Green Oaks Nursing & Rehab: Pain Device Left Without Ice - TX
The September 4 inspection at Green Oaks Nursing & Rehabilitation captured the scene in real time. Resident #1, new to the facility, had a DonJoy IceMan cold therapy unit on her knee for pain management. The machine works by circulating ice water through a pad to reduce pain and swelling. Without ice, it circulates nothing useful.
RN A told inspectors she had given the resident pain medication at 6 AM that morning. She said she had not checked the IceMan to see whether it had ice water in it. She said she and the CNA were both responsible for monitoring the machine. She was not sure who had ordered the device, thought the order might have come from the hospital, and noted the resident was new. She said the risk of the machine running without ice water was straightforward: increased pain.
The CNA had a different account. She told inspectors she was not responsible for monitoring the ice water in the IceMan. That, she said, was the nurse's job. She said that before the morning of the inspection, neither the nurse nor the resident had asked her to check the machine. She had passed ice in hydration cups that morning during her rounds. She said RN A had asked for her help a little while ago to get something to discard the old water. She acknowledged she did not know how to operate the IceMan but added that it looked easy.
Nobody had filled it.
The Director of Nursing, interviewed that afternoon, said her expectation was that all orders were transcribed correctly and that every nurse was trained to clarify physician orders. She said nurses were responsible for obtaining physician orders and that nurse managers should make sure all orders were in and accurate. Then she said she was unaware of who had ordered the IceMan or how long Resident #1 had been using it. She said the risk of not having orders was not knowing how long to keep the device on and off.
The medication record added another layer. Inspectors found that Resident #1 had been given her medications, including a blood sugar tablet, an antidepressant, and an antipsychotic, but the inspection narrative flagged the medication administration alongside the cold therapy failures under the same deficiency. The picture that emerges is of a newly admitted resident whose care arrived at the facility without a clear owner: orders of uncertain origin, a device nobody claimed, and pain that persisted through the morning.
The facility's own pain management policy, last revised in April 2009, calls for a treatment regimen built around the resident's medical condition, the nature and severity of the pain, and the course of the illness. Its medication order policy requires that treatment orders specify the treatment, frequency, and duration. The IceMan had none of that documented in a way anyone at the facility could point to on the morning inspectors arrived.
What the inspection captured, more than any single lapse, was a facility where a new resident in pain depended entirely on two staff members working out between themselves, in the moment, who was going to walk down the hall with a bucket of ice. On the morning of September 4, they did not work it out until inspectors were already there asking questions.
Resident #1 spent that time with a cold therapy machine on her knee that was not cold.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Green Oaks Nursing & Rehabilitation from 2025-09-04 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
GREEN OAKS NURSING & REHABILITATION in ARLINGTON, TX was cited for violations during a health inspection on September 4, 2025.
The September 4 inspection at Green Oaks Nursing & Rehabilitation captured the scene in real time.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.