Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Green Hills Center during CMS and state inspections, most recent first.
A resident with chronic pressure ulcers did not receive consistent care as per physician orders, with multiple missed dressing changes and wound vac applications. Despite being under a wound physician's care, the facility failed to adhere to the treatment regimen, as confirmed by the resident and staff interviews. The facility's policy on skin care management was not followed, leading to non-compliance.
A resident with Alzheimer's and cognitive impairments was physically abused by STNAs who restrained the resident's wheelchair with a desk chair and pushed the resident's head onto a pillow to induce sleep. The facility's investigation confirmed the abuse, and the local police were notified. Witnesses corroborated the incident, and the involved staff were barred from returning.
A facility failed to update a resident's care plan to include the use of a custom tilt and space wheelchair for comfort and positioning. The resident, with multiple cognitive and physical impairments, was observed without footrests in the wheelchair, contrary to therapy recommendations. Staff interviews confirmed the oversight, and the facility's policy requires care plan updates to reflect current needs.
A medication error occurred when an LPN administered bisacodyl instead of the prescribed Senna concentrate to a resident with severe cognitive impairment and constipation. This error contributed to a medication error rate of 6.3%, exceeding the acceptable threshold. The facility's policy mandates that medications be administered as prescribed, which was not followed in this case.
Two residents in an LTC facility received incorrect medications due to errors by an LPN. One resident, with vascular dementia, received another's insulin and other medications without proper monitoring. Another resident received their roommate's medications, with no documented monitoring for adverse reactions. The facility's policy requires medications to be administered as prescribed, but these incidents show a failure to comply.
A resident with moderate cognitive impairment and a history of elopement was found outside the facility unattended and returned by a visitor. Despite having a wander guard, staff did not respond appropriately to the alarm, and the resident's family was not notified until several hours later, contrary to facility policy.
A resident with dementia and other medical conditions eloped from the facility despite having a wander guard device. The facility's alarm system failed to prevent the elopement, and staff did not conduct a resident head count after responding to an alarm. The resident was found outside by a visitor and returned to the facility without injuries.
Failure to Follow Pressure Ulcer Care Orders
Penalty
Summary
The facility failed to provide appropriate care for a resident with pressure ulcers according to the physician's orders. The resident, who was admitted with a stage 3 and a stage 4 pressure ulcer, had a history of neuromyelitis, neurogenic bladder, chronic pain, and osteomyelitis. Despite being under the care of a community wound physician, the facility did not consistently follow the prescribed treatment regimen, which included specific dressing changes and the application of a wound vac. The Treatment Administration Record (TAR) revealed multiple instances where the resident did not receive the required dressing changes for both the left and right buttock wounds. These omissions occurred over several months, with specific dates noted in December, January, and February. Additionally, the wound vac care was not administered on two occasions in February. Interviews with the resident and staff confirmed the lack of consistent treatment, with the resident acknowledging that dressings were not changed daily as ordered. Staff interviews highlighted a lack of awareness and communication regarding the resident's treatment schedule. The LPN responsible for the unit was unaware of the specific dressing change orders and relied on the wound clinic for updates. The facility's policy on skin care management was not adhered to, as evidenced by the missing documentation and failure to promote healing of the pressure ulcers. This deficiency was investigated under specific complaint numbers, indicating a broader issue of non-compliance within the facility.
Resident Abuse Due to Improper Restraint and Physical Coercion
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving a resident with Alzheimer's disease and other cognitive impairments. The resident required substantial assistance with daily activities and was at risk for social isolation. On the date of the incident, a State tested Nursing Aide (STNA) positioned a desk chair to block the resident's wheelchair from moving, effectively restraining the resident. Additionally, it was reported that two STNAs were observed pushing the resident's head down onto a pillow at the nurse's station, attempting to make the resident sleep. The facility's investigation substantiated the abuse allegations, and the local police department was notified. Witness statements confirmed the inappropriate actions of the STNAs, and the facility's Director of Nursing and Administrator verified the occurrence of physical abuse. The facility's policy on abuse and neglect defines abuse as the willful infliction of injury or unreasonable confinement, which aligns with the actions taken by the staff involved. The facility was unable to obtain statements from the alleged perpetrators, who were subsequently barred from returning to the facility.
Failure to Update Care Plan for Wheelchair Use
Penalty
Summary
The facility failed to revise a resident's plan of care to reflect the use of a custom tilt and space wheelchair, which was necessary for the resident's comfort and positioning. The resident, who had Alzheimer's disease, dementia with psychotic disturbance, major depression, anxiety, mild neurocognitive disorder, psychosis, and muscle weakness, was dependent on staff for dressing and personal hygiene. Despite being placed in the custom wheelchair after receiving therapy for positioning and comfort, the comprehensive plan of care and physician orders did not document the use of this wheelchair or the need for footrests. Observations and staff interviews confirmed that the resident was seated in the tilt and space wheelchair without footrests, leaving their feet dangling. The Director of Nursing and an Occupational Therapist verified that the resident was supposed to have footrests and that the care plan should have been updated following the therapy intervention. The facility's policy on comprehensive resident-centered care plans requires modifications to meet the resident's current needs, but this was not adhered to in this case.
Medication Administration Error Exceeds Acceptable Rate
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders, resulting in a medication error rate exceeding five percent. During an observation, it was noted that there were 32 opportunities for medication administration, with two errors occurring, leading to a 6.3% error rate. This error affected one resident, who was observed during the medication administration process. The resident, identified as having severe cognitive impairment and a diagnosis of constipation, was supposed to receive Senna concentrate as per the physician's orders. However, during the medication administration, an LPN administered two bisacodyl tablets instead of the prescribed Senna concentrate tablets. The LPN confirmed the error upon reviewing the medication administration record and acknowledged that the resident did not have a physician's order for bisacodyl. The facility's policy on medication administration requires that medications be administered as prescribed, which was not adhered to in this instance. This deficiency was investigated under a specific complaint number.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure medications were administered without significant errors, affecting two residents. Resident #100, who had vascular dementia and other health issues, received another resident's medications, including Lantus insulin, which was not prescribed for them. The incident occurred during an evening medication pass, and although the physician was notified, there was no documentation of the physician's orders for monitoring the resident's blood sugar and vital signs. The nurse responsible for the error was marked as a Do Not Return to the facility, but the necessary monitoring was not completed as per the physician's verbal order. Resident #125, with diagnoses including heart failure and dementia, received their roommate's medications during a morning medication pass. The incident was reported to the physician, but there was no documentation of first aid or treatment provided. The nurse involved was sent home, and the staffing agency was informed. Despite the error, there was no documentation of monitoring for adverse reactions for at least 48 hours, as should have been done according to the facility's procedures. The facility's policy on medication administration states that medications should be administered as prescribed and by authorized personnel. However, the incidents involving Residents #100 and #125 demonstrate a failure to adhere to these policies, resulting in significant medication errors and inadequate monitoring and documentation following the errors. This deficiency was investigated under a specific complaint number.
Failure to Timely Notify Resident's Representative of Elopement Incident
Penalty
Summary
The facility failed to ensure timely notification of a resident's representative following an elopement incident involving a resident with moderate cognitive impairment and a history of elopement. The resident, who had diagnoses including dementia and required substantial staff assistance for mobility, was found outside the facility unattended and was returned by a visitor. Despite the presence of a wander guard device, staff did not respond appropriately to the alarm, and the resident's family was not notified until several hours after the incident. The medical record review revealed that the resident had a wander guard in place and was assessed as being at risk for elopement. On the night of the incident, staff responded to an alarm but failed to locate the resident, who was later found in the parking lot. The facility's policy required immediate notification of the resident's representative in such events, but this was not done in a timely manner. The administrator confirmed the delay in notification and the initiation of an investigation following the incident.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate interventions and supervision to prevent the elopement of a resident who was assessed as being at risk for elopement. The resident, who had medical diagnoses including cerebral infarction, dementia, and diabetes mellitus, was found outside the facility unattended. The resident had a wander guard device in place, but the facility's alarm system did not effectively prevent the elopement. Staff responded to an alarm but did not conduct a resident head count, leading to the resident being outside for approximately 45-50 minutes before being returned by a visitor. The resident did not sustain any injuries from the incident. The facility's Director of Nursing confirmed that the resident was able to exit through a set of sliding doors that did not have the ability to lock or alarm when a resident with a wander guard was near. The facility's policy on elopement was not effectively implemented, as staff failed to ensure the resident's safety and timely redirection to a safe environment. The facility had not completed the investigation, training, and audits for the elopement at the time of the report.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near West Liberty
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Logan Acres | 6.6 mi | — | 0 | 0 |
| Ayden Healthcare Of Belle Springs. | 7.1 mi | — | 0 | 0 |
| Vancrest Of Urbana, Inc | 8.4 mi | — | 0 | 0 |
| Urbana Health & Rehabilitation Center | 11.1 mi | — | 0 | 0 |
| Als Woodstock Inc | 12 mi | — | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.