Greenhill Villas
GREENHILL VILLAS in MOUNT PLEASANT, TX — inspection on February 26, 2026.
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 an interview on [DATE] at 8:15 a.m., Resident #3's responsible party stated that
that after discussion with the hospital physician and conversation with other family members had
his directive.
During an interview on [DATE] at 3:22 p.m., the DON stated that she expected the nursing staff to provide a copy of Advance Directives to EMS staff for all hospital transfers to ensure the resident's wishes are honored.
The DON stated it is important that external entities are provided with accurate information to ensure the resident's and/or responsible parties wishes are honored.
The DON stated that she had completed an Inservice training for the nursing staff on accurate completion of all transfer / discharge documents.
During an interview on [DATE] at 3:50 p.m., the Administrator stated the adverse effect of not providing accurate documentation on hospital transfers and all discharges could be negative outcomes for the resident if the care did not match the treatment orders.
The Administrator stated she expected the nursing staff to provide accurate information on transfers and discharges and that the DON is responsible for ensuring the nursing staff are trained on the discharge process and that she as the Administrator is ultimately responsible for monitoring the accuracy of documentation for discharges.
Review of facility policy titled, Self Determination End of Life Measures, undated, revealed Policy: 3.
The facility will respect the wishes of the resident as outlined in the advance directive.The primary nurse will note the resuscitation status of the resident on all applicable clinical records.and also, document whether or not the resident has executed the advance directive.
676241 02/26/2026
Greenhill Villas 2530 Greenhill Rd Mount Pleasant, TX 75455
During an interview on 02/26/2026 at 3:22 p.m., the DON stated that the MDS should accurately reflect the resident's needs to ensure the care plan is properly generated.
The DON stated that it is the responsibility of the MDS nurses to assess each resident and accurately record the findings on the MDS and that ultimately, it is her responsibility to ensure the data is accurate.
During an interview on 02/26/2026 at 3:50 p.m., the Administrator stated that improper coding on the MDS Assessment could result in inaccurate or improper treatment plan for the residents and potentially improper billing.
The Administrator stated the DON is ultimately responsible for ensuring the accuracy of the MDS Assessment and she expected the MDS information to be coded accurately.
Record review of the facility policy titled, Minimum Data Set Policy, undated, indicated Purpose: to utilize the most current version of the resident assessment instrument manual to guide all IDT members on the proper procedure for coding items on the MDS assessment, completion of care area assessment, and other instructions related to MDS procedure.
Record review of the MDS 3.0 Nursing Home Comprehensive Version 1.20.1 Effective 10/01/2025 revealed Section O - Special Treatments, Procedures, and Programs O0110, check all of the following treatments procedures, and programs that were performed b.
While a Resident within the last 14 days, G1.
Non-Invasive Mechanical Ventilator.