The Green House Cottages of Belle Meade

In the surveyor’s words

From the most serious findings on record at The Green House Cottages of Belle Meade, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Dec 19, 2024

  Based on observations, record review, document review, and interviews, the facility failed to ensure staff followed a resident's care plan, as evidenced by Resident #1 sliding off the side of the bed while 1 staff assisted with dressing, despite the care plan indicating the need for 2 staff, for 1 (Resident # 1) sampled resident. The failed practice resulted in noncompliance at the level of immediate jeopardy (IJ), which caused major injury to Resident # 1, who was at high risk for falls. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. […]

• No harm, potential for more than minimal, widespreadF812Aug 1, 2025

  Based on observations, interviews, and record reviews, the facility failed to ensure hands were washed between residents while serving dinner, and to ensure utensils were not used after contamination during meal preparation for one of one puree meal observed. The findings include: 1) During an observation on 07/28/2025 at 4:55 PM, Certified Nurse Aide (CNA) #5 and CNA #6 were observed passing trays with gloves on. CNA #5 retrieved a plate from a resident room while wearing gloves. She then took a plate to another resident room without removing gloves or performing hand hygiene. CNA #5 came out of this room, again without performing hand hygiene or removing gloves, and went to the dining room. […]

• No harm, potential for more than minimal, widespreadF812Feb 3, 2023

  Based on observation, record review, and interview, the facility failed to ensure food items stored in the refrigerator, freezer and dry storage areas, were sealed or covered and stored in accordance with the manufacturer's instructions; expired food items were promptly removed from stock; staff washed their hands between dirty and clean tasks and before handling clean dishes or food items; ice machines were maintained in clean and sanitary condition; and hot foods were maintained at or above 135 degrees Fahrenheit (F.) while awaiting service to prevent potential food borne illness for residents who received meals from 11 (Cottages #1, #2, #3, #4, #5, #6, #7, #8, #9, #10 and #11) of 11 kitchens. […]

• No harm, potential for more than minimal, widespreadF865Feb 3, 2023

  Based on observation, interview, and record review, the facility failed to ensure the Quality Assessment and Assurance (QAA) committee put forth good faith attempts to correct, monitor, and reassess its own quality deficiencies for proper respiratory care for residents who were on oxygen therapy. The findings are: 1. The Quality Assurance and Performance Improvement (QAPI) Plan undated, the Facility assessment dated [DATE], and the Quality Assessment and Assurance (QAA) Committee list provided by the Assistant Administrator on 01/30/23 at 1:04 PM documented, .Those in attendance varies occasionally but normally includes the Administrator, Director of Nursing, the Infection Control/Wound Nurse, the Campus Educator, The Assistant Director of Nursing, the MDS [Minimum Data Set] Coordinators,… […]

• No harm, potential for more than minimal, widespreadF812Aug 13, 2021

  Based on observation, record review and interview, the facility failed to ensure food items stored in the refrigerator, freezer and dry storage areas were sealed or covered and were stored in accordance with the manufacturer's instructions; expired food items were promptly removed from stock; staff washed their hands between dirty and clean tasks and before handling clean dishes or food items; ice machines were maintained in clean and sanitary condition; and hot foods were maintained at or above 135 degrees Fahrenheit (F.) and cold food items were maintained at or below 41 degrees F. while awaiting service to prevent potential food borne illness for residents who received meals from 10 (Cottage #1 through #9 and #11) of 11 kitchens. […]