Average — CMS composite of the measures below.
A standard survey is most likely before 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 Center during CMS and state inspections, most recent first.
Failure to Conduct Quarterly Care Conferences: The facility did not ensure quarterly care conferences were held for four residents. Records showed one resident had only two IDT members present at the last conference, another had no care conferences documented over an extended period, a third had a blank conference summary aside from activities, and a fourth had a conference attended only by the SW. The DON verified the residents did not have quarterly care conferences or the appropriate IDT members in attendance.
Failure to Provide Written Bed Hold Notices: The facility did not ensure written bed hold notices were given to two residents when they were transferred to the hospital or ED. One resident was cognitively intact and had COPD, respiratory failure, CHF, and other serious diagnoses when worsening SOB and pneumonia concerns led to hospital transfer. Another resident had moderate cognitive impairment with metabolic encephalopathy, DM2, CHF, seizures, and depression, and was sent out after a decline in speech, appetite, and alertness, then later returned from the ED with a UTI diagnosis. The Administrator confirmed no bed hold notices were provided.
Pressure ulcer care was not properly carried out for two residents. One resident with a stage 4 pressure ulcer had weekly skin checks documented, but the nursing notes lacked wound measurements and descriptions, and the resident was not seen weekly at the wound clinic. Another resident with multiple pressure ulcers had ordered wound dressings for the heel and ankle that were not started as ordered, with no evidence the treatments were completed on the first two days they were due.
Failure to complete dialysis communication forms as ordered for a resident with ESRD and DM2. The resident was cognitively intact and had physician orders for pre-dialysis forms on specified night shifts and post-dialysis forms on specified days, but multiple required forms were not completed. The Administrator verified the missing pre- and post-dialysis documentation was not completed as ordered.
Failure to protect a resident’s dignity during insulin administration. An RN gave insulin to a resident with DM and dementia while the resident was seated at a dining room table with a family member and other residents present, lifted the resident’s shirt, and administered the injection in the abdomen. The RN did not perform hand hygiene or wear gloves, and later stated the resident should have been moved away from the table before the injection.
Failure to perform hand hygiene and use proper infection control practices occurred during insulin administration and meal tray delivery. An RN gave insulin to a resident with DM and cognitive impairment in the dining room without gloves or hand hygiene while others were seated at the table, and a CNA passed meal trays to two residents in separate rooms without hand hygiene before starting or between rooms.
A resident with chronic pressure ulcers did not receive consistent care as per physician orders, with multiple missed dressing changes and wound vac applications. Despite being under a wound physician's care, the facility failed to adhere to the treatment regimen, as confirmed by the resident and staff interviews. The facility's policy on skin care management was not followed, leading to non-compliance.
A resident with Alzheimer's and cognitive impairments was physically abused by STNAs who restrained the resident's wheelchair with a desk chair and pushed the resident's head onto a pillow to induce sleep. The facility's investigation confirmed the abuse, and the local police were notified. Witnesses corroborated the incident, and the involved staff were barred from returning.
A facility failed to update a resident's care plan to include the use of a custom tilt and space wheelchair for comfort and positioning. The resident, with multiple cognitive and physical impairments, was observed without footrests in the wheelchair, contrary to therapy recommendations. Staff interviews confirmed the oversight, and the facility's policy requires care plan updates to reflect current needs.
A medication error occurred when an LPN administered bisacodyl instead of the prescribed Senna concentrate to a resident with severe cognitive impairment and constipation. This error contributed to a medication error rate of 6.3%, exceeding the acceptable threshold. The facility's policy mandates that medications be administered as prescribed, which was not followed in this case.
Two residents in an LTC facility received incorrect medications due to errors by an LPN. One resident, with vascular dementia, received another's insulin and other medications without proper monitoring. Another resident received their roommate's medications, with no documented monitoring for adverse reactions. The facility's policy requires medications to be administered as prescribed, but these incidents show a failure to comply.
A resident with moderate cognitive impairment and a history of elopement was found outside the facility unattended and returned by a visitor. Despite having a wander guard, staff did not respond appropriately to the alarm, and the resident's family was not notified until several hours later, contrary to facility policy.
A resident with dementia and other medical conditions eloped from the facility despite having a wander guard device. The facility's alarm system failed to prevent the elopement, and staff did not conduct a resident head count after responding to an alarm. The resident was found outside by a visitor and returned to the facility without injuries.
Failure to Conduct Quarterly Care Conferences
Penalty
Summary
The facility failed to ensure care conferences were conducted quarterly for four residents reviewed for care conferences. Resident #12 was admitted with diagnoses including type 2 diabetes, CHF, chronic atrial fibrillation, and major depressive disorder, and was cognitively intact on the MDS; the record showed the last care conference was held on 11/19/24 and only two IDT members were present. Resident #38 was admitted with diagnoses including cerebral infarction, fistula of the stomach and duodenum, ventral hernia, atrial fibrillation, acute gastric ulcer with perforation, type 2 diabetes, dysphagia, gastrointestinal hemorrhage, and bed confinement status; the resident was cognitively intact on the MDS, and review of records from 1/25 through 9/25 showed no care conferences were conducted. Resident #39 was admitted with diagnoses including type 2 diabetes, dementia, major depressive disorder, and hypertension, and the MDS showed moderately impaired cognitive impairment; the care conference summary dated 05/20/25 was attended by the DON, Activities, and the resident representative, but the form was blank except for the activities section. Resident #51 was admitted with diagnoses including COPD, essential tremor, hypertension, and emphysema, was cognitively intact on the MDS, and the last care conference documented was 08/21/23 with no one in attendance besides the social worker. During interview, the Administrator stated a mock survey had identified the care conference issue and that education had started, and verified that the four residents did not have quarterly care conferences or the appropriate IDT members in attendance.
Failure to Provide Written Bed Hold Notices
Penalty
Summary
The facility failed to ensure written bed hold notices were provided to residents upon hospitalization or transfer, affecting two of three residents reviewed for hospitalizations. Resident #75 was admitted with multiple diagnoses including acute and chronic respiratory failure with hypoxia, atrial fibrillation, heart failure, COPD, hypertension, and cerebral infarction. The resident was cognitively intact, required partial assistance with activities, and used a wheelchair. On 6/18/25, the resident developed increased shortness of breath while on 4 liters of oxygen, was coughing and expelling white and pink tinged sputum, and a chest x-ray showed bilateral airspace disease with modest pleural effusions, with pneumonia considered due to the resident's clinical condition. The resident's family requested hospital transfer, and the discharge information showed no bed hold notice was provided to the resident or representative. Resident #78 was admitted with diagnoses including metabolic encephalopathy, type 2 diabetes, hypertension, CHF, depression, seizures, and post traumatic seizures, and the MDS showed moderate cognitive impairment. Progress notes showed the resident had a decline in speech, appetite, and alertness and was sent to the hospital for admission after the family/representative was contacted. Another progress note showed the resident was sent to the ED and returned later with a diagnosis of UTI. The Administrator confirmed the facility did not provide a bed hold notice for the hospital stay or the ED visit, and the facility policy stated residents and representatives are to be notified of the bed hold policy at admission, prior to transfer, at therapeutic leave, and within 24 hours for emergent transfers.
Pressure ulcer assessments and ordered wound treatments were not completed as documented
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not ensured for two residents. Resident #67 was admitted with diagnoses including acute transverse myelitis in demyelinating disease of the central nervous system, paraplegia, a stage 4 pressure ulcer of the right buttock, and major depressive disorder. The resident’s MDS showed cognitive intactness and the pressure ulcer was not present on admission. Weekly skin observations were completed at intervals from 06/07/25 through 09/02/25, but the nursing documentation did not include wound measurements or wound descriptions. Wound clinic records dated 06/30/25, 07/09/25, 07/21/25, 08/04/25, 08/18/25, and 09/08/25 showed the resident was not seen weekly, although those records did include measurements and descriptions. Resident #52 was admitted with diagnoses including chronic diastolic heart failure, atherosclerotic heart disease, chronic pain, sarcoidosis of the lung, hyperlipidemia, protein-calorie malnutrition, history of venous thrombosis and embolism, pressure ulcers of the right heel, left heel, and left ankle, and lymphedema. Physician wound care orders dated 08/20/25 directed Hydrofera blue to the right heel and silver alginate to the left ankle, both with daily dressing changes starting 08/21/25. The treatment record showed no documentation that either order was implemented until 08/23/25, and the DON confirmed the treatments were not started on 08/21/25 as ordered and that there was no evidence the wound treatments were completed on 08/21/25 or 08/22/25.
Failure to Complete Dialysis Communication Forms
Penalty
Summary
Provide safe, appropriate dialysis care/services for a resident who requires such services was not met when the facility failed to ensure pre- and post-dialysis communication forms were completed as ordered for Resident #55. The resident was admitted on 06/20/25 with diagnoses including type 2 diabetes, end stage renal disease, and dependence on renal dialysis, and the MDS identified the resident as cognitively intact. Physician orders directed staff to complete the pre-dialysis communication form every night shift on Tuesday, Thursday, and Sunday, and the post-dialysis form every Monday, Wednesday, and Friday. Review of the records showed multiple missed pre-dialysis forms on 07/07/25, 07/09/25, 07/11/25, 07/16/25, 07/21/25, 07/28/25, 08/06/25, 08/11/25, 08/18/25, 08/20/25, 08/29/25, and 09/05/25, and multiple missed post-dialysis forms on 07/07/25, 07/11/25, 07/18/25, 07/21/25, 07/25/25, 08/04/25, 08/13/25, 08/15/25, 08/22/25, 08/25/25, and 08/27/25. During interview on 09/10/25 at 2:15 P.M., the Administrator verified the forms were not completed as ordered and should have been.
Failure to Protect Resident Dignity During Insulin Administration
Penalty
Summary
The facility failed to ensure resident dignity when administering insulin to a resident with type 2 diabetes, dementia, and major depressive disorder. The resident’s record showed moderate cognitive impairment on the MDS, and a physician order had been initiated allowing medications, blood sugar checks, and insulin administration in public spaces and the dining room after an observation in the dining room. During observation, the RN approached the resident while the resident was seated at a table in the dining room, told the resident she had insulin to administer, lifted the resident’s shirt, and gave the insulin in the abdomen while one family member and three other residents were seated at the same table. The RN did not wear gloves during the injection and did not perform hand hygiene before administering the insulin. During interview, the RN confirmed the insulin was given in the dining room with other residents at the table and stated she should have pulled the resident away from the table before giving the injection and should have donned gloves. The facility policy for subcutaneous injection stated to perform hand hygiene, provide privacy, explain the procedure, position the patient and expose the injection site, and use gloves when contact with blood or bodily fluids is likely or if skin is not intact.
Failure to Perform Hand Hygiene During Insulin Administration and Meal Tray Delivery
Penalty
Summary
The facility failed to ensure gloves and/or hand hygiene were completed prior to administering an insulin injection to Resident #39. Resident #39 was admitted on 08/26/22 with diagnoses including type 2 diabetes, dementia, and major depressive disorder, and the MDS assessment dated [DATE] indicated moderate cognitive impairment. On 09/08/25 at 11:22 A.M., RN #360 administered insulin to the resident in the dining room while the resident was seated at a table with one family member and three other residents present. The nurse lifted the resident’s shirt and gave the injection in the abdomen without wearing gloves and without performing hand hygiene before the procedure. During interview immediately afterward, RN #360 confirmed the insulin was given in the dining room with others at the table and stated she should have pulled the resident away from the table and donned gloves before administering the insulin. The facility also failed to provide a sanitary environment when passing meal trays in resident rooms. On 09/10/25 at 12:42 P.M., CNA #366 carried Resident #41’s lunch tray into the room, removed items from the bedside tray, placed the meal tray on the bedside table, removed the lid from the food, and took the silverware out of plastic wrap. The CNA then left the room, retrieved Resident #43’s tray, entered that resident’s room, removed the lid from the food, and exited. No hand hygiene was performed at the start of the meal tray pass or between serving Residents #41 and #43 in their separate rooms. During interview at 12:50 P.M., CNA #366 verified that hand hygiene was not completed before passing the trays or between the two residents’ meal deliveries.
Failure to Follow Pressure Ulcer Care Orders
Penalty
Summary
The facility failed to provide appropriate care for a resident with pressure ulcers according to the physician's orders. The resident, who was admitted with a stage 3 and a stage 4 pressure ulcer, had a history of neuromyelitis, neurogenic bladder, chronic pain, and osteomyelitis. Despite being under the care of a community wound physician, the facility did not consistently follow the prescribed treatment regimen, which included specific dressing changes and the application of a wound vac. The Treatment Administration Record (TAR) revealed multiple instances where the resident did not receive the required dressing changes for both the left and right buttock wounds. These omissions occurred over several months, with specific dates noted in December, January, and February. Additionally, the wound vac care was not administered on two occasions in February. Interviews with the resident and staff confirmed the lack of consistent treatment, with the resident acknowledging that dressings were not changed daily as ordered. Staff interviews highlighted a lack of awareness and communication regarding the resident's treatment schedule. The LPN responsible for the unit was unaware of the specific dressing change orders and relied on the wound clinic for updates. The facility's policy on skin care management was not adhered to, as evidenced by the missing documentation and failure to promote healing of the pressure ulcers. This deficiency was investigated under specific complaint numbers, indicating a broader issue of non-compliance within the facility.
Resident Abuse Due to Improper Restraint and Physical Coercion
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving a resident with Alzheimer's disease and other cognitive impairments. The resident required substantial assistance with daily activities and was at risk for social isolation. On the date of the incident, a State tested Nursing Aide (STNA) positioned a desk chair to block the resident's wheelchair from moving, effectively restraining the resident. Additionally, it was reported that two STNAs were observed pushing the resident's head down onto a pillow at the nurse's station, attempting to make the resident sleep. The facility's investigation substantiated the abuse allegations, and the local police department was notified. Witness statements confirmed the inappropriate actions of the STNAs, and the facility's Director of Nursing and Administrator verified the occurrence of physical abuse. The facility's policy on abuse and neglect defines abuse as the willful infliction of injury or unreasonable confinement, which aligns with the actions taken by the staff involved. The facility was unable to obtain statements from the alleged perpetrators, who were subsequently barred from returning to the facility.
Failure to Update Care Plan for Wheelchair Use
Penalty
Summary
The facility failed to revise a resident's plan of care to reflect the use of a custom tilt and space wheelchair, which was necessary for the resident's comfort and positioning. The resident, who had Alzheimer's disease, dementia with psychotic disturbance, major depression, anxiety, mild neurocognitive disorder, psychosis, and muscle weakness, was dependent on staff for dressing and personal hygiene. Despite being placed in the custom wheelchair after receiving therapy for positioning and comfort, the comprehensive plan of care and physician orders did not document the use of this wheelchair or the need for footrests. Observations and staff interviews confirmed that the resident was seated in the tilt and space wheelchair without footrests, leaving their feet dangling. The Director of Nursing and an Occupational Therapist verified that the resident was supposed to have footrests and that the care plan should have been updated following the therapy intervention. The facility's policy on comprehensive resident-centered care plans requires modifications to meet the resident's current needs, but this was not adhered to in this case.
Medication Administration Error Exceeds Acceptable Rate
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders, resulting in a medication error rate exceeding five percent. During an observation, it was noted that there were 32 opportunities for medication administration, with two errors occurring, leading to a 6.3% error rate. This error affected one resident, who was observed during the medication administration process. The resident, identified as having severe cognitive impairment and a diagnosis of constipation, was supposed to receive Senna concentrate as per the physician's orders. However, during the medication administration, an LPN administered two bisacodyl tablets instead of the prescribed Senna concentrate tablets. The LPN confirmed the error upon reviewing the medication administration record and acknowledged that the resident did not have a physician's order for bisacodyl. The facility's policy on medication administration requires that medications be administered as prescribed, which was not adhered to in this instance. This deficiency was investigated under a specific complaint number.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure medications were administered without significant errors, affecting two residents. Resident #100, who had vascular dementia and other health issues, received another resident's medications, including Lantus insulin, which was not prescribed for them. The incident occurred during an evening medication pass, and although the physician was notified, there was no documentation of the physician's orders for monitoring the resident's blood sugar and vital signs. The nurse responsible for the error was marked as a Do Not Return to the facility, but the necessary monitoring was not completed as per the physician's verbal order. Resident #125, with diagnoses including heart failure and dementia, received their roommate's medications during a morning medication pass. The incident was reported to the physician, but there was no documentation of first aid or treatment provided. The nurse involved was sent home, and the staffing agency was informed. Despite the error, there was no documentation of monitoring for adverse reactions for at least 48 hours, as should have been done according to the facility's procedures. The facility's policy on medication administration states that medications should be administered as prescribed and by authorized personnel. However, the incidents involving Residents #100 and #125 demonstrate a failure to adhere to these policies, resulting in significant medication errors and inadequate monitoring and documentation following the errors. This deficiency was investigated under a specific complaint number.
Failure to Timely Notify Resident's Representative of Elopement Incident
Penalty
Summary
The facility failed to ensure timely notification of a resident's representative following an elopement incident involving a resident with moderate cognitive impairment and a history of elopement. The resident, who had diagnoses including dementia and required substantial staff assistance for mobility, was found outside the facility unattended and was returned by a visitor. Despite the presence of a wander guard device, staff did not respond appropriately to the alarm, and the resident's family was not notified until several hours after the incident. The medical record review revealed that the resident had a wander guard in place and was assessed as being at risk for elopement. On the night of the incident, staff responded to an alarm but failed to locate the resident, who was later found in the parking lot. The facility's policy required immediate notification of the resident's representative in such events, but this was not done in a timely manner. The administrator confirmed the delay in notification and the initiation of an investigation following the incident.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate interventions and supervision to prevent the elopement of a resident who was assessed as being at risk for elopement. The resident, who had medical diagnoses including cerebral infarction, dementia, and diabetes mellitus, was found outside the facility unattended. The resident had a wander guard device in place, but the facility's alarm system did not effectively prevent the elopement. Staff responded to an alarm but did not conduct a resident head count, leading to the resident being outside for approximately 45-50 minutes before being returned by a visitor. The resident did not sustain any injuries from the incident. The facility's Director of Nursing confirmed that the resident was able to exit through a set of sliding doors that did not have the ability to lock or alarm when a resident with a wander guard was near. The facility's policy on elopement was not effectively implemented, as staff failed to ensure the resident's safety and timely redirection to a safe environment. The facility had not completed the investigation, training, and audits for the elopement at the time of the report.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 89 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near West Liberty
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Logan Acres | 6.6 mi | ★★★★★ | 0 | 0 |
| Ayden Healthcare Of Belle Springs. | 7.1 mi | ★★★★★ | 1 | 0 |
| Vancrest Of Urbana, Inc | 8.4 mi | ★★★★★ | 0 | 0 |
| Urbana Health & Rehabilitation Center | 11.1 mi | ★★★★★ | 1 | 0 |
| Als Woodstock Inc | 12 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Green Hills Center.
100% money-back within 48 hours.
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.