Greenhill Villas

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that appropriate information was communicated to the receiving health care institution to include Advance Directive information for 1 of 1 (Resident #3) resident reviewed for advance directives. Resident #3's Advance Directive information was inaccurately documented on the transfer form, and a copy of the advance directive was not provided to the EMS staff or hospital staff upon transfer to the emergency room. This deficient practice could place residents at risk for not having their wishes followed according to advance care planning.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 2 residents (Resident #1 and Resident #2) records reviewed for Resident #1 and Resident #2's Annual MDS did not correctly assess the resident's non-invasive ventilation (Bilevel Positive Airway Pressure) therapy. This deficient practice could place residents at-risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on interview and record review the facility failed to provide pharmaceutical services, including the accurate acquiring, administering and receipt of all drugs and biologicals, to meet the needs of 1 of 13 (Resident #2) residents reviewed for pharmacy services. The facility failed to ensure MA B stayed with Resident #2 and made sure she took her medications during medication pass 11/12/25. This failure could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications. Findings Include:1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services was provided, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 3 resident (Resident #1) reviewed for pressure injuries. 1. The facility failed to ensure CNA B and CNA C provided incontinent care, and turning and repositioning for Resident #1 on 10/09/25 and 10/10/25 causing Resident #1's wounds to worsen. 2. The facility failed to identify a wound prior to a PRN hospice visit on 10/11/2025, where the hospice nurse identified a stage ll sacral wound closed and dark in color, and by 10/13/2025 there was, per the evidence, a right heel abrasion, a left heel blister, and a sacral wound with eschar. 3. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 6 residents (Resident #1, Resident #2 and, Resident #3) room reviewed for infection control practices and enhanced barrier precautions. 1) The facility failed to ensure the Treatment nurse implemented enhanced barrier precautions and used PPE while providing care for Resident #1 on 10/27/25. 2) The facility failed to ensure CNA OO and CNA PP used the proper enhanced barrier precautions while providing incontinent care to Resident #1. [...]

Inspectors wrote3. Record review of Resident #40's face sheet, dated 06/17/25, indicated she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included dementia (a group of thinking and social symptoms that interferes with daily functioning), cerebral infarction (occurs when blood flow to the brain is blocked, causing brain tissue to die) and unstable angina (a serious heart condition characterized by chest pain or discomfort that occurs at rest). Record review of Resident #40's quarterly MDS assessment dated [DATE] indicated Resident #40 usually understood and usually understood others. Resident #40's had BIMS score of 5 which indicated severe cognitive impairment. Resident #40 required maximal assistance with toileting and showering. Resident #40 was dependent with lower body dressing and personal hygiene. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who require dialysis services receive such services consistent with professional standards of practice for 1 of 2 residents reviewed for dialysis services. (Resident #41) The facility failed to ensure the dialysis communication forms for Residents #41 were received back from the dialysis center after returning from dialysis treatment. The facility failed to ensure the post-dialysis assessments were completed and documented on Resident #41's dialysis communication forms on 02/17/25, 03/05/25. 04/16/25, and 06/04/25. The facility failed to ensure the post (after)-dialysis vital signs (are measurements of the body's most basic functions) were documented in Resident #41's EMR on 06/02/25, 06/11/25, 06/13/25, and 06/16/25. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in (1 of 1) kitchen reviewed for dietary services. The Facility failed to label and date all food items in the refrigerator. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on interview and record review the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of charges for those services, which included charges for services not covered under Medicare/Medicaid or by the facility's per diem rate for 2 of 3 residents (Resident #51, Resident #73) reviewed for Medicare/Medicaid coverage. The facility failed to ensure Resident #51, and Resident #73 was given a SNF ABN (is document that informs a Medicare beneficiary that Medicare will no longer pay for skilled services) when discharged from skilled services at the facility prior to covered days being exhausted. This failure could place residents at risk for not being aware of changes to provided services.

Inspectors wroteBased on observation, interviews and records reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to ensure the comprehensive care plan described the services and interventions to be used to attain and maintain the resident's practicable physical, mental, and psychosocial well-being for 1 of 20 residents reviewed for care plans (Resident #71). The facility failed to care plan Resident #71's oxygen therapy usage. Resident #71 was coded for oxygen therapy on the 04/29/25 MDS assessment. This failure could place residents at risk of not having their individualized needs met, and a decline in their quality of care and life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers based on the comprehensive assessment for 1 of 3 Residents (Resident #26) whose record were reviewed for skin integrity. The facility failed to ensure Resident #26's pressure-relieving mattress (is designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) was on the correct settings on 06/16/25 and 06/17/25. This failure could place residents at risk for developing pressure ulcers and could contribute to developing avoidable pressure ulcers.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 2 of 6 residents (Resident #14 and Resident #51) reviewed for respiratory care and services. 1. The facility failed to cover the nasal cannula tubing with a bag on an oxygen concentrator machine that was not in use for Resident #14. 2. The facility failed to cover the bi pap mask with a bag that was not in use for Resident #51. These failures could place residents at risk for developing respiratory complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked compartments for 1 medication cart of 3 (Medication Cart #3) reviewed for medication storage: The facility failed to ensure Medication Cart #3 was locked when unattended. This failure could place residents at risk of having access to unauthorized medications and/or lead to harm or drug diversions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents reviewed for enhanced barrier precautions (Resident #1) infection control practices. 1. The facility failed to ensure LVN J donned a gown prior to administering feeding to Resident #1 via g-tube. Resident #1 was on enhanced barrier precautions. This failure could place residents at risk of exposure to communicable diseases, cross-contamination, and infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents could call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 1 of 20 residents (Resident #71) reviewed for resident call system. The facility failed to ensure Resident #71 had a call light that was functional. Resident #71's call light did not turn on when the button was pressed on 06/17/25. This failure could place residents at risk for a delay in assistance and decreased quality of life, self-worth, and dignity.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident #1) reviewed for quality of care. 1. The facility failed to ensure Resident #1 was adequately supervised which resulted in Resident #1 leaving the facility on 08/22/24 and being found at a gas station in a town 38.1 miles east of the facility. 2. The facility failed to monitor and put measures in place to keep Resident #1 who was high risk for elopement from eloping from the facility on 08/22/24. 3. The facility failed to do a search of the surrounding area when they discovered a door alarm sounded on 08/22/24. The noncompliance was identified as PNC. The IJ began on 08/22/24 and ended on 08/23/24. [...]

Inspectors wroteBased on interview and record review the facility failed to provide the resident access personal and medical records pertaining to him or herself, upon an oral or written request, in the form and format requested by the individual, if it was readily producible in such form and format (including in an electronic form or format when such records were maintained electronically, or, if not, in a readable hard copy form or such other form and format as agreed to by the facility and the individual, within 24 hours (excluding weekends and holidays) and allow the resident to obtain a copy of the records or any portions thereof upon request and 2 working days advance notice to the facility for 1 of 2 residents (Resident #2) reviewed for access of records. [...]

Inspectors wroteBased on interviews and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 6 residents (Resident #1) reviewed for pharmacy services. The facility failed to follow orders from 10/02/2024 to 10/06/2024 and administered to Resident #1, Aricept (Alzheimer medication), and Meloxicam (nonsteroidal anti-inflammatory medication) after the medications were discontinued. This failure could place residents at an increased risk for inaccurate drug administration and not receiving the care and services to meet their individual needs.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 3 (Resident #1) residents reviewed for quality of care. 1. The treatment nurse failed to transcribe Resident #1's physician orders for wound care and provide wound care (clean with normal saline/wound wash, pat dry, apply collagen powder, med honey pad and secure with gauze island adhesive border once daily) to Resident #1's right lower shin from 08/23/24-08/31/24 as ordered resulting in hospitalization with a diagnosis of cellulitis (bacterial skin infection). 2. The facility failed to assess, document, and monitor for Resident #1's wound. An IJ was identified on 09/09/24. The IJ template was provided to the facility on [DATE] at 12:05 p.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide residents with personal privacy and confidentiality of his or her personal and medical records for 1 of 1 (Resident #1) resident reviewed for resident rights. The facility did not ensure the treatment nurse used a secure telephonic device to communicate with the wound nurse NP. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, for 1 of 3 (Resident #1) residents reviewed for abuse. 1. The facility failed to implement the abuse and neglect policy and procedure regarding reporting an injury of unknown origin. 2. The facility did not implement their policy on reporting neglect for laceration of unknown origin for Resident #1 to the abuse coordinator (Administrator) or HHSC. These failures could place the residents at increased risk for abuse and neglect.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported immediately, but no later than 2 hours after the allegation was made, for 1 of 3 (Resident #1) residents reviewed for abuse and neglect. The facility failed to report Resident #1's laceration to right lower leg, an injury of unknown origin, timely to HHSC. This failure to report could place the residents at risk for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have evidence that all alleged violations were thoroughly investigated for 1 of 3 (Resident #1) residents reviewed for abuse and neglect. The facility failed to conduct a thorough investigation when Resident #1 obtained a laceration to her right lower leg. This failure could place residents at risk of abuse and neglect.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food and nutrition services. 1. The facility failed to ensure all food items were properly dated and labeled in Refrigerator #1, Refrigerator #2, and Freezer #2. 2. The facility failed to ensure all food items were properly sealed in Freezer #1. 3. The facility failed to ensure Dishwasher E properly wore a facial hair cover while in the kitchen. These failures could place residents at risk of foodborne illness and food contamination.

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 18 residents (Resident #17) reviewed for infection control. 1. The facility failed to ensure CNA G changed her gloves after providing incontinent care to Resident #17 prior to touching Resident #17's clean brief, shoulder, hip, gown and her blanket. 2. The facility failed to ensure CNA G handled dirty linen appropriately. 3. The facility failed to ensure CNA G performed appropriate hand hygiene prior to handling Resident #17's bed remote, drinking cup and bedside table. 4. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 2 of 18 residents (Resident #25 and Resident #34), reviewed for care plans. 1. The facility failed to revise Resident #25's care plan after returning from the hospital with a urinary catheter (tubing inserted to the bladder to drain urine). 2. The facility failed to revise Resident #25's care plan to indicate he refused to have his urinary catheter removed 3. The facility failed to revise and update Resident #34's comprehensive care plan to reflect the resident was placed on hospice. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 18 residents (Resident #49) reviewed for accidents and supervision. The facility failed to ensure CNA A performed a safe mechanical lift transfer for Resident #49. This failure could place residents at risk of injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident with urinary incontinence, based on the resident's comprehensive assessment, received appropriate treatment and services to prevent urinary tract infections (UTI) for 2 of 4 residents (Residents #17 and Resident #25) reviewed for catheters. 1. The facility failed to ensure Resident #17 had an indwelling urinary catheter (tube inserted into the bladder to drain urine) securement/anchor device (used to secure an indwelling urinary catheter). 2. The facility failed to ensure Resident #25 had orders for care of his indwelling urinary catheter. These failures could place residents at risk for indwelling urinary catheter dislodgement, urethral (empties urine from the bladder and out of the body) damage, pain, urinary tract infections, and not receiving needed care.

Inspectors wroteBased on observations, interviews, and record review the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for 1 of 18 residents (Resident #66) reviewed for nutrition. 1. The facility failed to follow the dietician's recommended tubing feeding for Resident #66 to receive Glucerna 1.2 - 474 ml (2 cartons) four times a day for 2275 calories per day. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents the right to be free from abuse and/or neglect for 1 (Resident #1) of 15 residents reviewed for abuse and/or neglect. The facility failed to prevent CNA A from committing verbal abuse by telling Resident #1 to hush while he was upset. This failure could place residents at risk of emotional harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 12 residents (Resident #2) reviewed for accidents and hazards in that: 1. The facility failed to ensure the back door on the memory care unit was monitored and secured while there was a malfunction with the doors locking. During this time Resident #2 eloped. 2. The facility failed to monitor and supervise resident in the memory care unit who was an elopement risk. 3. The facility failed to in-service staff on elopement response. These failures could place residents at risk for inadequate supervision and accidents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene were provided for 3 of 6 (Resident #1, Resident #2, and Resident #3) residents reviewed for ADLs. The facility did not provide scheduled showers for Resident #1, Resident #2, and Resident #3. The facility did not schedule Resident #1 for a shower from February 18, 2024, through March 14, 2024 These failures could place residents at risk of skin irritation, skin infection, skin breakdown, not receiving services/care and decreased quality of life. Findings Include: 1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure respiratory care was provided consistent with professional standards of practice for 4 of 7 residents (Residents #261, #13, #2, and #28) reviewed for respiratory care and services. 1. The facility failed to document and monitor Resident #261's use of oxygen. 2. The facility failed to administer oxygen between 1-2 liters per minute via nasal cannula as prescribed by the physician for Resident #261. 3. The facility failed to administer oxygen at 2 liters per minute via nasal cannula as prescribed by the physician for Resident #13. The facility failed to ensure Resident #13's oxygen concentrator had a filter in place. 4. The facility failed to ensure Resident #2 and Resident #28's oxygen concentrator filters were cleaned. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that residents who require dialysis received such services, consistent with professional standards of practice for 3 of 3 resident (Resident # 41,#26, and #311) reviewed for dialysis. The facility failed to ensure nursing staff was checking Resident #41, #26, and #311's shunt (graft catheter aids the connection from a hemodialysis access point to a major artery) to left upper arm for bruit (sound heard through a stethoscope when held over the shunt) and thrill (vibration or buzz felt when fingers are laid on top of the shunt). This failure could place residents who receive dialysis at risk for complications and not receiving proper care and treatment to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 12 of 17 residents (Resident #6, Resident #51, and 10 Residents in a confidential group) reviewed for dietary services. The facility failed to provide palatable food served at an appetizing temperature and taste to Resident #6, Resident #51, and 10 Residents in a confidential group. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure: o food items were dated and sealed appropriately. o expired food items were discarded. o the deep fryer was cleaned and oil changed. o a dented can was stored separately. o the ranch dressing and taco seasoning holder was clean. These failures could place residents at risk for foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to maintain a quality assessment and assurance committee consisting at a minimum the required committee members for 6 of 6 meetings (October 2022, November 2022, December 2022, January 2023, February 2023, and March 2023) reviewed for QAPI. The facility did not ensure the Medical Director attended their QAPI meetings in October 2022, November 2022, December 2022, January 2023, February 2023, and March 2023. This failure could place residents at risk for quality deficiencies being unidentified, no appropriate plans of action developed and implemented, and no appropriate guidance developed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 3 residents (Residents #58 and #111) and 1 of 1 facility reviewed for infection control. 1. The facility failed to ensure Resident #111 was provided COVID-19 testing when she developed signs and symptoms. 2. The facility failed to ensure dirty linen bags were not tied to the clean linen carts. 3. NA P and Housekeeper U did not utilize appropriate PPE use throughout the facility. 4. LVN N did not wear gloves while checking Resident #58's blood sugar. 5. The facility did not ensure clean linen carts were covered. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 1 resident (Resident #17) reviewed for resident rights. The facility did not ensure CNA O and NA P treated residents with dignity and respect by referring to them as feeders. This failure could place residents at an increased risk of embarrassment, isolation, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to coordinate assessments with the (PASRR) program to the maximum extent practicable to avoid duplicative testing and effort for 1 of 6 residents (Resident #33) reviewed for PASRR. The facility failed to indicate on the PASRR level 1 screening that Resident #33 had a mental illness. This failure could affect residents with mental illnesses and place them at risk of not being assessed to receive needed services. Findings Include: Record review of Resident #33's consolidated face sheet dated 03/29/23 indicated she was an [AGE] year-old female that was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish based on the comprehensive assessment and consistent with the resident's needs and choices for 1 of 1 resident (Resident #58) reviewed for activities of daily living. The facility failed to provide communication assistance to effectively communicate with staff for Resident #58. This failure could place residents at risk for decline and diminished quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure a resident who is unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 17 residents reviewed for activities of daily living. (Resident #38 and Resident #51) 1. The facility failed to provide facial hair removal for Resident #38 and Resident #51. 2. The facility failed to ensure Resident #51 was routinely showered and his fingernails were clean. These failures could place residents who were dependent on staff to perform personal hygiene at risk or embarrassment, decreased self-esteem, or decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received appropriate treatment and services to prevent further decrease of ROM for 1 of 2 residents reviewed for range of motion. (Resident #40) The facility did not ensure Resident #40 had a contracture prevention device in place for the treatment of his left contracted hand. This failure could place residents at risk for decrease in mobility and range of motion and contribute to worsening of contractures.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 2 of 2 residents (Resident #8 and Resident #261) reviewed for pharmacy services. The facility failed to reconciliate on the treatment administration record and the Individual Patient's Narcotics Record the administration of Resident #8's Tylenol with Codeine #3 (controlled medication used for pain) on 3/21/2023 on the 6 AM to 6 PM. The facility failed to reconciliate on the Individual Patient's Narcotics Record the administration of Resident #261's Alprazolam (controlled medication used for anxiety) on 03/24/2023 at 9 PM. These failures could place the residents at risk of not having medications available for use and drug diversion.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled in accordance with professional standards for 1 of 4 medication carts (east nurse medication cart) reviewed for drugs and biologicals. The facility failed to ensure 2 insulin pens (device used to administer insulin to residents with high blood sugars) on the east nurse medication cart were dated when opened. This failure could place residents at risk of not receiving the therapeutic benefit of medications.