Green Valley Rehabilitation Health Center

In the surveyor’s words

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

• Actual harm, isolatedF697Feb 2, 2026

  Based 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. Findings include: Resident 66 was admitted to the facility in 2022 with diagnoses including severe osteoarthritis (a disease which destroys the cartilage protecting bones and cause pain, stiffness and reduced mobility) and chronic pain. The resident's 11/2025 BIMS revealed a score of 14 (cognitively intact).A review of the resident's pain monitoring (1-10 scale of pain level with 10 indicating the worst pain possible) in the TAR for the previous 12 months revealed the following:2/2025: Pain levels of 6-10 reported on 26 of 28 days.3/2025: Pain levels of 6-9 reported… […]

• Actual harm, isolatedF600Sep 13, 2024

  Based 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. Findings include: Resident 82 admitted to the facility in 1/2024 with diagnoses including stroke. A 1/19/24 Admission MDS indicated Resident 82 was moderately impaired with decision making due to aphasia (unable to formulate language). Resident 82 was able to answer yes or no questions and used thumbs up for yes, and thumbs down for no. A 7/24/24 FRI indicated Staff 74 (CNA) showered Resident 82 and bumped the resident's foot on the wall while exiting the shower room. […]

• Actual harm, isolatedF689Sep 13, 2024

  Based on observation, interview and record review it was determined the facility failed to ensure supervision for dysphagia, execute fall interventions, and execute elopement interventions for 3 of 8 sampled resident (#s 55, 93, and 164) reviewed for accidents. The facility failed to ensure a safe environment for residents on 1 of 1 unit (skilled) identified during random interviews. Resident 164 fell from an elevated bed resulting in fractured legs. Findings include: 1. Resident 55 admitted to the facility in 7/2024 with diagnoses including dysphagia (difficulty in swallowing) and dementia. Review of Resident 55's care plan revised on 7/29/24 revealed the resident had an ADL self-care performance deficit due to decreased mobility and generalized weakness. […]

• No harm, potential for more than minimal, widespreadF727Jan 15, 2026

  Based 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. Findings include:A review of the facility's Direct Care Staff Daily Reports for 8/2025, 9/2025, 10/2025, and 11/2025 indicated there were 21 days without RN coverage for eight consecutive hours. The dates were as follows: -8/3/25-8/8/25-8/10/25-8/11/25-8/16/25-8/17/25-8/18/25-8/19/25-8/24/25-8/25/25-8/29/25-8/31/25-9/1/25-9/7/25-9/15/25-9/29/25-10/20/25-10/25/25-10/27/25-10/28/25-11/3/25 On 1/15/26 at 9:23 AM, Staff 27 (Staffer) and Staff 23 (LPN) stated they were told to start reporting the RN manager on the Direct Care Staff… […]

• No harm, potential for more than minimal, widespreadF725Feb 5, 2025

  Based 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. Findings include: Intermittent call light and staffing observations conducted on 1/29/25 from 8:15 AM to 5:00 PM revealed call light wait times up to 27 minutes. Intermittent call light and staffing observations conducted on 1/30/25 from 5:00 AM to 2:00 PM revealed call light wait times up to 40 minutes. […]