Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Green Hills Health Care Center during CMS and state inspections, most recent first.
Two residents with cognitive impairments were placed in a small assisted dining room, limiting their social interaction during meals. One resident expressed feeling discarded, preferring the larger dining room. Staff moved these residents to address complaints from others, but this practice conflicted with the facility's policy on respect and non-discrimination.
Staff at the facility failed to maintain sanitary conditions during food service, with improper glove use and handwashing practices observed. The Food & Beverage Coordinator used gloves for multiple tasks without changing them, leaned over plates with his apron touching the surface, and handled serving scoops improperly. The Dietary Aide handled cups by placing fingers around the top edge before serving. These actions violated the facility's policy and the 2013 Food Code standards.
A facility failed to include a high-risk anticoagulant medication in a resident's baseline care plan within 48 hours of admission, as required by policy. The resident, with a history of transient cerebral ischemic attack, was on Warfarin Sodium, but the care plan lacked monitoring for side effects. The facility's policy mandates that the admitting RN develop a baseline care plan based on physician orders, which was not followed in this case.
A facility failed to timely update a care plan for a resident with pressure ulcers. The resident, with a history of stroke and Parkinson's, had documented Stage 2 and Stage 3 pressure ulcers, and a new unstageable ulcer on the right heel. Despite these conditions, the care plan did not include the pressure ulcer and treatment until much later. Facility policy required timely inclusion of such conditions in care plans, as confirmed by the DON.
A resident with a history of stroke and Parkinson's, and existing pressure ulcers, did not receive the prescribed prevalon boots on both feet as ordered by the physician. Observations showed the resident only had a boot on the right foot, contrary to the order. Interviews revealed a misunderstanding about the provision of the second boot, and the facility's policy to follow physician orders was not met.
A resident with a history of stroke and Parkinson's disease, and existing pressure ulcers, did not receive the prescribed treatment of prevalon boots on both feet as ordered by the physician. Observations showed the resident only had a boot on the right foot, while the left foot had a gripper sock. Interviews with the resident and staff confirmed the left boot was never provided, despite the order being marked as completed. The facility's policy requires adherence to physician orders, but this was not followed, leading to a deficiency.
A resident with severe cognitive impairment was mistakenly given another resident's medications, including Losartan, Metoprolol, and Verapamil, leading to bradycardia and hospitalization. The error occurred when a CMA prepared medications for two residents but administered the wrong set after returning from a break. The facility's medication administration policy was not followed.
Failure to Maintain Dignity in Dining for Residents
Penalty
Summary
The facility failed to maintain dignity in dining for two residents, both of whom were observed eating in a small, separate assisted dining room. Resident #10, with moderate cognitive impairment, was identified as needing partial to moderate assistance with eating but was observed eating independently. Resident #23, with severe cognitive impairment, also required partial to moderate assistance and expressed dissatisfaction with being placed in the smaller dining room, feeling discarded and preferring the larger dining room. Both residents expressed a desire for more social interaction during meals, which was limited in the smaller setting. Staff interviews revealed that the decision to move residents needing assistance to the smaller dining room was made to address complaints from residents with higher cognition in the open dining room. The facility's policy emphasized respect for individuality and non-discrimination, yet the practice of segregating residents needing assistance into a smaller room was perceived by some residents as undignified. The Director of Nursing stated that residents were placed in the assisted dining room based on evaluations and family requests, but the move was also influenced by the number of residents needing assistance at any given time.
Improper Food Handling and Sanitation Practices
Penalty
Summary
Staff at the facility failed to maintain sanitary conditions during food service, increasing the risk of contamination and foodborne illness. During a meal service, the Food & Beverage Coordinator, identified as Staff A, was observed using improper glove practices. Staff A put on gloves, opened a drawer, and then touched food items such as tater tots and cucumber slices without changing gloves. Additionally, Staff A leaned over plates with his apron touching the surface where food was placed, and used a dry cloth to wipe a cutting board before placing food on it. Staff A also drank from a personal cup and continued serving food without washing his hands, and handled serving scoops improperly, allowing them to come into contact with food. The Dietary Aide, identified as Staff B, was observed handling cups improperly by placing fingers around the top edge of the cups before serving them to residents. The facility's policy on preventing foodborne illness requires employees to wash their hands after drinking, before touching food surfaces, and during food preparation to prevent cross-contamination. The policy also states that gloves are single-use items and must be discarded after completing a task. The Director of Dietary Services confirmed the expectation for gloves to be used only once. The 2013 Food Code, a standard for the food service industry, outlines similar requirements for glove use and handwashing to prevent cross-contamination.
Failure to Include Anticoagulant in Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission, as required by their policy. The resident, identified as Resident #35, had a diagnosis of transient cerebral ischemic attack and was on long-term anticoagulant therapy with Warfarin Sodium, a high-risk medication. The Minimum Data Set (MDS) for the resident documented the use of this anticoagulant. However, the New Resident Initial Care Plan/Resident Summary did not include the anticoagulant or monitoring for its side effects. The facility's policy, reviewed and revised in November 2020, mandates that the admitting registered nurse develop a baseline care plan that includes initial goals based on physician orders. The Director of Nursing confirmed the expectation for anticoagulant medication and monitoring to be included in the baseline care plan.
Failure to Timely Update Care Plan for Pressure Ulcers
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with pressure ulcers. Resident #22, who had a history of stroke and Parkinson's, was documented to have a Stage 2 and Stage 3 pressure ulcer according to the Minimum Data Set (MDS) dated 10/8/24. Additionally, a Skin Evaluation on 10/2/24 noted a new unstageable pressure ulcer on the resident's right heel, measuring approximately 1.5 cm by 0.5 cm, with eschar tissue present. Despite these findings, the resident's care plan did not include the pressure ulcer and its treatment until 11/19/24. The facility's policy, reviewed and revised on 11/1/20, required that care plans address pressure ulcers. The Director of Nursing confirmed that pressure ulcers and their treatment should be included in the care plan in a timely manner.
Failure to Follow Physician's Order for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to follow a physician's order for a resident with a history of stroke and Parkinson's disease, who also had pressure ulcers. The resident's Minimum Data Set (MDS) indicated the presence of Stage 2 and Stage 3 pressure ulcers, and a new unstageable pressure ulcer was documented on the right heel. A physician's order dated 11/20/24 required the application of prevalon boots to both lower extremities at all times to prevent further pressure injuries. However, observations on multiple dates revealed that the resident was only wearing a prevalon boot on the right foot, while the left foot had only a gripper sock. Interviews with the resident and staff confirmed that the resident had never received a boot for the left foot, and there was a misunderstanding that hospice might provide the other boot. The facility's policy mandates that all physician orders are to be followed as written, yet this was not adhered to in this case. The Director of Nursing acknowledged that the expectation was to follow the physician's order, indicating a lapse in compliance with the facility's procedures.
Failure to Follow Physician Orders for Pressure Ulcer Treatment
Penalty
Summary
The facility failed to complete physician treatment orders for a resident with a history of stroke and Parkinson's disease, who also had pressure ulcers. The resident's Minimum Data Set (MDS) indicated the presence of Stage 2 and Stage 3 pressure ulcers, and a new unstageable pressure ulcer was documented on the right heel. The physician's order required the application of prevalon boots to both lower extremities at all times to prevent further pressure injuries. However, observations on multiple dates revealed that the resident only had a prevalon boot on the right foot, while the left foot only had a gripper sock. Interviews with the resident and staff confirmed that the resident never received a boot for the left foot, despite the order being documented as completed in the Treatment Administration Record (TAR). Staff members, including a Certified Nurse Aide (CNA) and a Registered Nurse, acknowledged the discrepancy between the physician's order and the actual care provided. The facility's policy mandates that all physician orders be followed as written, yet the Director of Nursing confirmed that the order was incorrectly signed as completed. This failure to adhere to the physician's orders resulted in a deficiency in the care provided to the resident.
Medication Error Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure that a resident received the correct medications, leading to hospitalization. Resident #8, who has severe cognitive impairment and multiple diagnoses including hypertension and dementia, was mistakenly given another resident's medications. This error occurred when a Certified Medication Aide (CMA) prepared medications for two residents but inadvertently administered the wrong set to Resident #8. The medications included Losartan, Metoprolol, and Verapamil, which are significant due to their effects on blood pressure and heart rate. Following the administration of incorrect medications, Resident #8's vital signs were closely monitored. Despite this, the resident developed bradycardia, with heart rates dropping between 41 and 48 beats per minute, necessitating hospitalization. The facility's investigation revealed that the CMA had intended to administer the correct medications but mistakenly gave the wrong set after returning from a break. The facility's policy on medication administration, which includes the five rights of medication administration, was not adhered to, resulting in this incident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Ames
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Northridge Village | 3.8 mi | ★★★★★ | 4 | 0 |
| Accura Healthcare Of Ames, Llc | 3.9 mi | ★★★★★ | 8 | 0 |
| Rolling Green Village Care Center | 9.9 mi | ★★★★★ | 2 | 0 |
| Story Medical Senior Care | 10.7 mi | ★★★★★ | 6 | 0 |
| Bethany Life | 12.7 mi | ★★★★★ | 17 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.