Deficiencies (last 3 years)
Deficiencies (over 3 years)
11.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
59% worse than Nevada average
Nevada average: 7.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Sep 26, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding failure to obtain informed consent for psychoactive medications, incomplete significant change assessments for hospice residents, inadequate care and assistance with activities of daily living, pressure ulcer care deficiencies, unsafe environment and supervision for residents with dementia, and improper food storage and safety in residents' personal refrigerators.
Complaint Details
The investigation was complaint-driven, focusing on issues such as informed consent for psychoactive medications, care planning for hospice residents, assistance with activities of daily living, pressure ulcer prevention, resident safety and supervision, and food safety in personal refrigerators.
Findings
The facility failed to obtain informed consent for psychoactive medications for 2 residents, did not complete significant change assessments or hospice care plans for 1 resident, failed to provide scheduled showers for 1 resident, did not perform required pressure ulcer risk assessments or identify new skin impairments for 1 resident, failed to ensure safe environment and supervision for a resident with dementia leading to ingestion of non-food items, and did not properly monitor or maintain residents' personal refrigerators leading to potential foodborne illness risks. Additionally, broken cabinet and refrigerator locks in the specialty care unit posed safety risks.
Deficiencies (7)
Failed to ensure each resident or resident's guardian provided signed evidence of informed consent prior to administration of psychoactive medication for 2 residents.
Failed to complete a significant change in status assessment for a hospice resident, resulting in no hospice care plan developed.
Failed to provide scheduled showers for a resident requiring assistance with bathing.
Failed to complete pressure ulcer risk assessment and identify/address new skin impairment for a resident.
Failed to ensure adequate supervision and safe environment to prevent a resident with dementia from accessing and ingesting non-food items.
Failed to ensure proper temperature, dating, and labeling of food in residents' personal refrigerators, and failed to maintain cleanliness and safety of refrigerators.
Failed to maintain working locks on cabinets and refrigerators in the specialty care unit, posing safety risks to residents with dementia.
Report Facts
Residents sampled: 51
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents in specialty care unit: 17
Sugar packets in cabinet: 200
Artificial sweetener packets in cabinet: 100
Right lateral foot wound size: 15mm length x 14mm width x 3mm depth
Braden assessment date: 02/18/2023
Medication dosage: 25
Medication dosage: 50
Personal refrigerator temperature: 50
Personal refrigerator temperature: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Verified lack of informed consent documentation and explained facility policies on psychotropic medication consent |
| Licensed Practical Nurse | LPN | Explained procedures for obtaining medication consent and reported on cabinet lock issues |
| Minimum Data Set Coordinator | MDS Coordinator | Confirmed lack of significant change assessment and hospice care plan for Resident 200 |
| Certified Nurse Assistant 4 | CNA4 | Explained documentation of showers and ADL assistance |
| Certified Nurse Assistant 5 | CNA5 | Explained shower schedules and documentation process |
| Medical Records Director | Medical Records Director | Confirmed missing documentation and shower sheets |
| Clinical Resource Nurse | Clinical Resource Nurse | Discussed Braden skin assessment tool and wound care |
| Certified Nursing Assistant 1 | CNA1 | Reported on broken cabinet locks and contents |
| Certified Nursing Assistant 2 | CNA2 | Identified resident frequently accessing cabinet contents |
| Certified Nursing Assistant 6 | CNA6 | Discussed responsibilities for cleaning and checking personal refrigerators |
| Certified Nursing Assistant 7 | CNA7 | Discussed responsibilities for cleaning and checking personal refrigerators |
| Certified Nursing Assistant 8 | CNA8 | Discussed responsibilities for cleaning and checking personal refrigerators |
| Certified Nursing Assistant 9 | CNA9 | Discussed responsibilities for cleaning and checking personal refrigerators |
| Housekeeping and Laundry Manager | Housekeeping and Laundry Manager | Explained cleaning schedules and temperature monitoring of personal refrigerators |
| Director of Maintenance | Director of Maintenance | Confirmed broken cabinet and refrigerator locks and explained maintenance request procedures |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 22, 2025
Visit Reason
The inspection was conducted as a complaint investigation triggered by allegations of abuse, medication errors, and infection control concerns at Oasis Nursing & Rehab of Green Valley.
Complaint Details
The complaint investigation substantiated abuse by Resident 5 against Resident 4, confirmed a medication error where Resident 3 was given Cialis instead of Tacrolimus due to pharmacy mislabeling, and identified failure to enforce the Legionella Water Management Program leading to Legionella exposure in residents.
Findings
The facility was found to have substantiated abuse of one resident by another, a medication error involving administration of the wrong drug to a resident, and failure to enforce the water management plan related to Legionella prevention. The facility took corrective actions including separating residents involved in abuse, staff training, and mitigation steps for Legionella contamination.
Deficiencies (3)
Failed to protect a resident from abuse by another resident, resulting in emotional distress and potential physical harm.
Administered the wrong medication (Cialis instead of Tacrolimus) to a resident, placing the resident at risk for kidney transplant complications.
Failed to enforce the water management plan, resulting in Legionella contamination and positive Legionella tests in two residents.
Report Facts
Medication doses administered in error: 6
Visual checks frequency: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Confirmed administering wrong medication to Resident 3 due to mislabeled medication pack. |
| LPN2 | Licensed Practical Nurse | Described medication verification process during administration. |
| Director of Nursing | Director of Nursing (DON) | Acknowledged medication error and facility corrective actions. |
| Consultant Pharmacist | Consultant Pharmacist | Explained pharmacy responsibilities for medication accuracy. |
| Registered Nurse | Registered Nurse (RN) | Primary nurse at dialysis clinic for Resident 3, explained clinical background. |
| Maintenance Director | Maintenance Director | Explained Legionella Water Management Program deficiencies and documentation gaps. |
| Administrator | Facility Administrator | Provided information on Legionella concerns, water testing, and remediation efforts. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 27, 2024
Visit Reason
The inspection was conducted in response to complaint #NV00072063 concerning the facility's failure to provide accurate resident assessments and adequate assistance with meals and hydration for Resident 96, who was clinically blind and hard of hearing.
Complaint Details
Complaint #NV00072063 regarding failure to provide accurate assessments and adequate feeding assistance to Resident 96, resulting in weight loss and hospitalization.
Findings
The facility failed to ensure accurate assessments of Resident 96's vision, hearing, and functional status, resulting in inadequate person-centered care. Additionally, the facility did not provide necessary 1:1 feeding assistance and hydration support, contributing to significant weight loss and hospitalization.
Deficiencies (2)
Failed to ensure each resident receives an accurate assessment, specifically for vision, hearing, and functional status impacting activities of daily living for Resident 96.
Failed to provide enough food/fluids to maintain Resident 96's health, who was clinically blind and required feeding assistance.
Report Facts
Residents sampled: 35
Weight loss: 25
Meal consumption: 25
Meal consumption: 50
Body Mass Index (BMI): 21.41
Body Mass Index (BMI): 21.18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | LPN | Steadily assigned nurse to Resident 96 who reported resident was blind and hard of hearing and verbalized assessments were inaccurate |
| MDS Coordinator | MDS Coordinator | Completed Resident 96's annual and quarterly assessments and acknowledged inaccuracies |
| Director of Nursing | DON | Reviewed Resident 96's assessments and medical record, confirmed inaccuracies and emphasized importance of accurate assessments |
| Certified Nursing Assistant | CNA | Provided feeding assistance to Resident 96 during observation and noted resident required full assistance |
| Director of Food Services | DFS | Explained breakdown in communication regarding Resident 96's feeding assistance needs |
| Registered Dietitian | RD | Consultant who assessed Resident 96's nutrition and was unaware feeding assistance was not provided |
| Nurse Practitioner | NP | Ordered hospital transfer for Resident 96 due to dehydration and was unaware feeding assistance was lacking |
Inspection Report
Complaint Investigation
Deficiencies: 12
Date: Sep 27, 2024
Visit Reason
The inspection was conducted based on complaint investigations regarding resident rights, assessment accuracy, PASRR evaluations, care planning, pressure ulcer care, feeding assistance, PICC line care, respiratory care, staff performance appraisals, medication monitoring, and food safety.
Complaint Details
Complaint #NV00072063 involved multiple issues including resident rights, assessment accuracy, PASRR evaluations, care planning, pressure ulcer care, feeding assistance, PICC line care, respiratory care, staff performance appraisals, medication monitoring, and food safety.
Findings
The facility was found deficient in multiple areas including failure to honor resident self-determination regarding outdoor access, inaccurate resident assessments, incomplete PASRR Level 2 evaluations, inadequate care plans for sleep apnea devices, improper pressure ulcer care, insufficient feeding assistance for a blind resident, lack of physician orders and care for PICC line and respiratory devices, failure to monitor psychotropic medication side effects, incomplete staff annual performance appraisals, and unsafe food storage and handling practices.
Deficiencies (12)
Failed to ensure residents have the right to make choices about aspects of their life, specifically restricting residents from going outside in the front porch area without accompaniment.
Failed to ensure accurate assessments for vision, hearing, and functional status impacting activities of daily living for a resident, resulting in inadequate care planning.
Failed to complete PASRR Level 2 evaluations for residents with behavioral or psychiatric diagnoses, risking inadequate behavioral health service determination.
Failed to develop and implement comprehensive care plans for management of sleep apnea devices for residents.
Failed to provide appropriate pressure ulcer care and complete weekly skin assessments for a high-risk resident with a deep tissue injury.
Failed to provide adequate feeding assistance to a clinically blind resident, contributing to significant weight loss and hospitalization.
Failed to obtain and carry out physician orders for bolus tube feeding, water flushes, and gastrostomy tube care for a resident with a feeding tube.
Failed to ensure physician orders for use and care of CPAP machine and oxygen administration and monitoring for residents.
Failed to obtain, transcribe, and carry out care orders for PICC line management, placing resident at risk for infection.
Failed to complete annual performance appraisals for several certified nursing assistants, risking substandard care quality.
Failed to monitor and document behaviors and side effects for residents receiving psychotropic medications.
Failed to ensure proper food labeling, discard expired food, maintain proper refrigerator temperatures, and prevent cross contamination during meal service.
Report Facts
Residents sampled: 35
Residents affected by choice restriction deficiency: 4
Weight loss: 25
PICC line dressing change frequency: 7
Oxygen flow rate: 5
Refrigerator temperature: 50
Refrigerator temperature: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee 6 | Certified Nursing Assistant | No annual performance appraisal completed for 2023 and 2024 |
| Employee 7 | Certified Nursing Assistant | No annual performance appraisal completed for 2023 and 2024 |
| Employee 9 | Certified Nursing Assistant | No annual performance appraisal completed for 2022, 2023, and 2024 |
| Employee 10 | Certified Nursing Assistant | No annual performance appraisal completed for 2022 and 2023 |
| Licensed Practical Nurse | Named in findings related to Resident 96 feeding assistance and PICC line care | |
| Director of Nursing | Named in findings related to Resident 96 feeding assistance, PICC line care, and CPAP care | |
| Social Services Director | Named in findings related to resident outdoor access and PASRR process | |
| Administrator | Named in findings related to resident outdoor access and staff appraisals | |
| Certified Nursing Assistant 1 | Named in findings related to pressure ulcer skin assessment | |
| Certified Nursing Assistant 2 | Named in findings related to pressure ulcer skin assessment | |
| Wound Care Treatment Nurse | Named in findings related to pressure ulcer care | |
| Wound Nurse Practitioner | Named in findings related to pressure ulcer care | |
| Director of Medical Records | Named in findings related to skin assessment documentation | |
| Director of Food Services | Named in findings related to feeding assistance communication and food safety | |
| Nurse Practitioner | Named in findings related to PICC line removal and feeding assistance | |
| Human Resources Coordinator | Named in findings related to staff annual performance appraisals | |
| Clinical Care Coordinator | Named in findings related to PICC line care, feeding tube orders, oxygen orders, and psychotropic medication monitoring |
Inspection Report
Routine
Deficiencies: 10
Date: Jun 16, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication administration, care planning, treatment and care, pharmaceutical services, dialysis care, medication storage, and dining room safety at Oasis Nursing & Rehab of Green Valley.
Findings
The facility was found deficient in multiple areas including failure to complete self-administration medication assessments, incomplete care plans for splint application, delayed and incomplete medication administration, improper PICC line care, failure to timely deliver nicotine patches, improper pain medication management, inconsistent dialysis access monitoring, unsecured medication carts and medications left at bedside, incomplete temperature monitoring for medication storage, and overcrowding in the dining room.
Deficiencies (10)
Failed to ensure an assessment was completed for self-administration of medication for 2 of 35 sampled residents (R417 and R69).
Failed to develop and implement a comprehensive care plan for splint application for management of contractures for 1 of 35 sampled residents (R81).
Failed to provide appropriate treatment and care according to orders and resident preferences for 3 residents including delayed antibiotic administration (R38), delayed physician follow-up for pain medication (R134), and nicotine patch delivery delay (R167).
Failed to follow physician orders for PICC line dressing changes and flushes for 1 of 35 sampled residents (R217) and failed to obtain orders for PICC line care for 1 of 35 sampled residents (R40).
Failed to ensure nicotine patch was timely delivered and available as ordered for 1 of 35 sampled residents (R167).
Failed to ensure application and documentation of splint application for 2 of 35 sampled residents (R81 and R39).
Failed to ensure safe, appropriate pain management including clarifying physician order and following manufacturer's instructions for Lidocaine patch for 1 of 35 sampled residents (R167).
Failed to ensure hemodialysis access catheter was assessed for patency for 1 of 35 sampled residents (R135).
Failed to ensure medication carts were locked and not left unattended, medications were not left unsecured at bedside, and medication storage temperature monitoring and disposal of medical supplies were properly conducted.
Failed to ensure the dining room was not overcrowded, placing residents and staff at risk for accidents and discomfort.
Report Facts
Residents sampled: 35
Nicotine patch delivery delay: 2
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed facility process for self-administration of medications and medication cart security |
| Licensed Practical Nurse | Licensed Practical Nurse | Acknowledged need for self-administration assessment and physician order |
| Pharmacist | Pharmacist | Confirmed nicotine patch order and delivery issues |
| Critical Care Coordinator | Critical Care Coordinator | Discussed medication administration expectations and nicotine patch delivery |
| Registered Nurse | Registered Nurse | Confirmed PICC line dressing and flush deficiencies |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Explained antibiotic administration and medication availability process |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Discussed medication security and follow-up on physician orders |
| Director of Clinical Services | Director of Clinical Services | Discussed PICC line care and medication administration expectations |
| Maintenance Director | Maintenance Director | Confirmed dining room occupancy signage and safety concerns |
| Pain Doctor | Pain Doctor | Discussed Lidocaine patch administration and removal instructions |
| Wound Treatment Nurse | Wound Treatment Nurse | Discussed need for Lidocaine patch order clarification |
| Corporate Director of Clinical Services | Corporate Director of Clinical Services | Discussed PICC line dressing change requirements |
| Licensed Practical Nurse (LPN) | Licensed Practical Nurse | Discussed nicotine patch order and pharmacy communication |
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