Deficiencies (last 4 years)
Deficiencies (over 4 years)
9.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
83% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 8, 2025
Visit Reason
The inspection was conducted due to concerns about the facility's failure to implement care planned fall interventions and failure to notify the guardian when Resident #1 refused ordered medications multiple times.
Complaint Details
The investigation was complaint-related, focusing on failure to implement fall interventions and failure to notify the guardian of medication refusals. The guardian was notified only sporadically despite requests for notification after each refusal.
Findings
The facility failed to implement fall prevention interventions for Resident #1 and did not notify the resident's guardian after multiple medication refusals. Observations confirmed absence of fall mats and signage in the resident's room. Medication Administration Records showed numerous refusals of prescribed medications. Interviews with staff and the guardian confirmed inconsistent notification of medication refusals.
Deficiencies (2)
Failure to ensure care planned fall interventions were implemented for Resident #1.
Failure to notify Resident #1's guardian that the resident refused to take ordered medication more than two times in a row.
Report Facts
Medication refusals: 21
Medication refusals: 15
Medication refusals: 21
Medication refusals: 21
Medication refusals: 21
Medication refusals: 16
Medication refusals: 15
Blood sugar level: 506
Medication refusals: 20
Medication refusals: 13
Blood sugar level: 470
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Verified absence of fall mat and Call Don't Fall sign in Resident #1's room and observed administering medications. |
| Director of Nursing | Director of Nursing (DON) | Reported expectations for medication refusal handling and guardian notification; unable to find documentation of guardian notifications. |
| Advanced Practice Registered Nurse | APRN | Aware of medication refusals and guardian notification requirements. |
| Administrator | Facility Administrator | Acknowledged importance of medication compliance and guardian notification upon refusal. |
Inspection Report
Routine
Deficiencies: 6
Date: Oct 4, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, safety, medication management, infection control, and food safety at The Green House Cottages of Poplar Grove nursing home.
Findings
The facility was found deficient in multiple areas including failure to develop a comprehensive care plan addressing pain management, improper use and storage of mechanical lifts, unsecured oxygen tanks, incorrect oxygen flow rates, improper medication storage and temperature monitoring, expired and undated food items, and inadequate infection prevention practices related to hand hygiene during incontinence care.
Deficiencies (6)
Failure to ensure a comprehensive care plan addressed pain management for a resident with cancer and diabetes.
Failure to ensure rear casters of mechanical lift were not locked during lifting and lowering, risking resident injury; unsecured oxygen tank found in bathroom.
Failure to ensure oxygen was administered at the physician-ordered flow rate, risking respiratory complications.
Failure to ensure drugs and biologicals were properly labeled and stored, including lack of temperature monitoring in narcotic refrigerator.
Failure to promptly remove expired food items and to properly date food stored in freezer.
Failure to ensure proper hand hygiene during peri care, risking cross contamination and infection spread.
Report Facts
Residents reviewed for accidents: 4
Residents reviewed for respiratory therapy: 2
Residents reviewed for bowel and bladder care: 2
Medication storage temperature range: 36
Medication storage temperature range: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shahbaz #8 | Interviewed regarding Resident #58's pain complaints and care plan | |
| MDS Nurse #2 | Interviewed about care plan and MDS documentation for Resident #58 | |
| Shahbaz #4 | Observed and interviewed regarding mechanical lift use and peri care | |
| Shahbaz #5 | Observed and interviewed regarding mechanical lift use and peri care | |
| Director of Nursing | Director of Nursing (DON) | Interviewed about mechanical lift procedures, oxygen storage, medication storage, and infection control policies |
| Licensed Practical Nurse #1 | Licensed Practical Nurse (LPN) | Interviewed and observed regarding oxygen therapy administration and medication storage |
| Licensed Practical Nurse #6 | Licensed Practical Nurse (LPN) | Interviewed regarding loose pills found in medication cart |
| Nurse Consultant #7 | Provided policy on pharmaceutical services | |
| Dietary Manager | Dietary Manager (DM) | Observed and interviewed regarding expired and undated food items |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON)/Infection Preventionist (IP) | Interviewed about oxygen cylinder storage |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Apr 30, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with regulations regarding maintaining a safe, clean, comfortable, and homelike environment for residents.
Findings
The facility failed to maintain an orderly, uncluttered environment for one resident (Resident #3), whose bathroom was cluttered with multiple wheelchairs, a shower chair, and other items, limiting access to the shower and toilet. The resident reported preferring showers but was unable to use the bathroom due to clutter, and staff confirmed the clutter prevented shower access.
Deficiencies (1)
Failed to maintain an orderly, uncluttered environment for Resident #3, resulting in limited access to bathroom facilities.
Inspection Report
Routine
Deficiencies: 2
Date: Dec 29, 2023
Visit Reason
The inspection was conducted to assess compliance with care standards related to activities of daily living (ADL) assistance and food service practices at The Green House Cottages of Poplar Grove.
Findings
The facility failed to ensure proper nail care for a resident requiring assistance, lacked a policy for ADL care, and failed to ensure staff washed hands when serving meals, followed the menu, and posted the menu as required.
Deficiencies (2)
Failed to ensure fingernails were regularly trimmed to maintain good hygiene and grooming for 1 resident requiring staff assistance with nail care.
Failed to ensure staff washed their hands when serving meals, follow the menu, and ensure the menu was posted.
Report Facts
Residents affected: 1
Residents affected: Many residents affected by food service deficiencies
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #6 | CNA | Responsible for nail care and described resident's nails |
| Certified Nursing Assistant #7 | CNA | Interviewed about nail care refusals |
| Director of Nursing | DON | Provided ADL care documentation and policy information |
| Certified Nurse Aid #1 | CNA | Observed not washing hands when serving meals |
| Certified Nurse Aid #3 | CNA | Interviewed about menu posting and meal service |
| Certified Nurse Aid #4 | CNA | Interviewed about menu posting and hand hygiene |
| Certified Nurse Aid #5 | CNA | Interviewed about missing gravy and menu posting |
| Certified Nurse Aid #9 | CNA | Interviewed about missing gravy and menu posting |
| Certified Nurse Aid #2 | CNA | Interviewed about hand hygiene and menu posting |
| Dietary Manager | Dietary Manager | Interviewed about meal preparation and menu posting |
Inspection Report
Routine
Census: 107
Deficiencies: 4
Date: Oct 20, 2023
Visit Reason
The inspection was conducted to evaluate compliance with nutritional, food safety, and infection control standards related to meal preparation and service at The Green House Cottages of Poplar Grove.
Findings
The facility failed to ensure meals were prepared and served according to planned menus and recipes, maintain palatability and safe temperature of foods, ensure pureed foods were smooth and safe, and maintain proper food storage and hygiene practices. Multiple issues with food consistency, temperature, contamination risks, and sanitation of equipment were observed across several cottages.
Deficiencies (4)
Meals were not prepared and served according to planned menus and recipes, including incorrect portion sizes and improper preparation of super calorie diets.
Meals were served in a manner that did not maintain palatability or nutritive value, with separation of water from pureed foods.
Pureed food items were not blended to a smooth, lump-free consistency, increasing risk of choking or complications.
Foods stored in freezer, refrigerator, and dry storage were not properly covered, sealed, or dated; expired items were not promptly discarded; poor hand hygiene and contamination risks during food handling; ice machines and scoop holders were unclean; hot foods not maintained at safe temperatures.
Report Facts
Census: 107
Food temperature: 115
Food temperature: 115
Food temperature: 110
Food temperature: 120
Food temperature: 98
Food temperature: 100
Food temperature: 124
Food temperature: 119
Food temperature: 116
Expired product: 1
Expired product: 1
Expired product: 1
Inspection Report
Routine
Deficiencies: 13
Date: Oct 20, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey of The Green House Cottages of Poplar Grove nursing home to assess compliance with healthcare facility regulations.
Findings
The facility was found deficient in multiple areas including failure to develop comprehensive care plans for diabetic nail care, medication administration errors, inadequate infection control practices including failure to clean glucometers and perform hand hygiene, failure to provide resident-centered activities, improper food preparation and storage practices, and failure to maintain sanitary conditions in food service areas.
Deficiencies (13)
Failed to develop and implement a complete care plan addressing diabetic fingernail care for a diabetic resident.
Failed to ensure physician orders were followed during medication administration, including insulin administration errors and improper topical medication dosing.
Failed to provide necessary services to maintain grooming, personal hygiene, and nail care for a diabetic resident.
Failed to ensure a resident-centered activities program was provided daily in each cottage.
Failed to maintain medication error rates below 5%, with observed errors during medication pass.
Failed to ensure expired medications were removed from medication storage rooms and carts.
Failed to ensure drugs and biologicals were labeled and stored properly, including expired medications present in storage.
Failed to ensure meals were prepared and served according to planned menus and recipes, including improper portion sizes and failure to provide prescribed pureed and super calorie diets.
Failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize choking risk.
Failed to ensure foods stored in kitchen areas were covered, sealed, dated, and free from contamination; failed to maintain sanitary conditions of ice machines and food service areas; failed to maintain proper food temperatures.
Failed to ensure staff maintained proper hand hygiene and hair containment during food preparation and service.
Failed to ensure garbage dumpsters were closed and contained to prevent pest infestation.
Failed to ensure multi-use glucometers were disinfected after each resident and failed to ensure staff performed hand hygiene during medication administration.
Report Facts
Medication error rate: 7.14
Temperature of food items: 115
Temperature of food items: 110
Temperature of food items: 120
Temperature of food items: 124
Temperature of food items: 119
Temperature of food items: 116
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #6 | Licensed Practical Nurse | Named in multiple medication administration and infection control deficiencies |
| Director of Nursing | Director of Nursing | Confirmed care plan and infection control deficiencies |
| Infection Control Preventionist | Infection Control Preventionist | Confirmed infection control practices and glucometer cleaning |
| CNA #8 | Certified Nursing Assistant | Observed failing hand hygiene and hair containment during meal service |
| CNA #3 | Certified Nursing Assistant | Observed improper food preparation and hand hygiene |
| Dietary Supervisor | Dietary Supervisor | Provided information on food preparation, storage, and sanitation deficiencies |
| Maintenance Supervisor | Maintenance Supervisor | Responsible for trash containment |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 3, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an elopement of a resident to the state agency.
Complaint Details
The complaint investigation found that Resident #1 eloped from the facility on 09/30/23 at approximately 6:47 AM. The facility reported the incident to the Office of Long-Term Care on 10/01/23 at 10:30 PM, which was beyond the required 2-hour reporting window. The Director of Nursing and Administrator confirmed the delay and lack of clear policy on timely reporting.
Findings
The facility failed to ensure that an elopement of Resident #1 was immediately reported to the Office of Long-Term Care as required. The resident eloped on 09/30/23 but the report was not made within the required 2-hour timeframe.
Deficiencies (1)
Failed to timely report an elopement of Resident #1 to the state agency within the required timeframe.
Report Facts
Time elapsed before reporting: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Provided witness statement regarding Resident #1 last seen at 4:00 AM on 09/30/23 | |
| Director of Nursing | Director of Nursing | Interviewed regarding facility policy and reporting requirements |
| Administrator | Administrator | Interviewed regarding awareness of elopement and reporting timeline |
Inspection Report
Routine
Deficiencies: 1
Date: Apr 19, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with providing care and assistance for activities of daily living, specifically bathing and personal hygiene, for residents unable to perform these tasks independently.
Findings
The facility failed to provide baths or showers to two sampled residents who required assistance, potentially affecting 20 residents dependent on bathing assistance. Documentation was incomplete or missing for bathing services during the review period, and staff were uncertain about the meaning of certain documentation codes.
Deficiencies (1)
Failure to provide baths or showers to residents unable to independently perform the task to maintain good grooming and personal hygiene.
Report Facts
Residents affected: 20
Residents sampled with bathing deficiencies: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing (ADON) | Provided Documentation Survey Report dated March 2023 | |
| Licensed Practical Nurse (LPN) #1 | Interviewed about frequency of resident showers | |
| Certified Nursing Assistant (CNA) #1 | Interviewed about frequency of resident showers | |
| Certified Nursing Assistant (CNA) #2 | Interviewed about frequency of resident showers | |
| Director of Nursing (DON) | Provided facility policy titled Skills Checklist: Full Bed Bath |
Inspection Report
Routine
Deficiencies: 1
Date: Mar 8, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with safety regulations, specifically to ensure the nursing home area was free from accident hazards and provided adequate supervision to prevent accidents.
Findings
The facility failed to ensure medications were properly stored in a secure location, resulting in unsecured medications being left out on a dining room table, posing a risk of accidental ingestion. Multiple staff members, including nurses and the Director of Nursing, acknowledged the importance of securing medications and the potential harm if left unsecured.
Deficiencies (1)
Failure to ensure medication was properly stored in a secure location to prevent unsupervised access that could result in accidental ingestion for one ambulatory resident.
Report Facts
Number of medication cards/bottles left unsecured: 51
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Acknowledged leaving medications unsecured while attending to another cottage | |
| Licensed Practical Nurse #2 | Stated medications should be put up as soon as possible to prevent access | |
| Director of Nursing | Director of Nursing | Stated all medications need to be locked in the cabinet until distribution |
| Infection Control Nurse | Stated medications should be locked up and unsecured medications could be stolen or ingested | |
| Administrator | Stated nurses should check and lock up medications; unsecured medications could cause death or be taken |
Inspection Report
Routine
Deficiencies: 7
Date: Aug 5, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, dietary services, and facility maintenance at The Green House Cottages of Poplar Grove.
Findings
The facility was found deficient in multiple areas including failure to assist a resident out of bed for breakfast, incomplete care plans for residents with Foley catheters and urinary tract infections, inadequate personal hygiene care such as nail care and shaving, medication errors including missed insulin doses, presence of expired medications, improper food storage and handling in kitchens, and multiple pieces of dietary equipment being out of order for extended periods.
Deficiencies (7)
Failed to ensure Resident #36 was assisted out of bed for breakfast.
Failed to review and revise care plan to include Foley Catheter and history of Urinary Tract Infection for Resident #25.
Failed to provide nail care and shaving for dependent residents (#35, #4, #85).
Failed to ensure Resident #19 received scheduled insulin dose, resulting in medication error.
Expired medications found in medication closets and resident rooms.
Failed to ensure proper food storage, dating, cleanliness, and hand hygiene in dietary services.
Multiple dietary equipment including refrigerators, freezers, dish machines, ice machines, and ovens were out of order for months.
Report Facts
Residents sampled: 32
Residents sampled: 7
Residents affected: 102
Medication doses missed: 1
Expired medications found: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | ADON | Interviewed regarding resident care, medication errors, and expired medications |
| Director of Nursing | DON | Interviewed regarding resident care and staffing |
| Certified Nursing Assistant #1 | CNA | Interviewed about failure to assist Resident #36 out of bed |
| Certified Nursing Assistant #2 | CNA | Interviewed about resident assistance |
| Certified Nursing Assistant #3 | CNA | Interviewed about resident assistance |
| Licensed Practical Nurse #1 | LPN | Observed medication pass and discussed missed insulin dose and expired medications |
| Dietary Employee #1 | Dietary Staff | Interviewed about food storage, equipment issues, and cleaning practices |
| Dietary Employee #2 | Dietary Staff | Interviewed about equipment failures and meal preparation |
| Dietary Employee #3 | Dietary Staff | Interviewed about equipment failures |
| Dietary Employee #4 | Dietary Staff | Observed handling of ice scoop holder and hand hygiene |
| Maintenance Director | Maintenance Director | Interviewed about reporting and repair of broken dietary equipment |
| Assistant Administrator | Assistant Administrator | Interviewed about delays in equipment repairs and outstanding invoices |
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