Inspection Report Summary
The most recent inspection on November 19, 2025, found the facility in substantial compliance with no deficiencies cited. Earlier inspections showed a mixed record, including a November 21, 2024 survey that identified deficiencies related to resident dignity during dining, care planning, medication errors resulting in hospitalization, and food handling practices. Complaint investigations were generally unsubstantiated, with the exception of the 2024 incident that led to the cited deficiencies; no fines or enforcement actions were listed in the available reports. Prior complaints were mostly unsubstantiated, and the facility has addressed some issues through performance improvement projects and updated policies. The overall trend suggests improvement since the 2024 deficiencies, with the most recent inspection showing compliance.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
1.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
70% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
44 residents
Based on a November 2024 inspection.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 19, 2025
Visit Reason
A complaint investigation for complaints #2632204-C was conducted from November 18th to November 19th, 2025.
Complaint Details
Complaint investigation for complaint #2632204-C; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance with no deficiencies cited.
Report Facts
Complaint number: 2632204
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 5, 2024
Visit Reason
The document serves as a Plan of Correction following a prior inspection, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance with health requirements, leading to certification effective December 5, 2024.
Inspection Report
Annual Inspection
Census: 44
Deficiencies: 7
Date: Nov 21, 2024
Visit Reason
The inspection was conducted as an annual recertification survey and included an investigation of a facility reported incident #123194-I.
Complaint Details
Facility reported incident #123194-I was substantiated during the investigation.
Findings
The facility was found deficient in multiple areas including failure to maintain dignity in dining for residents, incomplete baseline and comprehensive care plans, failure to follow physician orders, medication errors leading to hospitalization, unsanitary food handling practices, and incomplete documentation of treatment orders.
Deficiencies (7)
Failed to maintain dignity in dining for 2 of 4 residents by segregating residents needing assistance in a small assisted dining room causing feelings of being discarded.
Failed to develop and implement a baseline care plan including high-risk medication use for 1 of 5 residents reviewed.
Failed to develop and implement a comprehensive person-centered care plan including pressure ulcer and treatment for 1 of 12 residents reviewed.
Failed to follow physician's order for pressure injury treatment for 1 of 12 residents reviewed (prevalon boots applied only to one foot instead of both).
Failed to ensure quality of care by administering incorrect medications to 1 resident resulting in hospitalization.
Failed to serve food under sanitary conditions, including improper glove use and cross-contamination risks during meal service.
Failed to maintain complete and accurate resident records by documenting treatment orders as completed when not fully implemented.
Report Facts
Resident census: 44
Residents reviewed for baseline care plans: 5
Residents reviewed for comprehensive care plans: 12
Residents reviewed for medication error: 1
Residents reviewed for treatment order compliance: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Certified Nurse Aide (CNA) | Mentioned in assisted dining room supervision and dining dignity findings |
| Staff F | Registered Nurse (RN) | Provided explanation about assisted dining room placement |
| Staff G | Certified Nurse Aide (CNA) | Described resident assistance needs in assisted dining room |
| Director of Nursing | Provided multiple interviews regarding care plan expectations and assisted dining room rationale | |
| Staff C | Certified Nurse Aide (CNA) | Acknowledged only one prevalon boot applied to resident's feet |
| Staff E | Registered Nurse | Signed treatment administration record as completed despite incomplete treatment |
| Staff H | Certified Medication Aide (CMA) | Involved in medication error incident |
| Staff A | Food & Beverage Coordinator | Observed with improper glove use and unsanitary food handling |
| Staff B | Dietary Aide | Observed moving cups by top edge, risking contamination |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Nov 9, 2023
Visit Reason
The inspection was a recertification survey with an investigation of incident #116627 conducted from November 6, 2023 to November 9, 2023.
Complaint Details
Facility Reported Incident #116627 was investigated and found not substantiated.
Findings
The Green Hills Health Care Center was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities. The facility reported incident #116627 was not substantiated.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 19, 2022
Visit Reason
The document is a plan of correction submitted following a prior inspection, indicating acceptance of the facility's credible allegation of compliance.
Findings
The facility was certified in compliance effective November 23, 2022, based on acceptance of the plan of correction. No specific deficiencies or severity levels are detailed in this document.
Inspection Report
Annual Inspection
Census: 44
Deficiencies: 1
Date: Nov 22, 2022
Visit Reason
The inspection was conducted as the facility annual recertification survey from November 16, 2022 to November 22, 2022. Additionally, complaint investigations #99645-C and #103645-C were conducted but not substantiated.
Complaint Details
Investigation of complaint #99645-C and #103645-C was not substantiated.
Findings
The facility failed to administer prescribed bowel movement medications as ordered for a resident (#17) who had no bowel movement for 4 days, resulting in a deficiency related to medication administration and bowel management protocols. The facility implemented a performance improvement project and updated policies to address the issue.
Deficiencies (1)
Failed to administer medication as ordered for a resident with no bowel movement for 4 days.
Report Facts
Census: 44
Hospitalizations: 3
Days without bowel movement: 4
Medication dosages: 10
Medication dosages: 17
Medication dosages: 8.6
Medication dosages: 50
Medication dosages: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Confirmed bowel movement action form and medication administration issues |
| Director of Nursing | Director of Nursing (DON) | Confirmed resident did not receive PRN medication for lack of bowel movement and explained expectations |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 19, 2021
Visit Reason
A recertification health survey was completed on 08-19-21 to assess the facility's compliance with federal regulations.
Findings
The facility was found in substantial compliance at the time of the survey with no deficiencies cited.
Inspection Report
Routine
Census: 42
Deficiencies: 0
Date: Dec 17, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on 12/16/20 - 12/17/20 to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Census: 40
Deficiencies: 0
Date: Nov 21, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 40
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 0
Date: Sep 28, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with investigation of complaint #87612-C and facility self report #92401-I from 9/21/20 through 9/28/20.
Complaint Details
Complaint #87612-C and facility reported incident #92401-I were investigated and found not substantiated.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. Both the facility reported incident #92401-I and complaint #87612-C were not substantiated.
Report Facts
Total residents: 41
Inspection Report
Abbreviated Survey
Census: 46
Deficiencies: 0
Date: Jun 25, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on 6/25/20 to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 46
Viewing
Loading inspection reports...
