Inspection Reports for
The Green House Cottages of Wentworth Place
26 Warnock Springs Road, Magnolia, AR, 71753
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
8
6
4
2
0
Occupancy
Latest occupancy rate
79% occupied
Based on a October 2023 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Deficiencies: 8
Date: Sep 19, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident transfers, accident prevention, respiratory care, medication storage, food preparation, infection control, and other aspects of facility operations.
Findings
The facility was found deficient in timely notification to the long-term care ombudsman for resident hospital transfers, ensuring lift pads were free of damage, supervision of residents smoking outside, physician orders for oxygen therapy, secure medication storage, proper food preparation and consistency, food safety practices including handwashing and expired food removal, and infection control related to oxygen/nebulizer equipment changes.
Deficiencies (8)
Failed to notify and provide written notice to the long-term care ombudsman for hospital transfers of 3 sampled residents.
Lift pad used for resident transfers was frayed and had holes, posing accident risk.
Resident allowed to smoke outside without proper supervision contrary to care plan.
Resident receiving oxygen therapy without a physician's order specifying flow rate and usage.
Resident medications stored in unlocked cabinets accessible to residents.
Pureed food items served were not blended to smooth, lump-free consistency as required.
Dietary staff and aides failed to wash hands and change gloves appropriately; expired food items and spices were found in storage; hot foods not maintained at required temperatures.
Oxygen/nebulizer tubing and masks were not changed weekly as required, risking respiratory infections.
Report Facts
Residents reviewed for hospitalization notification: 3
Oxygen flow rate: 1.5
Nebulizer treatments frequency: 3
Expiration dates of expired food items: Examples include cottage cheese expired 8/28/2024, potato salad expired 9/11/2024
Food temperatures: 125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding lift pad removal, oxygen order requirements, and oxygen tubing change policy |
| Registered Nurse #11 | Registered Nurse (RN) | Interviewed about Resident #212's oxygen therapy order |
| Registered Nurse #10 | Registered Nurse (RN) | Interviewed about medication storage procedures |
| Licensed Practical Nurse #12 | Licensed Practical Nurse (LPN) | Interviewed about oxygen tubing and nebulizer mask change procedures |
| Dietary Manager | Dietary Manager | Provided recipes, policies, and interviewed about food preparation and safety |
| Shahbaz #7 | Identified holes and fraying in lift pad used for Resident #54 | |
| Shahbaz #8 | Confirmed lift pad condition and risk | |
| Shahbaz #9 | Observed assisting Resident #59 smoking unsupervised | |
| Shahbaz #6 | Observed and commented on pureed food consistency | |
| Shahbaz #5 | Prepared meals with improper pureed food consistency | |
| Dietary Aide #2 | Observed handling beverages without handwashing | |
| Dietary [NAME] (DC) #1 | Observed food preparation and blender cleaning practices |
Inspection Report
Routine
Census: 107
Deficiencies: 5
Date: Oct 13, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to medication management, food safety and handling, infection control, and overall facility operations at The Green House Cottages of Wentworth Place.
Findings
The facility was found deficient in multiple areas including improper medication storage and administration, failure to maintain appropriate food temperatures and safe food handling practices, inadequate infection prevention and control procedures, and failure to ensure proper use of personal protective equipment by staff. These deficiencies had the potential to cause minimal harm or actual harm to residents.
Deficiencies (5)
Medications were left unattended at the bedside, controlled substances were not properly secured, insulin vials were not dated after opening, and residents without self-administration rights were administering medications.
Meals were served at inappropriate temperatures, specifically ham served at 87 degrees Fahrenheit which is not safe.
Visitors accessed kitchen areas without proper hygiene, staff did not consistently wear hairnets, and improper handling of cups and drinks was observed.
Food items were stored improperly with missing dates, dented cans were present, expired food was not promptly discarded, and cross contamination risks were observed in multiple kitchens.
Infection control practices were inadequate including improper handling of trays from isolation rooms, failure to properly doff PPE, and contamination risks from staff handling ice with bare hands.
Report Facts
Medication counts: 46
Medication counts: 57
Medication counts: 50
Medication counts: 30
Medication counts: 21
Medication counts: 27
Medication counts: 21
Residents affected: 11
Residents affected: 104
Total census: 107
Inspection Report
Annual Inspection
Census: 96
Deficiencies: 6
Date: Jul 15, 2022
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident assessments, discharge summaries, respiratory care, nutrition and food safety.
Findings
The facility was found deficient in multiple areas including inaccurate resident assessments, incomplete discharge summaries, improper oxygen administration and nebulizer mask storage, failure to prepare and serve meals according to planned menus and nutritional needs, inadequate pureed food consistency, and failure to ensure food safety practices such as removal of expired food and proper hand hygiene by dietary staff.
Deficiencies (6)
Failed to ensure the Annual Minimum Data Set (MDS) was completed accurately related to smoking for 1 resident.
Failed to ensure a written discharge summary included a concise recapitulation of the resident's stay for 1 discharged resident.
Failed to ensure oxygen was ordered and administered at prescribed flow rate and nebulizer mask was stored properly for 1 resident.
Failed to ensure meals were prepared and served according to the planned written menu to meet nutritional needs for residents.
Failed to ensure pureed food items were blended to a smooth, lump-free consistency for residents requiring pureed diets.
Failed to ensure expired food items were promptly removed and dietary staff washed hands before handling clean equipment or food items.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 10
Residents affected: 2
Residents affected: 96
Total census: 96
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Acknowledged error in Annual MDS tobacco use assessment for Resident #43 |
| Registered Nurse #1 | Registered Nurse | Provided information about discharge summary responsibilities and requirements |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Confirmed oxygen flow rate and proper storage of nebulizer mask for Resident #75 |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Observed preparing pureed food with improper consistency and serving meals |
| Dietary Employee #1 | Dietary Employee | Acknowledged failure to puree cabbage and described poor consistency of pureed foods |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Observed preparing pureed food with improper consistency |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Observed handling clean bowls with contaminated hands and improper hand hygiene |
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Observed contaminating gloves and improper hand hygiene |
| Dietary Employee #5 | Dietary Employee | Observed handling food and equipment with contaminated gloves and poor hand hygiene |
Report
September 19, 2024
Report
October 13, 2023
Report
July 15, 2022
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