Complete Care at Green Acres

In the surveyor’s words

From the most serious findings on record at Complete Care at Green Acres, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF804Feb 8, 2024

  Based on observation, interview, and record review for two of three units (Rehabilitation unit and Secure unit) and five residents (Resident (R) 17, R196, R125, R2, R18) of 28 sampled residents revealed the food served was bland and residents did not receive salt, pepper, or Mrs. Dash to season their food after being served. Findings include: Review of R17's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/10/23 revealed R17 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R17 was cognitively intact. During the initial tour of the facility on 02/05/24 at 11:39 AM, R17 stated, The food doesn't have any taste, no spices in it at all. […]

• No harm, potential for more than minimal, patternF880Feb 8, 2024

  Based on observation, record review, interviews, and facility policy review, the facility failed to follow infection control procedures during a wound cleaning process, while delivering a meal tray to a resident in droplet isolation, and during room cleanings for residents in C-diff isolation for four of seven residents (Resident (R)86, R345, R134, and R194) reviewed for infection control standards of 28 sampled residents. Findings include: 1. Review of R86's undated Admission Record located under the Profile tab in the electronic medical record (EMR) revealed R86 was readmitted to the facility on [DATE] with diagnoses of hypertension and peripheral vascular disease. […]

• No harm, potential for more than minimal, patternF712Nov 10, 2021

  Based on observation, interview, and record review, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents conducted face to face visits and wrote progress notes at least every thirty days for the first ninety days for new admissions or every sixty days after. This deficient practice was identified for 4 of 6 residents (Resident #3, #42, #49, and #66) during the Resident Council group meeting and evidenced by the following: On 11/8/21 at 10:01 AM, the surveyor conducted a resident group meeting with six residents who were alert and oriented and selected by the facility to attend the group meeting. […]

• No harm, potential for more than minimal, isolatedF842Jul 31, 2025

  Based on record review, interview, and document review, the facility failed to have a complete and accurate medical record for three out of 32 (Resident (R) 126, R164, and R191) sampled residents. This failure had the potential to adversely affect the care of these residents with inaccurate information in the medical record.Findings include: 1. Review of R126's undated Face Sheet, located under the Profile tab in the electronic medical record (EMR), indicated R126 was admitted to the facility on [DATE] with diagnoses that included heart failure, hypertension, and stroke. […]

• No harm, potential for more than minimal, isolatedF881Jul 31, 2025

  Based on record review, interview, policy review, and review of McGeer criteria, the facility failed to have an Antibiotic Stewardship Program that followed current standards of practice for prescribing an antibiotic for one of four residents (Resident (R) 99) reviewed for antibiotic stewardship out of total sample of 32. This failure had the potential to cause residents to be prescribed antibiotics that were potentially unnecessary.Findings include: Review of the facility's policy titled, Infection Surveillance, dated 09/01/2,4 indicated, A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. […]