Green Hills Center for Rehabilitation and Healing

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Feb 5, 2024

  Based on facility policy review, facility video footage, hospital record review, www.accuweather.com review, medical record review, observation, and interview, the facility failed to provide an environment that remained free of accident hazards and failed to adequately supervise Resident #106. Resident #106 exited the building in his wheelchair when a staff member unlocked the front door for a visitor to exit. Resident #106 followed the visitor out the door unnoticed on 12/8/2023 at 12:31 PM. Resident #106 exited the building for a second time when a staff member again unlocked the front door for a visitor and Resident #106 followed the visitor out the door unnoticed on 12/8/2023 at approximately 1:35 PM. […]

• Immediate jeopardy, isolatedF867Jan 28, 2021

  Based on the facility's Quality Assurance Performance Improvement (QAPI) Plan review, policy review, medical record review, and interview, the facility failed to identify, assess, implement and monitor quality deficiencies which resulted in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) for 1 of 2 residents (Resident #3) reviewed for blood glucose monitoring. […]

• Immediate jeopardy, isolatedF867Jan 28, 2021

  Amended 2/19/2021 Based on the facility's Quality Assurance Performance Improvement (QAPI) Plan review, policy review, medical record review, and interview, the QAPI Committee failed to identify quality deficiencies which resulted in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) for 3 of 7 residents (Resident #17,#18, and #20) requiring wound care and 1 of 2 residents (Resident #3) reviewed for blood glucose monitoring. The Administrator and Director of Nursing were informed of the Immediate Jeopardy (IJ) on 1/27/2021 at 7:30 PM in the Conference room. F-867 and F-880 were cited at a scope and severity of J. […]

• Immediate jeopardy, isolatedF880Jan 28, 2021

  Based on the glucometer manufacturer guideline, policy review, medical record review, observation, and interview, the facility failed to follow standard precautions during the performance of routine fingerstick blood glucose (FSBG) testing resulting in potential exposure of residents who required blood glucose testing to prevent the spread of bloodborne pathogens in the facility for 1 of 2 diabetic residents (Resident #3) requiring FSBG testing, placing Resident #3 in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). […]

• Actual harm, isolatedF600Feb 6, 2024

  Based on facility policy review, review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review, facility investigation review, and interview, the facility failed to protect the resident's right to be free from neglect for 1 of 22 (Resident #319) sampled residents reviewed for abuse. The facility's failure to provide the necessary structure and processes to meet the care needs of Resident #319 resulted in actual HARM when Resident #319 fell from the bed and sustained a left hip fracture. […]