The Green House Cottages of Walnut Ridge

In the surveyor’s words

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

• Immediate jeopardy, patternF689May 19, 2021

  Based on observation, record review, and interview the facility failed to ensure a resident who was at high risk for elopement and wore a wander guard transmitter was properly monitored and resulted in an elopement for 1 (Resident #4) resident and failed to accurately assess and determine elopement risk for 1 (Residents #5) residents of 2 (Residents #4, and #5) sampled residents. These failed practices resulted in immediate jeopardy that caused or was likely to cause serious harm, injury, or death to Resident #4 who eloped from the facility and Resident #5 who exited the front door but did not leave the front porch and had the potential to affect 11 residents who were an elopement risk per the list provided by the Assistant Director of Nursing (ADON) on [DATE] at 12:32 p.m. […]

• Immediate jeopardy, isolatedF689Sep 23, 2022

  Based on observation, record review, and interview, the facility failed to ensure adequate supervision was provided to prevent elopement for 1 (Residents #30) of 3(Resident #30, #48, #126) sampled residents who were at high risk for elopement. This failed practices resulted in past immediate jeopardy that caused or was likely to cause serious harm, injury, or death to Resident #30 who eloped from the facility. The Administrator, Director of Nursing (DON), and Consultant were informed of the past Immediate Jeopardy on 9/20/22 at 12:30 p.m. and the current on 9/21/22 at 3:21 p.m. and The facility failed to ensure adequate supervision was provided to prevent elopement for 1 (Resident #126) of 3 sampled residents (Residents #30, #48, #126). […]

• No harm, potential for more than minimal, widespreadF812Sep 23, 2022

  Based on observation and interview, the facility failed to ensure dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen; failed to ensure food items stored in dry goods area were sealed, labeled, and dated; failed to ensure 1 of 4 ice machines were maintained in sanitary condition, failed to ensure hot foods on the steam table were maintained at or above 135 degrees Fahrenheit to prevent potential food borne illness for residents who received meals from 1 (main Kitchen) of 4 out of the kitchens; foods were dated when received to assure first in first out usage to prevent potential for food bone illness. […]

• No harm, potential for more than minimal, widespreadF812Jun 25, 2021

  Based on observation, interview and record review, the facility failed to ensure staff washed their hands before handling clean equipment or food items failed to ensure food item stored in the freezer and dry storage areas were covered, sealed and dated; failed to ensure the kitchen floor, dry storage area floors, dish washing room, and walls were free of debris, dirt, grease, grime, stains and standing water and kitchen appliances (toaster, shelves where pans, pots and water pitchers were stored) were cleaned and free of stains; and expired food item was promptly removed/ discarded by the expiration or use by dates to prevent potential for cross contamination and/or food bone illness. […]

• No harm, potential for more than minimal, patternF689Dec 21, 2023

  Based on observation and interview the facility failed to ensure an oxygen cannister was stored securely to prevent accidents and hazards in Cottage One. The failed practice had the ability to affect all 8 residents who reside in the cottage. The findings are: 12/20/23 11:05 AM 9:40 AM, the medication closet in Cottage 1 was observed to contain a small number of supplies. OTC (Over the Counter) meds were observed to be within the use by the window. Tubing and supplies were also observed to be in date. At 9:42 AM, upon opening the double doors to the medication closet, an oxygen cannister was observed standing in the corner. The cannister was not secured in a rack. The Nurse Consultant immediately instructed the nurse to get a holder to secure the oxygen tank.