The Green House Cottages of Southern Hills

Number of residents sampled: Number of residents cited: Based on record review and interviews, the facility failed to ensure a resident’s wheelchair was properly secured to ensure the resident was safely transported in the facility van for one (Resident #4) of one resident reviewed. The findings include: A review of a Police Incident Report Form indicated that near an address between [town name] and the facility, Certified Nursing Assistant (CNA) #1 was driving the van with two passengers inside: the Activities Director (AD) and Resident #4. While traveling, the wheelchair Resident #4 was seated in suddenly rolled backwards. This caused Resident #4 to bump the back of their head. The resident was transported to the emergency room for evaluation and treatment. A review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 06/04/2025, revealed Resident #4 had a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. The MDS also indicated the resident had diagnoses which included fracture of unspecified part of thigh…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview, the facility failed to ensure (1) food preparation equipment was free of peeling and chipped paint to prevent potential food borne illness for resident who received meals from the kitchen in Cottage #6, (2) expired food items were promptly removed from stock to prevent potential food borne illness for residents who received meal trays from 7 of 7 kitchens, (3) foods stored in the freezer, refrigerator and dry storage area were covered, sealed, dated and were stored in accordance with the manufacturer's instructions for residents who received meals from the kitchen in Cottage #7, (4) that 1 of 7 ice scoop holder was maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages for residents who received meals from the kitchen in Cottage #7, and dietary staff washed their hands before handling clean equipment to prevent potential food borne illness for residents who received meals from the kitchen in Cottage #2. The failed practices had the potential to affect 12 residents who receive meals…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure medications were not left at the bedside for 2 (Residents #7 and #29) sampled residents. The findings are: 1. Resident #7 had diagnoses of dementia and pelvic/perineal pain. a. An admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/06/2024 documented Resident #7 scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status. b. Resident #7 had a Physician's Order for Diclofenac Sodium External Gel 1 % to be applied as needed for localized pain. c. Resident #7's Care Plan documented that the resident has pelvic and perineal pain and included intervention as follows: administer pain medications as ordered/needed, notify MD/Practitioner if not effective, administer PRN (as needed) pain medications as ordered to alleviate pain or for breakthrough pain. d. On 04/22/2024 at 10:10 AM, the Surveyor observed a container of Diclofenac Sodium 1% in the Resident's bathroom on a shelf. e. On 04/22/2024 at 12:13 PM, the Surveyor observed a container of Diclofenac…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. This failed practice had the potential to affect 1 resident who received pureed diets in Cottage #4, 1 resident who received pureed diets in Cottage #6, and 3 residents who received pureed diets in Cottage #7. The findings are: 1. On 04/22/2024 at 12:28 PM, the lead Certified Nursing Assistant (CNA) in Cottage #7 used a 4-ounce spoon to place 4 servings of cut green beans into a blender and pureed. She poured it into a divided plate on the counter. The consistency of the pureed green beans was runny and was not formed. Water was separated from the beans. 2. On 04/22/2024 at 12:30 PM, the lead CNA placed 4 servings of bread sticks into a blender, added whole milk and pureed. She poured the pureed bread into a divided plate. The consistency of the pureed bread was lumpy, and not smooth. The consistency of the pureed chicken alfredo on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure staff used proper hand hygiene while passing medication and providing perineal care for 2 (Resident #16 and #25) sampled residents. The findings are: 1. On 04/24/2024 at 07:24 AM, Licensed Practical Nurse (LPN) #3 prepared medications for Resident #16. At 07:32 AM, she put on gloves, administered eye drops, inhaler, and injected scheduled insulin into the abdomen of Resident #16. She then applied cream to Resident #16's arms and hands. At 7:36 AM, LPN #3 discarded the gloves and retrieved a clean pair and, without washing or sanitizing her hands, put on the clean pair of gloves and administered a second dose of eye drops in each eye of Resident #16. a. On 04/25/2024 at 07:59 PM, the Infection Preventionist (IP) was interviewed by telephone and was asked what should a nurse do before changing gloves during medication administration. She asked what the scenario was and was informed the nurse was changing administration routes. The IP then answered, Use hand sanitizer. She was asked why and stated, To…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure medications were not self-administered without a physician's order, and the interdisciplinary team (IDT) assessed residents to determine self-administration of medications was safe for 1 (Resident #33) of 1 sampled resident. The findings are: On 04/22/2024 at 11:44 AM, a bottle of Nystatin-Triamcinolone Cream was found in Resident #33's bathroom. Resident #33 stated that the resident applies the cream to the resident because of where it is located. On 04/24/2024 at 09:19 AM, a bottle of Nystatin-Triamcinolone Cream was found in Resident #33's bathroom. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/16/2024 documented Resident #33 scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS). Resident #33's Care Plan dated 04/01/2024, did not identify the resident as able or assessed to self-administer medications. The Medication Administration Record (MAR) dated April 2024 documented that Resident #33 had been diagnosed with candidiasis (a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure resident restrooms were cleaned to promote a clean and sanitary environment for 1 (Resident #43) of 1 sampled resident who used the bathroom in their room. The findings are: 1. Resident #43 had diagnoses of weakness and constipation as documented on an order summary. a. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/09/2024 documented the resident had a Brief Interview of Mental Status (BIMS) of 15 (13-15 indicates cognitively intact) and required substantial/maximal assistance with toileting hygiene. b. A Care Plan dated 02/16/2024 documented Resident #43 required assistance with some functional abilities related to weakness and requires assistance of one staff with toileting hygiene. c. On 04/22/2024 at 12:55 PM, Resident #43's toilet had brown stains on the inside and outside of the toilet bowl. d. On 04/23/2024 at 03:38 PM, Resident #43's toilet had brown stains on the inside and outside of the toilet bowl. e. On 04/25/2024 at 06:00 PM, Resident #43's toilet had a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure residents received proper and punctual incontinence care for 1 (Resident #25) sampled resident. The findings are: Resident #25 had diagnoses of Urinary tract infection and Candidiasis. An admission Minimum Data Set (MDS) with an Assessment Referenced Date (ARD) of 02/13/2024 documented Resident #25 scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status and was occasionally incontinent of bowel and bladder. A Care Plan with a review date of 02/23/2024, documented Resident #25 required assistance with functional abilities related to muscle weakness, lack of coordination, and fracture to left femur and shaft of right tibia. On 04/22/2024 at 09:55 AM, the Surveyor noted the odor of urine upon entering Resident #25's room that got stronger upon approach to the resident. Resident #25 was lying in bed with a blue disposable incontinence pad visible underneath the resident's body. On 04/22/2024 at 12:15 PM, the Surveyor observed Resident #25 lying in bed. The Surveyor noted that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to provide appropriate treatment and services for residents receiving enteral nutrition via Percutaneous Endoscopic Gastrostomy (PEG) tube for 1 (Resident #23) of 1 sampled resident. The findings are: Resident #35 had diagnoses of sequelae of cerebral infarction, epilepsy, aphasia, and dysphagia. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/23/2024 documented Resident #35 scored 3 (3 indicates severely impaired cognitive skills) on a Staff Assessment for Mental Status (SAMS) and had a PEG tube while a Resident. A Physician ' s Order for Resident #35 documented, Enteral Feed 45 ml (milliliter)/hour for 23 of 24 hours a day, enteral feed every shift flush rate of water (H2O) 60ml/hour, elevate HOB (Head of Bed) 30 to 45 degrees. A Care Plan with a review date of 04/04/2024 documented that Resident #35 had a PEG tube and needs HOB elevated 30 to 45 degrees during tube feeding. On 04/22/2024 at 10:40 AM, the Surveyor observed Certified Nursing Assistant (CNA) #1 at the bedside of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure a pharmacist's recommendation for the provider to provide an appropriate diagnosis before administering an antipsychotic medication was followed for 1 (Resident #20) sampled resident. The findings are: 1. Resident #20 had diagnoses of Dementia, Major depression, and Delirium due to unknown physiological condition. 2. Resident #20 had an order in place for Zyprexa, which is an antipsychotic medication that can treat several mental health conditions like schizophrenia and bipolar disorder. 3. A Medication Regimen Review (MRR) dated 09/29/2023 documented, A. Consultant Pharmacist .Antipsychotic recommendation . Unnecessary Psychotropic Medication . ZyPREXA Oral Tablet 5 MG (milligram) . Diagnosis: F33.1 MAJOR DEPRESSIVE DISORDER, RECURRENT, MODERATE . Consultant Pharmacist Notes .Consider appropriate diagnosis . a. The Attending Physician/Prescribing Practitioner response was, .Continue current medication regimen with no changes . Clinical rationale and/or documentation for continued need (risk vs. benefit): hospice .…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure that residents who experienced a significant change in status had a comprehensive assessment completed within 14 days of the facility determining that there had been a significant change for 2 (Residents #26, and #86) of 24 (#2, #11, #14, #26, #28, #29, #42, #43, #51, #57, #61, #63, #67, #69, #72, #73, #75, #77, #82, #85, #86, #87, #138, and #191) sampled residents who relied on the facility for accurate Minimum Data Set (MDS) documentation. The findings are: 1. Resident #26 had diagnoses of Systemic Lupus Erythematosus, Hemiplegia and Hemiparesis following Cerebral Infarction affecting left Dominant Side, and Primary generalized Osteoarthritis. The Quarterly MDS with an Assessment Reference Date (ARD) of 02/21/23 documented a score of 9 (8-12 indicates moderate impairment) on a Brief Interview for Mental Status (BIMS). a. The Quarterly MDS with an ARD of 11/21/22 documented the following under Section G, Subsection G0110. Activities of Daily Living (ADL) Assistance: i. Bed mobility required limited assistance with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards to prevent the worsening of a skin condition for 1 (Resident #11) sampled resident who had a non-pressure related skin condition and failed to provide services to prevent the worsening of a contracture for 1 (Resident #42) sampled resident who required a hand roll. The findings are: 1. Resident #11 had a diagnosis of Chronic Venous Hypertension (Idiopathic) with Ulcer of Bilateral Lower Extremities. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/07/23 received a score of 14 (13-15 indicates cognitively intact) on a Brief Interview Mental Status (BIMS). Requires one-person physical assist with bathing, supervision with locomotion on and off unit, toileting, dressing, personal hygiene and is independent with bed mobility and transfers. a. The Care Plan with a revision date of 05/11/22 documented, .Resident #11 is at risk for Impaired Skin Integrity .Report any skin concerns to nurse .Unna boot to bil…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide service to maintain appropriate sleep hygiene for 2 (Residents #11 and #67) sampled residents who use Continuous Positive Airway Pressure (CPAP). The findings are: 1. Resident #11 had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/07/23 documented a score of 14 (13-15 indicates cognitively intact) on a Brief Interview Mental Status (BIMS), required one-person physical assist with bathing, supervision with locomotion on and off unit, toileting, dressing, personal hygiene and was independent with bed mobility and transfers. a. The Care Plan with a revision date of 05/11/22 documented, .Resident #11 is at risk for altered respiratory status, complications/SOB [Shortness of Breath] r/t [related to] COPD and Respiratory Failure .CPAP @ [at] HS as ordered . b. The Physician's Order with a start date of 02/16/23 documented, .Auto BPAP [Bilevel Positive Airway Pressure] to be worn at bedtime IPAP [Inspiratory…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.