Resident #1 scored 6 out of 15 on a cognitive assessment in April, indicating severe mental impairment. On April 30, the resident reported falling to a certified occupational therapy assistant during a treatment session.
The therapy assistant confirmed the resident "couldn't say when the fall occurred or what happened" but complained of left arm pain near their dialysis access site. No visible injury was observed at the time.
The licensed practical nurse assigned to the resident's care that day acknowledged receiving the fall report from the therapy assistant. She checked on the resident and found "no change or injury," then applied prescribed lidocaine cream to the dialysis site and sent the resident to their scheduled dialysis appointment "in good condition."
The nurse admitted to inspectors she never reported the fall to supervisors, the resident's physician, or the responsible relative. She also confirmed she failed to initiate the facility's required fall incident protocol.
Hours later, the dialysis center called Green Hill with alarming news. Staff there had discovered a bruise on the resident's face and were sending them to the emergency room for evaluation.
The registered nurse supervisor explained to inspectors that facility policy required immediate action when residents report falls or new injuries. Staff must complete skin assessments and vital signs, notify supervisors and doctors, update care plans, and start incident reports.
None of this happened.
The current director of nursing acknowledged to inspectors that the LPN "did not follow the facility's fall protocol." When the licensed nursing home administrator and director met with inspectors later that day, they provided no additional information about the incident.
Green Hill's own undated policy document titled "Assessing Falls and Their Causes" clearly states under required procedures: "Notify the resident's attending physician and family in an appropriate time frame."
The therapy assistant who first received the fall report said the resident complained specifically of left arm pain at the dialysis access site. For dialysis patients, protecting vascular access points is critical for ongoing treatment. Any trauma to these sites can compromise life-sustaining care.
The resident's severe cognitive impairment, documented through standardized testing, made their self-reported fall particularly concerning. Residents with dementia face higher fall risks and often cannot accurately describe what happened to them or when injuries occurred.
The nursing staff's failure created a dangerous gap in medical oversight. The resident went to dialysis without their physician knowing about the reported fall or potential injuries. Only the dialysis center's vigilance in spotting facial bruising triggered the emergency room visit.
Federal inspectors cited Green Hill for failing to ensure residents received proper treatment and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being. The violation affected few residents but created minimal harm or potential for actual harm.
The licensed practical nurse's admission that she knew about the fall but chose not to report it represents a clear breakdown in the facility's safety systems. Her decision to send the resident to dialysis without medical evaluation put the resident at risk.
The therapy assistant followed appropriate protocol by informing nursing staff about the resident's complaint. The breakdown occurred when nursing staff received this critical information but failed to act on facility policies designed to protect vulnerable residents.
Green Hill's policy requires notifying physicians and families in "an appropriate time frame" after falls. In this case, the appropriate time frame stretched from morning therapy sessions to afternoon dialysis appointments, when outside medical staff finally noticed what the nursing home had missed.
The resident's facial bruising, discovered only by dialysis center staff, raised questions about what other injuries might have gone undetected during the nursing home's cursory assessment. Emergency room evaluation became necessary because the facility's own staff had failed to properly examine someone who reported falling.
For a resident already managing complex medical needs requiring regular dialysis, the additional trauma of an unreported fall and delayed medical response created unnecessary complications. The emergency room visit that followed could have been prevented with proper adherence to the facility's own safety protocols.
The director of nursing's acknowledgment that staff violated fall protocols confirmed what inspectors already documented through interviews with the involved nurses and therapy assistant. The facility's leadership offered no explanation for why their safety systems failed a vulnerable resident who trusted them with their care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Green Hill from 2025-10-29 including all violations, facility responses, and corrective action plans.