580Sep 4, 2024

  Based on observation, interviews and record reviews, the facility failed to immediately consult with the resident's physician and notify the resident representative when there was a significant change in the resident's condition or need to alter treatment significantly for one (Resident #1) of eight residents reviewed for notify of changes. -The facility failed to notify Resident #1's physician and responsible party when the resident showed signs of an altered mental status for at least 22 hours and was later diagnosed with severe sepsis at the local hospital. On 09/03/24, an Immediate Jeopardy was identified. The IJ template was provided to the facility on [DATE] at 5:45 PM. […]

• Immediate jeopardy, patternF684Sep 4, 2024

  Based on interview and record review, the facility failed to identify and provide needed care or services that resulted in an actual or potential decline in one or more resident's physical, mental, and psychosocial well-being for one (Resident #1) of four residents reviewed for quality of care. The facility failed to identify, monitor, assess, evaluate, and document Resident #1's changes in the bowel regimen. The facility failed to provide Resident #1 as needed (PRN) medication for constipation. The facility failed to evaluate Resident #1's bowel sounds as indicated and report significant abnormalities to the provider per the care plan intervention initiated, 07/12/2024. The facility failed to notify the provider of Resident #1's last known bowel movement on 08/08/24. […]

• Immediate jeopardy, patternF693Jan 13, 2023

  Based on observation, interview and record review, the facility failed to ensure that a resident who was fed by enteral feeding received the appropriate treatment and services to prevent complications for two (Residents #1 and #2) of four residents reviewed for tube feedings. LVN A failed to correctly unclog Resident #1's g-tube when it appeared clogged. LVN A used a de-clogging tool (a flexible threaded device that is serrated approximately 2 inches at the end) incorrectly on Resident #1's j/g-tube that could have resulted in perforation (hole) of the j/g-tube and/or abdominal/ intestinal wall. LVN A used the tool without training or a physician's order. Following the use of the tool, LVN A failed to complete an assessment on Resident #1 or notify the physician or nursing administration. […]

• Immediate jeopardy, isolatedF689Sep 5, 2025

  Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 9 residents reviewed for accidents. The facility failed to ensure Resident #1, who required a mechanical lift transfer, was free of an accident hazard on 08/12/25 when she was transferred by CNA B without a mechanical lift and sustained a significant injury. Resident #1 was transported to the local hospital and diagnosed with a right humerus fracture. An Immediate Jeopardy (IJ) was identified on 09/04/25 at 04:00 PM and an IJ Template was provided to the DON at 04:41PM. […]

• Immediate jeopardy, isolatedF773Sep 4, 2024

  Based on interview and record review, the facility failed to promptly notify the physician of laboratory results in accordance with facility policy and procedures for notification for one (Resident #1) of four residents reviewed for laboratory services. The facility failed to notify the provider about Resident #1's STAT lab results received on 08/26/24 at 3:21 PM. On 08/27/24, Resident #1 was admitted to the hospital for altered mental status (AMS). Resident #1 was admitted , diagnosed , and treated for severe sepsis, chronic constipation, and fecal impaction. On 09/03/24, an Immediate Jeopardy was identified. The IJ template was provided to the facility on [DATE] at 5:45 PM. […]