Green Hill

In the surveyor’s words

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

• Actual harm, isolatedF686Jan 27, 2023

  Based on observation, interview, and record review it was determined that the facility failed to a. provide effective preventative treatment to a known high risk resident who was admitted to the facility with a Stage 1 (redness) pressure ulcer that progressed and developed into an open pressure ulcer (Stage 2) and, b. accurately monitor and document weekly skin assessments resulting in the development of an open pressure ulcer that had a delay in being identified and treated, for a resident who was found in pain. This deficient practice resulted in the development, progression delaying the identification and treatment of an open pressure ulcer. This deficient practice was identified for 1 of 5 resident, Resident #3 reviewed for pressure ulcers. […]

• No harm, potential for more than minimal, widespreadF806Feb 24, 2025

  Based on observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that resident's dietary preferences were consistently implemented and followed for 4 of 4 residents (Resident #104, #105, #1 and #3) reviewed for dietary preferences during meal observations. This deficient practice was evidenced as follows: 1. On 2/18/25 at 11:55 AM, the surveyor was observing the lunch meal on first floor unit. The surveyor observed Resident #104's tray, per the tray ticket, Resident #104 was supposed to receive 4 ounce (oz) assorted ice cream and a 6oz Coffee, both items were missing from the tray. On 2/20/25 at 10:00 AM, the surveyor reviewed the electronic medical record (E-mar) for Resident #104. […]

• No harm, potential for more than minimal, widespreadF809Feb 24, 2025

  Based on interview, and review of pertinent facility documents, it was determined that the facility failed to serve and document residents received a nourishing snack in the evening when there was more than a 14-hour span between dinner and breakfast mealtimes. This deficient practice was identified for 6 of 6 (Resident's #9, #34, #41, #53, #60, and #78) residents during the resident council meeting and was evidenced by the following: On 02/18/25 at 11:08 AM, the surveyor conducted a group meeting with six residents who were alert and oriented and selected by the facility to participate. Six out of six residents stated they were not offered nor receive snacks in the evening. […]

• No harm, potential for more than minimal, widespreadF812Feb 24, 2025

  REPEAT DEFICIENCY Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 2/14/25 at 10:23 AM, the surveyor in the presence of the Food Service Director (FSD) observed the following during the kitchen tour: 1. Upon entering the kitchen, the surveyor observed the Regional FSD (RFSD) and three dietary aides (DA) all wearing large earrings. FSD alerted staff and earrings were removed. 2. In the cooking area of the kitchen the surveyor observed on top of the 2-door standing oven, burnt-on debris and a large build up of a greyish dust like substance. […]

• No harm, potential for more than minimal, patternF880Feb 24, 2021

  Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to: a) ensure proper use of personal protective equipment (PPE) for 1 of 3 staff; b) perform handwashing appropriately for 1 of 10; c) ensure that workers are knowledgeable of the cleaning chemical used in the workplace for 2 of 3 staff; and, d) maintain 6 feet of social distancing in accordance with the Centers for Disease Control and Prevention guidelines for infection control to mitigate the spread of COVID-19 and other transmission-based precaution infection. This deficient practice was evidenced by the following: According to the U.S. […]