Greenhill Villas

In the surveyor’s words

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

• Immediate jeopardy, patternF684Sep 9, 2024

  Based on observations, interviews, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 3 (Resident #1) residents reviewed for quality of care. 1. The treatment nurse failed to transcribe Resident #1's physician orders for wound care and provide wound care (clean with normal saline/wound wash, pat dry, apply collagen powder, med honey pad and secure with gauze island adhesive border once daily) to Resident #1's right lower shin from 08/23/24-08/31/24 as ordered resulting in hospitalization with a diagnosis of cellulitis (bacterial skin infection). 2. The facility failed to assess, document, and monitor for Resident #1's wound. An IJ was identified on 09/09/24. […]

• Immediate jeopardy, patternF760Apr 2, 2023

  Based on interview, observation and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 4 (Resident #1) residents reviewed for medication errors. The facility failed to administer the correct dosage of Potassium after the order was transcribed incorrectly resulting in Resident #1 having a critical high potassium level of 6.52 (the normal potassium lab value range 3.7 - 5.2) and being hospitalized . An Immediate Jeopardy (IJ) was identified on 03/31/2023. The IJ template was provided to the facility on [DATE] at 6:18 p.m. […]

• Immediate jeopardy, patternF600May 19, 2022

  Based on observation, interview, and record review the facility failed to ensure residents were free from sexual abuse and neglect for 5 of 7 residents reviewed (Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5) for abuse. The facility failed to determine if Resident #'s 1, 2, 3, 4, and 5 had the capacity to engage in sexual acts. The facility failed to perform sexual assessments on any residents. The facility failed to develop care plans with interventions that targeted the resident needs. The facility failed to protect residents who did not have the mental capacity to determine the consequences of their actions. […]

• Immediate jeopardy, patternF880Jan 7, 2022

  Based on observation, interview, and record review, the facility failed to maintain an effective infection control program to help prevent the development and transmission of communicable diseases and infections 4 of 68 residents reviewed for infection control (Resident #s 10, 50, 53, and 48) and The facility did not ensure the staff used proper personal protective equipment (masks, gloves, gowns, and masks) donning and doffing (putting on and taking off) while moving a COVID positive resident to a hot zone (area of isolation for COVID positive residents) The facility did not ensure a resident with known COVID-19 exposure was isolated from residents with no known COVID-19 exposure. […]

• Immediate jeopardy, isolatedF689Feb 18, 2025

  Based on interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident #1) reviewed for quality of care. 1. The facility failed to ensure Resident #1 was adequately supervised which resulted in Resident #1 leaving the facility on 08/22/24 and being found at a gas station in a town 38.1 miles east of the facility. 2. The facility failed to monitor and put measures in place to keep Resident #1 who was high risk for elopement from eloping from the facility on 08/22/24. 3. […]