Green Hills Center

In the surveyor’s words

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

• Immediate jeopardy, patternF689Jan 22, 2024

  Based on observations, staff interviews, medical record review, review of Joerns Hoyer user instruction manual and Invacare patient slings operator's manual, review of the facility's Self-Reported Incident (SRI) and investigation including witness statements, review of the emergency medical services (EMS) report, review of hospital documentation, review of the facility policies on transfer, mechanical lifts, and the mechanical lift checklist, the facility failed to ensure a resident requiring transfers with a mechanical lift was transferred safely. […]

• No harm, potential for more than minimal, patternF657Sep 11, 2025

  Based on record review, resident interview, staff interview, and policy review the facility failed to ensure care conferences were conducted quarterly. This affected four (#12, #38, #39, and #51) of four residents reviewed for care conferences. The facility census was 67. 1.Review of medical record for Resident #12 revealed an admission date of 04/29/25 with diagnoses including but not limited to type two diabetes, congestive heart failure, chronic atrial fibrillation, and major depressive disorder. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 was cognitively intact. Review of care conference notes revealed the last care conference was held on 11/19/24 and only two members of the interdisciplinary team (IDT) were present. […]

• No harm, potential for more than minimal, patternF842Mar 29, 2021

  Based on medical record review, staff, interview, and review of facility policy, the facility failed to ensure staff monitored and documented resident's meal intakes. This affected four (#7, #18, #28 and #61) out of four residents reviewed for nutrition risk. The facility's census was 60. Findings included: 1. Medical record review for Resident #7 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #7's care plan with a start date of 02/15/21 revealed Resident #7 was at nutritional risk and would have meal intakes monitored and recorded. Review of Resident #7's State tested Nursing Assistant (STNA) Daily Charting revealed there was no documentation of meal intake for 03/21/21 for breakfast; 03/22/21 for dinner; and 03/23/21 for breakfast, lunch or dinner. […]

• No harm, potential for more than minimal, isolatedF550Sep 11, 2025

  Based on record review, observation, interview, and policy review the facility failed to ensure resident dignity when giving insulin injections. This affected one (#39) resident of one resident reviewed for insulin injections. The facility census was 67.Review of medical record for Resident #39 revealed an admission date of 08/26/22 with diagnoses including type two diabetes, dementia, and major depressive disorder.Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had moderate cognitive impairment.Review of current physician orders revealed an order initiated on 09/08/25 following the observation in the dining room indicating may give medications, check blood sugar and give insulin in public spaces and dining room.Observation on 09/08/25 at 11:22 A.M. […]

• No harm, potential for more than minimal, isolatedF628Sep 11, 2025

  Based on record review, interview, and policy review the facility failed to ensure residents were provided written bed hold notices. This affected two (#75 and #78) of three reviewed for hospitalizations. The facility census was 67. 1. Review of Resident #75 medical record revealed an admission date of 6/10/25, diagnoses included acute and chronic respiratory failure with hypoxia, atrial fibrillation, heart failure, hypo-osmolality and hyponatremia, chronic lymphocytic leukemia of B-cell, atherosclerotic heart disease, chronic obstructive pulmonary disease, hypertension, and cerebral infarction. […]