The Green House Cottages Of Walnut Ridge

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review and facility policy review, it was determined that the facility failed to provide the resident with needed medical services for one (Resident #24) of one resident reviewed. Specifically, the facility failed to enter a treatment order on the Treatment Administration Record (TAR), which resulted in an open wound to Resident #24's chest not being treated or assessed for one month. The findings include: Review of Resident #24's admission Record revealed the facility admitted Resident #24 on 01/19/2026 with diagnoses which included heart failure, muscle weakness, diabetes, protein calorie malnutrition, muscle wasting and atrophy, reduced mobility. Review of Resident #24's Care Plan initiated on 05/11/2026 revealed the resident had a skin tear/potential for skin tear of the right chest and the right elbow. Interventions included if a skin tear occurred to obtain an order, staff were to treat the skin tear as ordered and identify causative factors. Review of an Office 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 observation, interviews, record reviews and facility policy review, it was determined that the facility failed to notify staff that a resident who had a Peripherally Inserted Central Catheter (PICC) line in place was on Enhanced Barrier Precautions (EBP), resulting in a staff member transferring the resident without appropriate Personal Protective Equipment, and to ensure staff followed EBP when the requirement was posted for one (Resident #99) of one resident reviewed. The findings include: Review of Resident #99's admission Record revealed the resident was admitted by the facility on 04/08/2026 with an open wound to the lower left leg. Review of Resident #99's admission Minimum Data Set (MDS) with an Assessment Reference Date of 04/09/2026, revealed Resident #99 had a Brief Interview for Mental Status score of 10, which indicated Resident #99 had moderate cognitive impairment. The MDS also revealed that Resident #99 received intravenous (IV) medications and antibiotics via midline IV access.Review of Resident #99's Care Plan initiated 04/09/2026, revealed Resident #99…

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 1 of 1 meal observed. The findings are: 1. On 12/16/24 at 11:20 AM, Certified Nursing Assistant (CNA) #2 used a 6 ounce spoon to place a serving of chicken and dumplings into a blender, pureed, and poured in a divided plate to serve to residents. The texture of the pureed chicken and dumpling was too thick. 2. On 12/16/24 at 12:26 PM, CNA #2 used a regular spoon to place 2 servings of cut green beans into a blender, pureed and poured it in a divide plate. The texture of the pureed cut green beans was not smooth, not form, water was separated from the vegetables and there were noticeable pieces of stringy beans in the mixture. 3. On 12/16/24 at 11: 35 AM, CNA #2 placed a serving of cornbread into a blender, added milk, and pureed. CNA #2 poured the pureed cornbread into a divided plate. The texture of the pureed cornbread was too thick. 4. On 12/16/24 at 12:28 PM, CNA #2 was interviewed and was…

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, record review, and facility policy review, the facility failed to ensure CNAs thoroughly washed their hands before handling clean equipment, and 1 of 1 ice machine in the main building was maintained in clean and sanitary condition for 2 of 2 meals observed. The findings are: 1. On 12/16/24 at 11:13 AM, Certified Nursing Assistant (CNA) #1, who was preparing lunch meal in Cottage #1 ' s kitchen, placed a serving of strawberry cake into a blender, added whole milk and two tablespoons of thickener, and pureed. At 11:20 AM, CNA #1 picked up a spatula that was resting on top of a coffee pot inside the dirty side of the food preparation sink waiting to be washed, which had been in contact with food residue, and used it to scrape pureed strawberry cake into a bowl to be served to the resident on the pureed diet, there by contaminating the food. CNA #1 immediately was interviewed and was asked should a spatula in contact with the coffee pot inside the dirty sink be used in food. CNA #1 confirmed she should not have used dirty spatula in food. 2. On 12/16/24…

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 an oxygen cannister was stored securely to prevent accidents and hazards in Cottage One. The failed practice had the ability to affect all 8 residents who reside in the cottage. The findings are: 12/20/23 11:05 AM 9:40 AM, the medication closet in Cottage 1 was observed to contain a small number of supplies. OTC (Over the Counter) meds were observed to be within the use by the window. Tubing and supplies were also observed to be in date. At 9:42 AM, upon opening the double doors to the medication closet, an oxygen cannister was observed standing in the corner. The cannister was not secured in a rack. The Nurse Consultant immediately instructed the nurse to get a holder to secure the oxygen tank.

Based on observation and interview, the facility failed to ensure medications in a medication cart was used within date in accordance with accepted principles of pharmacy laws and regulations for 1 med cart. It had the potential to affect 4 Residents (#18, #28, #29, and #43) sampled residents who received insulin, and was stored in the med cart for 100 and 600 hall. The findings are: a. On 12/20/23 at 9:03AM, the medication cart for 100 & 600 halls was checked for expired medications. There were 4 vials of Novolog insulin with written date open on them. Novolog insulin for Resident # 29 had an opened date of 11/17/23. Novolog insulin for Resident #28 had an opened date of 11/12/23, Novolog insulin for Resident #43 had an opened date of 11/10/23 and Novolog insulin for Resident #18 had an opened date of 11/05/23. Licensed Practical Nurse (LPN) #2 was asks how long is insulin good for after being opened? She stated, 4 weeks. b. On 12/20/23 at 9:04 AM, the Surveyor asked LPN #2 how often do you check for expired medications? LPN #2 stated, The night nurses are responsible for checking…

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 record review and interview, the facility failed to ensure the Quality Assurance and Performance Improvement program [QAPI] Committee developed and implemented appropriate plans of action to prevent repeated deficiencies for (689) preventing accident and hazards. These failed practices had the potential to affect 8 residents residing in Cottage 1. The findings are: 1. A Recertification survey was conducted on 12/18/23 at the facility. During this survey, F689 was cited for facility failure to ensure an oxygen cannister was stored securely to prevent accidents and hazards in Cottage One. The review of the facility' s Plan of Correction, with a correction date of 12/14/22 indicated: This Plan of Correction and the individual responses are submitted as a Credible Allegation of Compliance solely to meet the requirements of continued certification in the Medicare and Medicaid Programs. These responses do not constitute an admission by the Provider of the truth of the facts alleged or the conclusions set for in the CMS-2567. Step #1: Corrective Action: Upon notification of the…

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 the call light was within reach for one Resident (Resident #73) in cottage 4. This failed practice endangers the health and safety of residents and had the potential to affect 11 residents that utilize call lights. The findings are: a. On 12/18/23 at 2:29 PM, Resident # 73 was lying in a specialty bed in high position. Resident #73 was awake and wearing a neck pillow, and glasses. The Surveyor observed the call light on the floor and under bed out of reach. b. On 12/18/23 at 3:04 PM, the Surveyor observed the call light in Resident #73's room in the same position, on the floor under the bed, and out of reach. The Surveyor asked Resident #73 if he could reach his call light and if he knew where it was. Resident # 73 answered, No to both questions. c. On 12/18/23 at 3:14 PM, the Surveyor asked CNA (Certified Nursing Assistant) if Resident #73's call light was within the Resident's reach. The CNA answered, No it's in the floor. We normally lay it across the bed across his lap because the clip is broken. The Surveyor…

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 that a Bi Pap (Bilevel Positive Airway Pressure) mask was stored properly to prevent cross contamination for 1 Resident (R #343) of two (#18 and #343) sampled residents who have physician's orders for a Bi pap machine. The findings are: On 12/18/23 at 11:45 AM, Resident #343 mask and bi-pap machine were on top of a hard plastic, 3 drawer storage unit. The mask was observed to be open to air, not stored in a bag to prevent cross contamination. On 12/20/23 at 9:30 AM, Resident #343's bi-pap mask was observed to be lying beside the bi-pap machine on top of the hard plastic, 3 drawer storage unit. The mask is open to air, not stored in a bag to prevent cross contamination. On 12/21/23 at 9:00 AM, Resident #343's bi pap mask was observed to be in the same location, where it had been observed all week. On 12/21/23 at 9:15 AM the Surveyor asked the Director of Nursing (DON) to view the resident's mask laying exposed to air and contaminants. The DON was asked how the Resident's mask should be stored. She…

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.