Inspection Reports for
The Green House Cottages of Belle Meade
2200 Chateau Blvd, Paragould, AR, 72450
Back to Facility ProfileInspection Report — Aug 1, 2025
Routine
Deficiencies: 3
Date: Aug 1, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication management, food handling and hygiene practices, and infection prevention and control at The Green House Cottages of Belle Meade nursing facility.
Findings
The facility was found deficient in ensuring psychotropic medications were reviewed and updated every 14 days for one resident, proper hand hygiene and glove use during meal service, safe food preparation practices including utensil contamination prevention, and proper disposal of personal protective equipment (PPE) when exiting a resident's room on Enhanced Barrier Precautions.
Deficiencies (3)
Failed to ensure an as needed psychotropic medication was reviewed and updated every 14 days for one resident.
Failed to ensure hands were washed between residents while serving dinner and utensils were not used after contamination during meal preparation.
Failed to ensure personal protective equipment (PPE) was disposed of before walking out of one resident's room on Enhanced Barrier Precautions.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: Many
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner | Indicated psychotropic medication should be reviewed every 14 days | |
| Director of Nursing | Unaware that antianxiety medication order had to be rewritten every 14 days | |
| Licensed Practical Nurse #3 | Uncertain about renewal timing of anxiety medication | |
| Medical Director | MD | Unaware that as needed medications should be reviewed and updated every 14 days |
| Certified Nurse Aide #4 | CNA | Observed not washing hands or changing gloves properly during meal service |
| Certified Nurse Aide #5 | CNA | Observed not washing hands or changing gloves properly during meal service |
| Certified Nurse Aide #6 | CNA | Observed not washing hands or changing gloves properly during meal service |
| Dietary Manager #7 | DM | Confirmed contamination of utensils and planned in-service for handwashing |
| Registered Nurse #8 | RN | Observed improper PPE disposal and confirmed proper procedures |
| Registered Nurse #9 | RN | Observed improper PPE disposal and confirmed proper procedures |
| Certified Nurse Aide #1 | CNA | Observed contaminating utensils during food preparation |
Inspection Report — Dec 19, 2024
Complaint Investigation
Deficiencies: 1
Date: Dec 19, 2024
Visit Reason
The inspection was conducted due to an immediate jeopardy incident where Resident #1 slid off the side of the bed while being assisted by only one staff member, contrary to the care plan requiring two staff, resulting in a major injury.
Complaint Details
The complaint investigation found that Resident #1 was assisted by only one staff member instead of two as required, leading to a fall and injury. The immediate jeopardy was substantiated and removed after corrective actions were implemented.
Findings
The facility failed to ensure staff followed Resident #1's care plan for assistance with dressing, leading to a fall and serious injury requiring hospitalization and surgical repair. The facility implemented a Plan of Removal including staff in-services, care plan reviews, and monitoring to prevent recurrence.
Deficiencies (1)
Failure to ensure adequate supervision and assistance per care plan, resulting in Resident #1 sliding off bed and sustaining a broken femur.
Report Facts
Residents assessed for 2-person assistance: 12
Residents observed for ADL care: 6
Staff interviewed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Involved in incident where Resident #1 fell; provided witness statements and interviews |
| CNA #2 | Certified Nursing Assistant | Witnessed incident and provided statements and interviews |
| LPN #3 | Licensed Practical Nurse | Provided witness statement and interview regarding care plan and incident |
| Administrator | Notified of immediate jeopardy and involved in corrective actions | |
| Assistant Administrator | Notified of immediate jeopardy and involved in corrective actions | |
| Director of Nursing | Conducted resident assessments, monitored care, and led staff in-services |
Inspection Report — Apr 25, 2024
Routine
Deficiencies: 4
Date: Apr 25, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, activities, dietary services, and infection control at The Green House Cottages of Belle Meade.
Findings
The facility was found deficient in multiple areas including failure to provide regular fingernail care for a resident, lack of meaningful activity programs for residents, improper preparation of pureed food consistency, and failure to ensure proper hand sanitation by nursing staff during medication administration.
Deficiencies (4)
Failure to ensure a resident who required assistance with personal hygiene was regularly offered fingernail cleaning to maintain good grooming and hygiene.
Failure to provide a meaningful program of activities for 5 sampled residents and failure to ensure the activity program met individual needs, interests, and abilities.
Failure to ensure pureed food was blended to a smooth, lump-free consistency for residents requiring pureed diets.
Failure to ensure nurse completed hand sanitation before and after giving medication to residents.
Report Facts
Residents affected: 1
Residents affected: 5
Meals observed: 2
Date of survey completion: Apr 25, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #4 | Responsible for fingernail care; interviewed about nail care practices | |
| Certified Nursing Assistant (CNA) #3 | Interviewed about activity calendars and activity program | |
| Certified Nursing Assistant (CNA) #5 | Interviewed about activity occurrences and plans | |
| Certified Nursing Assistant (CNA) #6 | Interviewed about activities offered and attendance logs | |
| Certified Nursing Assistant (CNA) #9 | Interviewed about activities on Dalton Hall | |
| Certified Nursing Assistant (CNA) #1 | Assisted resident with pureed food; described food consistency | |
| Certified Nursing Assistant (CNA) #2 | Assisted resident with pureed food; described food consistency | |
| Dietary Manager (DM) | Described desired consistency of pureed food and confirmed deficiencies | |
| Clinical Manager | Confirmed pureed food items were grainy and not smooth | |
| Consultant | Confirmed lack of policy concerning specialized diets, specifically pureed food | |
| Licensed Practical Nurse (LPN) #1 | Observed failing to sanitize hands before and after medication administration | |
| Director of Nursing (DON) | Interviewed about hand sanitation responsibilities and infection control | |
| Administrator | Provided inservice documentation on medication administration and infection control |
Inspection Report — Feb 3, 2023
Annual Inspection
Census: 117
Deficiencies: 7
Date: Feb 3, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements, including resident care, safety, infection control, nutrition, and staff vaccination status.
Findings
The facility was found deficient in multiple areas including failure to implement individualized comprehensive care plans for residents on oxygen and insulin therapy, unsafe laundry room conditions, improper respiratory care including oxygen administration errors, inadequate food preparation and storage practices, infection control breaches, and incomplete COVID-19 vaccination coverage for residents and staff.
Deficiencies (7)
Failure to ensure individualized comprehensive Care Plans were implemented to meet residents' medical and nursing needs, including oxygen therapy and insulin use.
Laundry room doors unlocked, dryer lint traps not properly maintained, and electrical cords in water creating fire and injury hazards.
Oxygen therapy not administered at physician ordered flow rates; lack of physician orders for oxygen therapy for some residents; improper storage of CPAP and nebulizer equipment.
Meals not prepared and served according to planned menus; pureed foods not blended to smooth consistency; food temperatures not properly checked; food storage and handling violations including expired and uncovered food items.
Failure to follow infection control precautions including improper cleaning of glucometers between residents and failure to use appropriate personal protective equipment for residents on isolation.
Failure to provide timely COVID-19 vaccinations to consenting residents and incomplete or missing documentation of consents and declinations.
Failure to ensure all staff received complete primary COVID-19 vaccinations or had approved exemptions or delays, with some staff working unvaccinated.
Report Facts
Residents affected: 117
Laundry rooms unlocked: 6
Dryer lint traps improperly maintained: 6
Residents with oxygen therapy flow rate errors: 4
Residents without physician oxygen orders: 2
Residents with improper CPAP storage: 3
Residents on pureed diets: 5
Residents on mechanical soft diets: 22
Residents on regular diets: 74
Staff COVID-19 positive cases: 14
Resident COVID-19 positive cases: 6
Staff working unvaccinated days: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Named in oxygen therapy flow rate errors and improper oxygen order adherence |
| CNA #13 | Certified Nursing Assistant | Named in improper food preparation and hand hygiene violations |
| Administrator | Named in QAA meeting and COVID-19 vaccination policy discussion | |
| DON | Director of Nursing | Named in infection control and COVID-19 vaccination policy discussion |
| HRA | Human Resource Assistant | Named in COVID-19 vaccination record and staff vaccination tracking |
| ADON | Assistant Director of Nursing | Named in infection control and COVID-19 vaccination record discussion |
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