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Complaint Investigation

Green Hills Center

September 11, 2025 · West Liberty, OH · 6557 Us 68 South
Citations 6
CMS Rating 4/5
Beds 74
Provider ID 365362
Healthcare Facility
Green Hills Center
West Liberty, OH  ·  View full profile →
Inspection Summary

GREEN HILLS CENTER in WEST LIBERTY, OH — inspection on September 11, 2025.

Found 6 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0550
Resident Rights Deficiencies
Potential for More Than Minimal Harm

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview, and policy review the facility failed to ensure resident dignity when giving insulin injections.

This affected one (#39) resident of one resident reviewed for insulin injections.

The facility census was 67.Review of medical record for Resident #39 revealed an admission date of 08/26/22 with diagnoses including type two diabetes, dementia, and major depressive disorder.Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had moderate cognitive impairment.Review of current physician orders revealed an order initiated on 09/08/25 following the observation in the dining room indicating may give medications, check blood sugar and give insulin in public spaces and dining room.Observation on 09/08/25 at 11:22 A.M. of Registered Nurse (RN #360) revealed the nurse came up to Resident #39 sitting at a table in the dining room and informed the resident she had her insulin to administer. RN #360 proceeded to lift the resident's shirt and administer the insulin in the resident's abdomen.

One family member and three other residents were observed sitting at the same table.

RN #360 did not have gloves on during the administration of the insulin, nor did she perform hand hygiene prior to administering the insulin.Interview on 09/08/25 at 11:23 A.M. with RN #360 revealed the nurse verified she gave insulin in the dining room with other residents at the table. RN #360 stated she should have pulled the resident away from the table before administering the insulin. RN #360 stated she should have donned gloves prior to administering the insulin.Review of policy provided by the facility titled Subcutaneous injection revised 05/19/2025 revealed perform hand hygiene, provide privacy, explain the procedure to the patient, position the patient and expose the injection site, perform hand hygiene, put on gloves if contact with blood or bodily fluids is likely or if your skin or the patient's skin isn't intact.

Gloves are not required for routine subcutaneous injections because they do not protect against needlestick injury.This deficiency represents noncompliance investigated under Complaint Number 2601174.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/11/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Green Hills Center

6557 US 68 South West Liberty, OH 43357

SUMMARY STATEMENT OF DEFICIENCIES

Federal health inspectors cited GREEN HILLS CENTER in WEST LIBERTY, OH for a deficiency under regulatory tag F-F0628 during a standard health inspection conducted on 2025-09-11.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 6 deficiencies cited during this inspection of GREEN HILLS CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-27.

Federal health inspectors cited GREEN HILLS CENTER in WEST LIBERTY, OH for a deficiency under regulatory tag F-F0657 during a standard health inspection conducted on 2025-09-11.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 6 deficiencies cited during this inspection of GREEN HILLS CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-27.

Federal health inspectors cited GREEN HILLS CENTER in WEST LIBERTY, OH for a deficiency under regulatory tag F-F0686 during a standard health inspection conducted on 2025-09-11.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 6 deficiencies cited during this inspection of GREEN HILLS CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-27.

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Federal health inspectors cited GREEN HILLS CENTER in WEST LIBERTY, OH for a deficiency under regulatory tag F-F0698 during a standard health inspection conducted on 2025-09-11.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide safe, appropriate dialysis care/services for a resident who requires such services.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 6 deficiencies cited during this inspection of GREEN HILLS CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-27.

Federal health inspectors cited GREEN HILLS CENTER in WEST LIBERTY, OH for a deficiency under regulatory tag F-F0880 during a complaint investigation conducted on 2025-09-11.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Provide and implement an infection prevention and control program.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 6 deficiencies cited during this inspection of GREEN HILLS CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-27.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in WEST LIBERTY, OH, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from GREEN HILLS CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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