Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Wentworth Place during CMS and state inspections, most recent first.
Two residents had inaccurate MDS coding. One resident was coded as a non-current tobacco user even though smoking safety screens, care planning, and staff observations showed regular tobacco use. Another resident was coded as requiring tracheostomy care even though the resident did not have, and had never had, a tracheostomy. The MDS Coordinator confirmed both were coding errors, and the information was submitted to CMS.
The facility failed to notify the long-term care ombudsman of hospital transfers for three residents. One resident with severe cognitive impairment was not reported until a month later, another with a subarachnoid bleed and pneumonia was overlooked, and a third with end-stage renal disease was omitted due to a bed hold oversight. The facility's policy required ombudsman notification before discharge, which was not followed.
A facility failed to ensure the safety of a lift pad for a resident with severe impairments, as it had holes and fraying, posing a risk during transfers. Additionally, another resident with COPD was left unsupervised while smoking outside, contrary to their care plan requiring supervision and a smoking apron. Staff were unclear on procedures for equipment removal and supervision, as confirmed by the DON.
The facility failed to prepare meals according to specified recipes, compromising their nutritive value and taste. Observations revealed that dietary staff used incorrect amounts of water and thickener in meal preparations, leading to bland and unpalatable food. This deviation from recipes affected the quality of meals served to residents.
The facility failed to provide pureed food items with a smooth, lump-free consistency for residents requiring pureed diets during observed meals. Pureed fried chicken, mixed vegetables, and tater tots were chunky and lumpy, while pureed bread was runny and sausage had a mechanical texture. Staff confirmed the improper consistency, acknowledging the need for longer pureeing and more liquid to meet the facility's policy of a pudding-like consistency.
The facility failed to ensure proper handwashing and glove usage by dietary staff, leading to potential foodborne illnesses. Staff handled clean equipment without washing hands and used unsanitized blenders for pureeing food. Expired food items and spices were not discarded, and hot food items were served at incorrect temperatures, affecting residents receiving meals.
A resident with multiple diagnoses was observed using oxygen therapy without a physician's order, leading to a deficiency in respiratory care. The absence of an order was confirmed by a nurse and the DON, who stated that oxygen is a medication requiring a physician's directive. The facility lacked a policy on oxygen use, indicating procedural gaps.
A facility failed to secure medications in a resident's room, leaving them accessible in unlocked cabinets. Various prescription drugs were found unsecured, contrary to the facility's policy. Staff interviews confirmed that medications should be locked to prevent unauthorized access.
A resident with COPD and obstructive sleep apnea did not have their nebulizer mask and tubing changed weekly as expected, posing a risk of respiratory infections. The facility lacked a formal policy for changing this equipment, although it was informally expected to be done every seven days. This deficiency was confirmed by both an LPN and the DON.
MDS Coding Errors for Tobacco Use and Tracheostomy Care
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately completed for two residents reviewed for MDS accuracy. For one resident, the annual MDS identified the resident as a non-current tobacco user even though the resident’s care plan included smoking safety care and quarterly smoking safety screens documented that the resident smoked 5 to 10 cigarettes per day. Observations also showed staff monitoring the resident during smoke breaks, and staff stated the resident smoked regularly and would smoke after therapy. For another resident, the quarterly MDS identified tracheostomy care as a special treatment/procedure even though the resident did not have a tracheostomy and had never had one. During observation, the resident’s neck showed no tracheostomy or scar indicating a prior tracheostomy. The MDS Coordinator confirmed the entry was a coding error and stated the resident did not have a tracheostomy. The record review also showed the first resident had diagnoses including COPD, pulmonary fibrosis, asthma, dementia, cerebral ischemic attack, vitamin D deficiency, heart failure, and respiratory failure, while the second resident had diagnoses including hemiplegia and non-Alzheimer’s dementia and was on palliative care. The MDS Coordinator stated the facility used the RAI manual to complete the MDS and that the information should accurately reflect the resident’s condition at the time of assessment because it is submitted to CMS.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to notify and provide a copy of the written notice to the long-term care ombudsman when residents were transferred to the hospital. This deficiency was identified for three residents who were hospitalized. Resident #88, with severe cognitive impairment, was transferred to a hospital for further evaluation, but the ombudsman was not notified until a month later. Similarly, Resident #85, who had severe cognitive impairment and was hospitalized for a subarachnoid bleed and pneumonia, was not reported to the ombudsman at the time of transfer. The oversight was acknowledged by the facility staff during the survey. Resident #212, who had end-stage renal disease and other serious health conditions, was transferred to a hospital for acute renal failure and sepsis. The facility's records did not include this resident in the list of notifications sent to the ombudsman because the resident was placed on bed hold, and the list generated did not account for such cases. The facility's policy required notification to the ombudsman before discharge, but this was not adhered to in these instances.
Deficiencies in Equipment Safety and Resident Supervision
Penalty
Summary
The facility failed to ensure the safety of a lift pad used for a resident with severe impairments, including Huntington's disease and stroke. The resident was observed using a lift pad that had a small hole and several frayed areas, which could potentially lead to an accident during transfers. Staff members were unsure of the procedure to remove such defective equipment from service, and the Director of Nursing confirmed that lift pads with holes and fraying are unsafe and should be discarded. Additionally, the facility did not provide adequate supervision for a resident with chronic obstructive pulmonary disease and other conditions who was observed smoking outside alone. Despite the care plan indicating the need for supervision and a smoking apron, the resident was left unsupervised, and staff incorrectly believed that checking from a window constituted supervision. The Director of Nursing confirmed that proper supervision requires a staff member to be present outside with the resident while smoking.
Failure to Follow Recipes Compromises Meal Quality
Penalty
Summary
The facility failed to ensure that meals were prepared in a manner that maintained their nutritive value and taste, which were acceptable to the residents. During an observation, it was noted that the dietary staff did not follow the quantified recipes provided by the Dietary Manager. For instance, the recipe for Breaded Chicken on a Bun required 1.75 cups plus 2 tablespoons of water or stock for five sandwiches, but the dietary staff used 4 cups of hot water instead. Similarly, the recipe for a Vegetable Blend required no water and a specific amount of thickener, but the staff added 1.25 cups of tap water and an incorrect amount of thickener. Additionally, the preparation of a puree dinner roll was not in accordance with the recipe, which specified the use of 0.75 teaspoons of thickener and 2 tablespoons of water or milk. Instead, the dietary staff used 1.25 cups of tap water. These deviations from the recipes resulted in meals that were not palatable, as evidenced by the dietary staff's acknowledgment that food pureed with water would taste bland. This failure to adhere to the specified recipes compromised the quality and palatability of the meals served to the residents.
Improper Pureed Food Consistency
Penalty
Summary
The facility failed to ensure that pureed food items were blended to a smooth, lump-free consistency for residents requiring pureed diets during two observed meals. During the supper meal observation, pureed fried chicken breast, mixed vegetables, and tater tots were found to be chunky and lumpy, with visible pieces of chicken, vegetables, and potatoes. The Dietary Manager and Shahbaz staff confirmed the improper consistency, acknowledging that the food items should have been pureed longer to achieve a pudding-like consistency as per facility policy. During the breakfast meal observation, pureed bread was runny with visible bread particles, and pureed sausage had a mechanical texture rather than a pureed one. The Dietary Manager and Shahbaz staff again confirmed the improper consistency, noting that more liquid should have been added to achieve the correct texture. The facility's policy on pureed foods, which was reviewed, indicated that pureed food should be the consistency of pudding or mashed potatoes, highlighting a failure to adhere to this standard.
Deficiencies in Food Handling and Expired Items
Penalty
Summary
The facility failed to ensure proper handwashing and glove usage by dietary staff, which could lead to foodborne illnesses. Observations revealed that a dietary staff member handled clean equipment without washing hands after removing a pan from the oven. Additionally, the same staff member washed a blender bowl, blade, and lid with hot water but without soap or sanitization before using it to puree food for residents. Another dietary aide contaminated her hands by pushing a cart and then handled glasses by their rims without washing her hands before serving beverages to residents. The facility also failed to discard expired food items and spices, which were found in various kitchens. Expired items included cottage cheese, potato salad, chili powder, garlic powder, ground thyme, Mediterranean-style ground oregano, hot buns, and bread. Furthermore, hot food items were not maintained at the required temperatures, with ground fried chicken breast and mechanical tater tots being served at temperatures below the required level. These practices had the potential to affect residents receiving meals from the facility's kitchens.
Lack of Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to ensure there was a physician's order for oxygen therapy for a resident, leading to a deficiency in providing safe and appropriate respiratory care. Resident #212, who had diagnoses of end-stage renal disease, diabetes mellitus, and sleep apnea, was observed using oxygen therapy at a flow rate of 1.5 liters per nasal cannula on multiple occasions. However, a review of the resident's Order Summary Report for September 2024 revealed no physician's order for the oxygen therapy. During the survey, a registered nurse confirmed the absence of an oxygen order in the electronic record and acknowledged that a physician's order is necessary to ensure the correct oxygen perfusion based on the resident's diagnosis. The Director of Nursing also confirmed the requirement for a physician's order, stating that oxygen is considered a medication. The facility's administrator admitted that there was no policy on the use of oxygen, highlighting a gap in the facility's procedures for managing respiratory care.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were stored securely behind locked compartments, as required by their policy. During an observation, a surveyor found that the medication cabinets in a resident's room were not locked, allowing easy access to various medications. This included prescription drugs such as Jardiance, Metformin, Lantus, and others, which were found in an unlocked state, posing a risk of unauthorized access by residents or staff. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, confirmed that the expectation was for all medications to be stored securely behind locked doors. The Registered Nurse acknowledged that the medication cabinets in the resident's room should have been locked to prevent residents from accessing medications that were not prescribed to them. The Director of Nursing also confirmed the requirement for medications to be kept locked to prevent self-medication and potential harm.
Failure to Change Respiratory Equipment Weekly
Penalty
Summary
The facility failed to ensure that oxygen and nebulizer tubing and masks were changed weekly for a resident, leading to a potential risk of respiratory infections. Resident #59, who has chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea, was receiving albuterol updrafts three times a day. However, observations revealed that the nebulizer mask and tubing had not been changed since 09/05/2024, despite the facility's expectation that these should be replaced every seven days. This oversight was confirmed by both a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), who acknowledged that the equipment should have been changed to maintain cleanliness and prevent infection. Interviews with the LPN and DON revealed that the facility lacked a formal policy or procedure for changing oxygen tubing and nebulizer masks, although it was expected to be done weekly. The LPN stated that night shift nurses were responsible for changing the equipment on Wednesday nights, and staff were instructed to notify a nurse if they found equipment that had not been changed. Despite these expectations, the equipment for Resident #59 remained unchanged, indicating a lapse in adherence to the facility's informal protocol. The Social Services Director confirmed the absence of a written policy, further highlighting the deficiency in the facility's infection prevention and control program.
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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.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Springs Magnolia | 4.6 mi | ★★★★★ | 1 | 0 |
| The Blossoms At Stamps Rehab & Nursing Center | 17.2 mi | ★★★★★ | 3 | 0 |
| Summit Health & Rehab Center | 19 mi | ★★★★★ | 2 | 0 |
| Heritage Nursing Center | 22.8 mi | ★★★★★ | 2 | 0 |
| Timber Springs Rehab And Retirement | 24 mi | ★★★★★ | 4 | 0 |
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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.