Greenhill Villas
GREENHILL VILLAS in MOUNT PLEASANT, TX — inspection on October 30, 2025.
Found 2 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.
Inspection Findings
During interviews conducted on 10/30/25 at 9:59 AM- 10/30/25 at 1:57 PM with the Administrator, DON, ADON, Business Office Manager, Activity Director, Social Worker, Dietary Manager, LVN A, CNA B, CNA C, CNA D, Housekeeping E, LVN F, CNA G, LVN H, LVN K, CMA L, CNA M, CMA N, LVN O, COTA P, Medical Records Director, Laundry R, Maintenance Director S, LVN T, CNA U, CNA V, Housekeeping Supervisor W, Housekeeping Supervisor X, CNA Y, CMA Z, CMA AA, CNA BB, CNA CC, Dietary cook DD, Floor Maintenance EE, ADON FF, CNA GG, and CNA HH indicated they had been in-serviced on the facilities abuse and neglect policy, the pressure prevention policy, the skin assessment policy, documentation, notifying change of condition, and rounding to be completed in the facility.
Record review of Resident #1's skin assessment indicated it was completed on 10/28/25 with no new skin issues noted and signed by the DON.
Record review of Resident #1's pressure ulcer assessment indicated it was completed on 10/28/25 with no new concerns and signed by the DON.
Record review of Resident #1's treatment orders, supplements, and care plan indicated they were completed with orders in place and care plan updated as of 10/28/25.
Record review of all resident head-to-toe assessments completed by the DON and ADON with no concerns noted as of 10/28/25.
Record review of 6 residents with pressure ulcers with completed ulcer assessments completed with no concerns noted on 10/28/25.
Record review completed on10/30/25 of copies of all residents with updated care plans with interventions put in place for wounds.
Record review of the signature sheet for the ADHOC QAPI meeting that was held on 10/29/25 indicated the medical director and the IDT team were in attendance.
Record review of the 1:1 in-service provided to the Administrator, DON, and ADON completed on 10/29/25 indicated they were in-serviced over the pressure prevention policy, the skin assessment policy, documentation, notifying change of condition, abuse and neglect, and rounding in the facility.
Record review of the staff in-services related to the IJ provided indicated the staff that had been to work were in-serviced over the pressure prevention policy, the skin assessment policy, documentation, notifying change of condition, abuse and neglect, and rounding in the facility.
The Administrator was informed that the Immediate Jeopardy was removed on 10/30/2025 at 1:57 PM.
The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that was not Immediate Jeopardy and a scope of isolated due to the facility's need to monitor the implementation of the plan of removal.
Evaluate the effectiveness of the corrective systems that were put into place.
676241 10/30/2025
Greenhill Villas 2530 Greenhill Rd Mount Pleasant, TX 75455
MDRO when Contact Precautions do not otherwise apply (see MDRO list on page 3); orWounds and/or
orskin tears covered with an adhesive bandage (e.g., Band-Aid(R)) or similar dressing.
Examples of
wounds, and venous stasis ulcers.Indwelling medical device examples include central lines, urinary catheters, feeding tubes, andtracheostomies. A peripheral intravenous line (not a peripherally inserted central catheter) is not considered an indwelling medical device for the purpose of EBP.The facility will ensure PPE and alcohol-based hand rub are readily accessible to staff prior to entry to their room .Communication to Staff The facility will utilize postings outside the room and Point Click Care to communicate to staff if a resident requires EBP.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.