Inspection Reports for
The Green House Cottages of Southern Hills
701 S. Main St., Rison, AR, 71665
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
6.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
21% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 7, 2025
Visit Reason
The inspection was conducted following a complaint related to an incident where a resident's wheelchair was not properly secured during transport in the facility van, resulting in the resident sustaining a head injury.
Complaint Details
The complaint investigation was substantiated by findings that the wheelchair was not properly secured, leading to the resident's injury. The incident involved one resident (Resident #4) who sustained a head injury when the wheelchair tipped backwards during transport. The facility conducted in-service training and a safety inspection of the van following the incident.
Findings
The facility failed to ensure the resident's wheelchair was properly secured, causing the wheelchair to tip backwards and the resident to hit their head on the van lift. The resident was transported to the emergency room for evaluation. Safety inspection of the van revealed tie downs were not properly positioned, and staff received in-service training on proper securing procedures. The incident was described as a 'freak accident' by facility staff.
Deficiencies (1)
Failed to ensure a resident’s wheelchair was properly secured during transport in the facility van, resulting in injury.
Report Facts
Assessment Reference Date: Jun 4, 2025
Incident Date: May 9, 2025
Van Safety Inspection Date: May 15, 2025
In-service Training Date: May 7, 2025
In-service Training Date: May 22, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in the incident involving improper securing of wheelchair and transport |
| AD | Activities Director | Present in the van during the incident and assisted resident |
| ADON | Assistant Director of Nursing | Notified of the incident and reported on the event |
| DON | Director of Nursing | Arrived at the scene of the incident and assessed the resident |
| Maintenance Director | Maintenance Director | Drove the van after the incident and participated in safety inspection and training |
| Administrator | Administrator | Responded to the incident, called emergency services, and oversaw follow-up |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 7, 2025
Visit Reason
Annual inspection survey completed for The Green House Cottages of Southern Hills nursing home.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 3
Date: Apr 30, 2024
Visit Reason
The inspection was conducted due to a complaint investigation triggered by an incident where Resident #82 eloped from the facility and was found walking near a public highway. The visit also addressed other safety concerns including hazardous chemical storage and fall risk management.
Complaint Details
The complaint investigation was substantiated with findings of immediate jeopardy related to Resident #82 eloping from the facility on 04/23/2024. The Immediate Jeopardy began on 04/23/2024 and was removed on 04/26/2024 after the facility implemented a Plan of Removal including increased supervision, staff in-service training, and environmental safety measures.
Findings
The facility failed to provide adequate supervision to prevent elopement of Resident #82, resulting in immediate jeopardy to resident health or safety. Additional deficiencies included unsecured hazardous chemicals and equipment accessible to wandering residents, and failure to maintain assistive devices and interventions to prevent falls for Resident #20.
Deficiencies (3)
Failed to ensure adequate supervision to prevent elopement of Resident #82, who was found walking near a public highway.
Failed to ensure hazardous chemicals and equipment were secured in a locked room, accessible to wandering residents.
Failed to ensure adequate supervision, assistive devices, and interventions to decrease fall risk for Resident #20.
Report Facts
Resident census at risk for elopement: 35
Wandering Risk Scale score: 9
Fall risk assessments: 7
Bed height measurement: 69
Staff interviewed for in-service verification: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Involved in notification and implementation of Immediate Jeopardy Plan of Removal | |
| Assistant Director of Nursing (ADON) | Interviewed regarding hazardous chemical storage and bed height policy | |
| Admissions and Marketing Director | Found Resident #82 off campus and returned resident to facility | |
| Certified Nursing Assistant (CNA) #11 | Last saw Resident #82 before elopement, interviewed about supervision | |
| Certified Nursing Assistant (CNA) #12 | Second day working with Resident #82, interviewed about supervision | |
| Registered Nurse (RN) #1 | Interviewed about Resident #82 incident and supervision | |
| Licensed Practical Nurse (LPN) #1 | Provided information on bed height intervention for Resident #20 | |
| Certified Nursing Assistant (CNA) #4 | Observed bed height and interviewed about fall prevention for Resident #20 |
Inspection Report
Routine
Census: 35
Deficiencies: 11
Date: Apr 30, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including medication administration, resident safety, infection control, food safety, and overall quality of care.
Findings
The facility was found deficient in multiple areas including failure to ensure proper medication self-administration assessment, inadequate cleaning of resident restrooms, inadequate supervision to prevent elopement, improper bed height use for fall prevention, improper incontinence care, failure to follow enteral feeding protocols, medication storage violations, improper food preparation and storage, and failure to follow infection control hand hygiene practices.
Deficiencies (11)
Failed to ensure medications were not self-administered without a physician's order and proper assessment.
Failed to ensure resident restrooms were cleaned to promote a clean and sanitary environment.
Failed to ensure adequate supervision to prevent elopement resulting in immediate jeopardy.
Failed to maintain bed in lowest position for fall prevention.
Failed to provide proper and punctual incontinence care and hand hygiene.
Failed to provide appropriate care for residents receiving enteral nutrition via PEG tube.
Failed to ensure pharmacist's recommendation for appropriate diagnosis before antipsychotic medication administration was followed.
Failed to ensure medications were not left at bedside and stored properly.
Failed to ensure pureed food items were blended to a smooth, lump-free consistency.
Failed to ensure food preparation equipment was free of peeling paint, expired food was removed, foods were properly stored and dated, ice scoop holder was clean, and staff washed hands before handling clean equipment.
Failed to ensure staff used proper hand hygiene while passing medication and providing perineal care.
Report Facts
Residents at risk for elopement: 35
Wandering Risk Scale score: 9
Fall risk assessments: 7
Bed height measurement: 69
Medication Regimen Review date: Sep 29, 2023
Inspection completion date: Apr 30, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #3 | Named in medication administration and hand hygiene deficiency. | |
| Director of Nursing (DON) | Interviewed regarding medication self-administration and medication regimen review. | |
| Assistant Director of Nursing (ADON) | Interviewed regarding multiple deficiencies including medication, bed height, infection control, and policies. | |
| Certified Nursing Assistant (CNA) #11 | Interviewed regarding cleaning responsibilities and elopement supervision. | |
| Certified Nursing Assistant (CNA) #12 | Interviewed regarding resident supervision on porch. | |
| Registered Nurse (RN) #1 | Interviewed regarding medication storage and elopement incident. | |
| Infection Preventionist (IP) | Interviewed regarding hand hygiene during medication administration. | |
| Admissions and Marketing Director | Involved in elopement incident response. | |
| Administrator | Involved in elopement incident response and staff training. | |
| Maintenance #1 | Interviewed regarding microwave with peeling paint. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 13, 2023
Visit Reason
The inspection was conducted due to a complaint investigation following an incident where Resident #1 eloped from the secure unit without supervision on 07/04/2023.
Complaint Details
The complaint investigation was substantiated as Resident #1 eloped from the secure unit on 07/04/2023, was found outside the facility by a member of the public, and required ambulance transport to the hospital. The facility was found to have inadequate supervision and security measures contributing to the incident.
Findings
The facility failed to ensure adequate supervision and safety to prevent elopement from the secure unit for Resident #1, resulting in immediate jeopardy to resident health or safety. The investigation revealed that staff had given the secure door code to family members, allowing Resident #1 to exit unsupervised. The facility lacked alarms and signage on secure doors, and corrective actions were implemented including staff training, changing door codes, increased supervision, and plans for alarms and fencing.
Deficiencies (1)
Failure to ensure safety and supervision to prevent elopement from the secure unit for Resident #1.
Report Facts
Residents affected: 3
Residents affected: 1
Temperature: 90
Humidity: 61
Trail length: 20
Trail width: 3
Supervision duration: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #4 | Last saw Resident #1 at 12:38 PM and did not realize he was missing until 12:45 PM | |
| Certified Nursing Assistant (CNA) #1 | Last saw Resident #1 at approximately 12:36 PM | |
| Licensed Practical Nurse (LPN) #1 | Received ambulance call and stated CNA's had been looking for Resident #1 for about 10 minutes | |
| Certified Nursing Assistant (CNA) #3 | Had the code to the secure cottage entrance/exit front door on 07/04/2023 | |
| Director of Nursing (DON) | Interviewed regarding staff providing door code to families and lack of signage on exit doors | |
| Administrator | Interviewed about the elopement incident and door code practices | |
| Maintenance Director | Checked all locks and changed keypad lock number after the incident |
Inspection Report
Routine
Deficiencies: 3
Date: May 4, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, treatment and care, and respiratory care in a nursing home facility.
Findings
The facility failed to ensure comprehensive assessments were completed within 14 days after significant changes in residents' conditions for 2 sampled residents. Additionally, the facility did not provide appropriate treatment to prevent worsening of skin conditions and contractures for 2 residents, and failed to maintain proper respiratory care and sleep hygiene for 2 residents using CPAP machines.
Deficiencies (3)
Failed to ensure residents with significant change in status had comprehensive assessments completed within 14 days.
Failed to provide treatment and care to prevent worsening of skin condition and contracture.
Failed to provide safe and appropriate respiratory care and maintain sleep hygiene for residents using CPAP.
Report Facts
Residents sampled: 24
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Mentioned in relation to wound care treatment and communication with provider |
| Director of Nursing | Director of Nursing | Involved in notification of provider orders and discussion of policies related to wound care, hand rolls, and respiratory equipment |
| MDS Coordinator | Interviewed regarding assessment requirements and resident condition changes |
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