Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Green House Cottages Of Southern Hills during CMS and state inspections, most recent first.
A resident with multiple medical conditions was injured when their wheelchair tipped backward during van transport due to improper placement of tie-downs, despite staff having attended in-service training on proper securing procedures. Inspection revealed that the retractors were not positioned correctly, allowing the wheelchair to move and resulting in the resident sustaining a head injury and bruising.
The facility failed to adequately supervise a resident with Alzheimer's, leading to an elopement incident. Additionally, aerosol cans were found in residents' rooms, and hazardous chemicals and equipment were not secured. The facility also did not consistently implement fall prevention measures for a high-risk resident.
The facility failed to ensure food preparation equipment was free of peeling paint, promptly remove expired food items, and maintain clean and sanitary conditions for food storage and preparation. Numerous expired and improperly stored food items were found, and staff were observed not following proper hand hygiene practices.
The facility failed to ensure medications were not left at the bedside for two residents. One resident with dementia had Diclofenac Sodium 1% left unsecured in their bathroom, while another resident with Down syndrome had triple antibiotic ointment without a physician's order left in their room. Staff confirmed that medications should not be left in residents' rooms, and the facility's policy on medication storage was not followed.
The facility failed to ensure that pureed food items were blended to a smooth, lump-free consistency for residents requiring pureed diets. Observations revealed that pureed green beans, bread sticks, chicken alfredo, sausage, and French toast sticks did not meet the required consistency standards, potentially affecting multiple residents.
The facility failed to ensure proper hand hygiene during medication administration and perineal care for two residents. An LPN did not sanitize hands between glove changes while administering medications, and two CNAs did not perform proper hand hygiene or change gloves appropriately during incontinence care, leading to incomplete cleaning and potential contamination.
A facility failed to ensure medications were not self-administered without a physician's order and an IDT assessment for one resident. The resident was found with Nystatin-Triamcinolone Cream in their bathroom and stated they applied it themselves. The care plan did not identify the resident as able to self-administer medications, and there was no policy or form for self-administration.
The facility failed to ensure a clean and sanitary environment for a resident with weakness and constipation, who required substantial assistance with toileting hygiene. Observations revealed brown stains and substances on the resident's toilet over multiple days. A CNA stated that deep cleaning was done on bath days, and the facility lacked a policy on cleaning resident rooms.
A resident with a urinary tract infection and candidiasis did not receive proper incontinence care, resulting in skin irritation and improper hygiene practices by CNAs, including failure to clean all affected areas and inadequate hand hygiene.
A resident with severe cognitive impairment and multiple diagnoses was observed receiving enteral nutrition via a PEG tube while lying flat, contrary to the care plan and physician's order to elevate the head of the bed. Staff confirmed the importance of this practice to prevent aspiration, and the ADON acknowledged the lack of a facility policy on enteral feeding.
The facility failed to follow a pharmacist's recommendation for an appropriate diagnosis before administering an antipsychotic medication to a resident with Dementia, Major Depression, and Delirium. The attending physician continued the medication citing hospice care, but there was no documentation that hospice was notified, and the facility lacked a policy on unnecessary medications.
Failure to Properly Secure Wheelchair During Resident Transport
Penalty
Summary
A deficiency occurred when a resident's wheelchair was not properly secured during transportation in the facility van, resulting in the wheelchair tipping backward and the resident sustaining injuries. The incident took place while a CNA was driving the van, accompanied by the Activities Director and the resident. During the return trip from an outing, the resident's wheelchair rolled backward, causing the resident to hit the back of their head on the lift rack. The resident was transported to the emergency room for evaluation and treatment, where injuries including a bump on the back of the head, bruising, and swelling were documented. The resident involved was cognitively intact and had multiple diagnoses, including a thigh bone fracture, worn cartilage, anxiety, diabetes, and muscle wasting. The resident used a wheelchair or walker for mobility. Documentation and interviews revealed that the CNA had attended in-service training on proper lift operation and securing residents, and that the wheelchair had been strapped in with a seatbelt and tie-downs before departure. However, a subsequent inspection by a van safety company found that the tie-downs (retractors) were not in the proper position to secure the wheelchair, which could allow for tipping or side-to-side movement. The inspection also noted that the way the retractors were positioned would not have allowed them to be tight enough to prevent the incident. Interviews with staff and the inspection company confirmed that the tie-downs were not correctly placed at the time of the incident. The Activities Director and CNA both reported that all straps and belts appeared to be in place after the incident, but the inspection company clarified that the retractors were not in the correct position to safely secure the wheelchair. The facility did not have a specific policy for accidents at the time of the event.
Failure to Prevent Elopement and Ensure Safety Measures
Penalty
Summary
The facility failed to ensure adequate supervision to prevent elopement for Resident #82, who was diagnosed with Alzheimer's disease and identified as at risk for wandering. On the evening of 04/23/2024, Resident #82 followed two other residents to the back patio for a smoke break and subsequently eloped from the facility. The resident was found walking in the grass on the side of a public highway approximately 100 yards from the facility by a staff member who was leaving for the day. Despite being instructed to closely monitor Resident #82, staff failed to adequately supervise the resident, leading to the elopement incident. Additionally, the facility failed to ensure that aerosol cans were removed from residents' rooms to decrease the potential for harm. During observations, aerosol cans of air freshener were found in the open shelves and cabinets of residents' rooms, which is against the facility's policy. Staff members confirmed that residents should not have aerosol cans in their rooms, indicating a lapse in adherence to safety protocols. The facility also failed to secure hazardous chemicals and equipment in a locked room, posing a potential risk to residents. An unlocked closet containing portable oxygen tanks and other care items was observed, with keys left in the doorknob. Staff acknowledged that the door should remain locked to prevent residents from accessing potentially harmful items. Furthermore, the facility did not ensure that assistive devices and interventions were consistently implemented to prevent falls for Resident #20, who was identified as a high fall risk. Despite care plan instructions to keep the resident's bed in the lowest position, the bed was repeatedly observed at normal height, increasing the risk of falls.
Removal Plan
- Resident #82 was returned to the campus by the Admission Coordinator, a body audit was conducted by a Licensed Practical Nurse with no negative findings and Resident #82 was placed in the secure cottage.
- Resident #82's wandering risk assessment was reassessed by the Minimum Data Set Coordinator and the plan of care was updated to include risk of wandering.
- CNA in Secure Cottage began 15 minute checks on Resident #82. These 15-minute checks will continue until Resident #82 no longer exhibits exit seeking behavior.
- The Administrator and Assistant Administrator began in-service training for all staff on duty related to abuse, neglect, and elopement. All other staff will be trained before coming on duty on abuse and neglect and elopement. The training included if an elder seems more confused, is exit seeking, found to have an increase in wandering or any change of condition, staff are to notify a supervisor/nurse immediately and staff to perform more frequent checks on them.
- Facility Registered Nurse and Licensed Practical Nurse reassessed all other elders on current census for their wandering risk assessment. Resident's care plans and wandering assessments will indicate if a resident is at risk for wandering. All corrections were completed.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure that food preparation equipment was free of peeling and chipped paint, which could potentially lead to foodborne illness. Specifically, the microwave in Cottage #6 had a gray finish peeling off the inside top, and dark particles came off when wiped with a wet towel. Additionally, a spatula with several areas chipped off was found in the utensil drawer, which was used for icing cakes. Maintenance staff confirmed that the microwave needed to be replaced due to the peeling paint, but no work order had been received for this issue. The facility also failed to promptly remove expired food items from stock, which could potentially lead to foodborne illness. Numerous expired food items were found in the refrigerators, freezers, and storage rooms across multiple cottages. These included expired milk, cottage cheese, sour cream, and various other food items without open dates. Additionally, several food items were found to be improperly stored, such as opened bags of food that were not sealed or dated, and items that should have been refrigerated but were not. Furthermore, the facility did not maintain clean and sanitary conditions for food storage and preparation. An ice scoop holder in Cottage #7 was found with standing water and brownish residue, and the ice scoop was resting directly on the residue. Dietary staff were also observed not washing their hands before handling clean equipment, and one CNA was seen contaminating gloves by turning off a faucet and then handling food without changing gloves. These practices had the potential to affect the health and safety of the residents receiving meals from the facility's kitchens.
Failure to Secure Medications
Penalty
Summary
The facility failed to ensure medications were not left at the bedside for two residents. Resident #7, who had diagnoses of dementia and pelvic/perineal pain, was observed multiple times with a container of Diclofenac Sodium 1% in their bathroom on a shelf. Despite having a physician's order for the medication to be applied as needed, the medication was not stored securely. The Medication Administration Certified aide identified the presence of the medication along with other items that should not be unlocked in the resident's room. Resident #29, who had diagnoses of Down syndrome, adjustment disorder, and other specified mental disorders, was observed with three sample size packs of triple antibiotic ointment on a shelf near the entrance of their room. There was no physician's order for this medication. The Registered Nurse confirmed that the medication should not be left in the resident's room. The Assistant Director of Nursing also confirmed that no residents were self-administering medications and that over-the-counter medications should not be in the resident's room. The facility's policy on medication storage was not followed, as medications and biologicals are supposed to be stored safely, securely, and properly, accessible only to authorized personnel.
Failure to Ensure Proper Consistency of Pureed Food
Penalty
Summary
The facility failed to ensure that pureed food items were blended to a smooth, lump-free consistency for residents who required pureed diets. During observations, it was noted that the pureed green beans were runny with water separated from the beans, and the pureed bread sticks were lumpy and not smooth. Additionally, the pureed chicken alfredo was gritty with pieces of noodles and chicken visible. These inconsistencies were confirmed by the Dietary Supervisor, who acknowledged that the pureed food items were not of the appropriate consistency. Further observations revealed that residents in Cottage #7 were served pureed sausage and pureed French toast sticks for breakfast, both of which did not meet the required consistency standards. The pureed sausage was lumpy, runny, and contained visible pieces of meat, while the pureed French toast sticks were thick. The Medication Assistant-Certified also confirmed these observations, describing the pureed sausage as mushy and running with pieces of sausage, and the pureed French toast as thick. These deficiencies had the potential to affect multiple residents who required pureed diets in different cottages within the facility.
Failure to Follow Hand Hygiene Protocols
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by staff during medication administration and perineal care for two residents. In the first instance, an LPN administered medications to a resident without sanitizing her hands between glove changes, despite switching administration routes. This was confirmed by the facility's Infection Preventionist, who stated that hand sanitizer should be used to prevent contamination. The facility's policy also required hand cleansing before handling medication and before contact with a resident, which was not followed in this case. In the second instance, two CNAs provided incontinence care to a resident without performing proper hand hygiene or changing gloves appropriately. The resident's perineal area was not thoroughly cleaned, and soiled gloves were used to handle clean items and apply topical skin barrier cream. The Assistant Director of Nursing confirmed that all areas in contact with urine should be cleaned to prevent skin irritation and breakdown, and that hand sanitation should occur between glove changes. The facility's policies on hand hygiene and perineal care were not adhered to during this incident.
Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that medications were not self-administered without a physician's order and without an assessment by the interdisciplinary team (IDT) to determine if self-administration was safe. This deficiency was identified for one resident who was found with a bottle of Nystatin-Triamcinolone Cream in their bathroom on two separate occasions. The resident stated that they applied the cream themselves due to its location. The resident's care plan did not identify them as able or assessed to self-administer medications, and there was no physician's order for self-administration. The Medication Administration Record (MAR) documented that the resident had a physician's order for the cream to be applied topically every 24 hours as needed for itching/redness due to candidiasis. However, the resident was not assessed for self-administration, and the facility did not have a policy or form for resident self-administration of medications. Interviews with the Licensed Practical Nurse (LPN) and the Director of Nursing (DON) revealed that there were no residents assessed for self-administration of medications in over a year. Both the LPN and DON emphasized the importance of assessing residents for self-administration to ensure they can safely take the medication, avoid over or under-medicating, and prevent other residents from accessing the medication. The DON confirmed that the resident was instructed that medication could not be kept at bedside, and the resident understood. However, the facility was unable to produce a policy or form for resident self-administration of medications, highlighting a gap in their procedures and oversight.
Failure to Maintain Clean and Sanitary Restroom for Resident
Penalty
Summary
The facility failed to ensure a clean and sanitary environment for Resident #43, who had diagnoses of weakness and constipation and required substantial assistance with toileting hygiene. Observations on multiple dates revealed that the resident's toilet had brown stains and a brown substance on various parts of the toilet bowl and seat. Certified Nursing Assistant (CNA) #11 stated that CNAs were responsible for cleaning the resident's rooms and performed deep cleaning on bath days, which for Resident #43 were Tuesdays and Thursdays. The Administrative Assistant confirmed that the facility did not have a policy on cleaning resident rooms.
Failure to Provide Proper Incontinence Care
Penalty
Summary
The facility failed to provide proper and timely incontinence care for a resident diagnosed with a urinary tract infection and candidiasis. The resident, who was occasionally incontinent of bowel and bladder, was found lying in a bed with a wet incontinence pad and sheet, emitting a strong odor of urine. The resident acknowledged having an episode of urinary incontinence, and upon receiving care from two CNAs, it was observed that the resident's incontinence brief, pad, and sheet were saturated with urine. The resident also had visible skin irritation in the form of reddened excoriation in the areas that contacted the wet brief. During the incontinence care, the CNAs did not properly clean all affected areas of the resident's skin, failed to perform proper hand hygiene, and did not change gloves appropriately. The CNAs admitted to not sanitizing their hands between glove changes and using soiled gloves to handle clean items. The Assistant Director of Nursing confirmed the importance of cleaning all areas that come in contact with urine to prevent skin irritation and breakdown, and emphasized the need for proper hand hygiene to prevent the spread of infection. Facility policies on hand hygiene and peri care were not followed during the incident.
Failure to Elevate Head of Bed During Enteral Nutrition
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident receiving enteral nutrition via a PEG tube. The resident had diagnoses including sequelae of cerebral infarction, epilepsy, aphasia, and dysphagia, and was documented to have severely impaired cognitive skills. The physician's order and care plan required the head of the bed (HOB) to be elevated 30 to 45 degrees during tube feeding to prevent aspiration. However, during an observation, the resident's bed was positioned flat while enteral nutrition was infusing, contrary to the care plan and physician's order. Certified Nursing Assistant (CNA) #1 and Registered Nurse (RN) #1 both confirmed the importance of pausing the enteral nutrition pump and elevating the HOB to prevent aspiration. The Assistant Director of Nursing (ADON) also confirmed that residents should not be laid flat during enteral nutrition to prevent aspiration or pneumonia. Additionally, the ADON revealed that the facility did not have a policy on enteral infusion/feeding, contributing to the deficiency in care provided to the resident.
Failure to Follow Pharmacist's Recommendation for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a pharmacist's recommendation for the provider to provide an appropriate diagnosis before administering an antipsychotic medication was followed for a resident with diagnoses of Dementia, Major Depression, and Delirium. The resident had an order for Zyprexa, an antipsychotic medication, and the Medication Regimen Review (MRR) noted the need for an appropriate diagnosis. The attending physician chose to continue the medication without changes, citing hospice care as the rationale. However, there was no documentation indicating that hospice was notified of the pharmacist's recommendations. Additionally, the facility did not have a policy on unnecessary medications.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 9 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Rison
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Johns Place Of Arkansas, Llc | 15 mi | ★★★★★ | 3 | 0 |
| Pine Bluff Transitional Care | 16.7 mi | ★★★★★ | 6 | 0 |
| Trinity Village Medical Center | 17.1 mi | ★★★★★ | 0 | 0 |
| The Springs Of Pine Bluff | 17.2 mi | ★★★★★ | 0 | 0 |
| The Blossoms At Star City Rehab & Nursing Center | 19.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.