Green Acres Care Center LLC

Based on observations, staff interviews, and a review of the facility's records, and facility's policies titled Date Marking for Food Safety, and Sanitation Inspection, the facility failed to discard expired food items and failed to properly label and date. Additionally, the facility failed to maintain sanitary practice with ice machine. The deficient practices had the potential to place 101 of 102 residents who received an oral diet from the kitchen at risk of contracting a foodborne illness. Findings Include:Review of facility's policy titled, Date Marking for Food Safety review dated 01/08/2026, documented in Policy Explanation and Compliance Guideline for Staffing 3.The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. 4. The marking system shall consist of a color-coded label, the day/date of opening, and the day/date the item must be consumed or discarded. Review of facility's policy titled, Sanitation Inspection dated 01/08/2026, documented in Policy Explanation and Compliance Guideline for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, and review of the facility policy titled, Promoting/Maintaining Resident Dignity the facility failed to protect and value one resident (R88) of 39 sampled resident private space. Specifically, staff failing to ensure knocking on R88 bedroom door before entering. Findings include: Review of facility policy titled, Promoting/Maintaining Resident Dignity with a revision date of 01/08/2026 stated under the Policy section, it is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of like by recognizing each resident's individually. Under the section Compliance Guidance (1) all staff members are involved in providing care to residents to promote and maintain resident dignity and respect residents' rights and (12) maintain resident privacy. A review of the quarterly Minimum Data Set (MDS)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, record review and review of the facility's policy titled Resident Self-Administration of Medication, the facility failed to remove medications from the bedside of one of 39 sampled residents (R35) for self-administration of medications. This deficient practice had the potential to cause medication overdose and worsening of R35's medical condition.Findings include:Review of the facility's policy titled Resident Self-Administration of Medication reviewed 01/08/2026 documented Policy: It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. Policy Explanation and Compliance Guidelines: 7. Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the other resident's rooms or to confused roommates of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, record review and review of the facility's policy titled Preventative Maintenance Program, the facility failed to ensure call device was within reach of one of 39 residents (R) R53 and failed to ensure proper accommodation of wheelchair device for R70. This deficient practice had the potential to cause delayed care and injury to the residents.Findings include: Review of R70 clinical record revealed that he was admitted to the facility on [DATE], with diagnoses included but not limited to cervical disc dsorder with dadiculopathy. The R70s most recent Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 15, which indicated no cognitive impairment. Review of the Care Plan date 02/26/2024 revealed in Focus the resident has had a fall. Goals the resident will not sustain serious injury through the review date. Intervention Therapy to evaluate resident for a new wheelchair. Date Initiated: 01/26/2025 Review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview, record review, and review of the facility policy titled, Comprehensive Care Plan the facility failed to ensure one of 39 sampled residents (R) (R52) care plan was revised in a timely manner related to her code status. Findings include: Review of the facility policy title, Comprehensive Care Plan with a revision date of 01/08/2026 stated it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. Under the section Policy Explanation and Compliance Guidelines (5) the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. Review of R54 profile tab in the electronic medical record (EMR) revealed R54 is documented as a do not resuscitate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, interviews, and review of the facility's policy titled, Oxygen Administration the facility failed to obtain a physician's orders for oxygen therapy for one resident (R) (R103) of 13 residents receiving oxygen therapy.Review of the facility's policy titled, Oxygen Administration with a revision date of 01/08/2026 documented in the section Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician, except in the case of an emergency. R103 was admitted to the facility on [DATE] with diagnoses not limited to chronic respiratory failure with hypoxia.Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed R104 had a Brief Interview of Mental Status (BIMS) score of 15 indicating cognition was intact. Further review of the MDS in section (O) documented resident is receiving oxygen therapy. Review of the care plan documented R103 required oxygen therapy and to give medications as ordered by physician. Review of the Physician's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews and record review, the facility failed to remove one pair of scissors from the bedside of one of 39 sampled residents (R) (R35). This deficient practice had the potential to cause injury to residents.Based on observations, resident and staff interviews and record review, the facility failed to remove one pair of scissors from the bedside of one of 39 sampled residents (R35). This deficient practice had the potential to cause injury to residents.Findings include:Requests were made for the facility's policy regarding accident hazards however, none was provided. Review of the facility's Electronic Medical Records (EMR) revealed R35 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis included but not limited to cirrhosis of the liver.Review of the Medicare 05-day Minimum Data Set (MDS) dated [DATE] Section C (Cognition) Brief Interview for Mental Status (BIMS) score of 15, which indicated R35 had intact cognition, Section I…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, and review of facility policy titled, Medication Storage, the facility failed to ensure medications were secured on one (cart 3) of four medication carts reviewed and failed to ensure two of four medication (medication cart 1 and 2) carts were locked and secure.Review of the facility policy titled Medication Storage with a revised date of 01/08/2026 stated under Policy, it is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, lights, ventilation, moisture control, segregation, and security. Under Policy Explanation and Compliance Guidelines (1) General Guidelines (a) all drugs and biologicals will be stored in locked compartments (i.e, medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature control. During an observation and interview on 04/24/2026 at 09:10 AM with the Assistant Director of Nursing (ADON) and Registered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interviews, and review of the facility policy titled, Promoting/Maintaining Resident Dignity the facility failed to ensure a privacy curtain for one of 4 residents (R) (R49) in room [ROOM NUMBER] bed-A. Findings include: Review of facility policy titled, Promoting/Maintaining Resident Dignity with a revision date of 01/08/2026 stated under the Policy section, it is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of like by recognizing each resident's individually. Under the section Compliance Guidance (1) all staff members are involved in providing care to residents to promote and maintain resident dignity and respect residents' rights. A review of the annual Minimum Data Set (MDS) assessment dated [DATE] documented that R49 had a Brief Minimum Data Set (BIMS) score of 3, indicating severe…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, and review of the facility policies titled Food Storage Areas and Food from Family Members, the facility failed to ensure food items were labeled, dated, and securely wrapped in the kitchen storage areas and in two of two resident pantries. In addition, the facility failed to ensure that staff food items were stored separately from resident food items. These failures had the potential to place the 89 residents who consumed food from the kitchen at risk of foodborne illness. Findings include: Review of the facility's policy titled, Food Storage Areas, dated 4/20/2024, indicated, It is the intent of this center to store food in a manner that maintains quality and safety. First in, first out should be followed with Refrigerator Food codes, and internal tools may be used as a reference for proper dating. Review of the facility's policy titled, Food from Family Members, dated 3/20/2024, indicated, It is the intent of this center to store food in a manner that maintains quality and safety. First in, first out should be followed with Refrigerator…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on resident and staff interviews, record review, review of facility documents, and review of the facility policy titled, Management of Residents' Personal Funds, the facility failed to provide written quarterly statements within 30 days of the end of the quarter to one of 43 residents (R) (R78) and/or the resident representative to inform them of the residents' balance in their personal funds account. This failure had the potential to cause R78 and/or the resident representative to be uninformed of the balance in their account. Findings include: Review of the facility's undated policy titled, Management of Residents' Personal Funds, revealed, Policy Statement: Our facility manages the personal funds of residents who request the facility do so. Policy Interpretation and Implementation: . 3. Should the facility manage the resident's funds, the facility acts as a fiduciary of the resident funds and holds, safeguards, manages and accounts for the personal funds of the resident . 4. Should our facility be appointed the resident's representative payee, and directly receive monthly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interviews, record review, and review of the facility policy titled, Admission, Transfer, and Discharge, the facility failed to provide a written notification of transfer to the hospital to the resident and resident representative for one resident (R) (R26) reviewed for hospital transfer. This deficient practice had the potential to affect the resident and their representative by not having the knowledge of where and why a resident was transferred and/or how to appeal the transfer, if desired. Findings include: Review of the facility's undated policy titled Admission, Transfer, and Discharge revealed that the policy did not provide guidance related to providing the written notification of transfer to the resident and the resident representative. Review of R26's Electronic Medical Record (EMR) revealed a Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/30/2025, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R26 was cognitively intact. Review of R26's EMR located under the Census tab revealed that R26…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.