Green Acres Healthcare

In the surveyor’s words

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

• Actual harm, patternF689Jun 30, 2022

  Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to provide supervision to ensure an environment free from accidents and hazards for two (2) of eighteen (18) sampled residents (Residents #3 and #5). The facility assessed Resident #3 and Resident #5 to be at high risk for falls. Review of Resident #3's Electronic Medical Record (EMR), revealed for seven (7) of the fourteen (14) falls the resident experienced between January 2021 through June 2022, the facility failed to ensure appropriate interventions were implemented to reduce or prevent additional falls and possible injuries. […]

• Actual harm, isolatedF656Jun 30, 2022

  Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to develop and implement a Comprehensive Care Plan which ensured residents received the necessary adequate supervision and assistance for one (1) of eighteen (18) sampled residents (Resident #3). The facility assessed Resident #3 to be at high risk for falls on admission, quarterly; and, with falls he/she sustained. However, the facility failed to implement the necessary assistive devices and supervision to reduce/prevent further falls. Resident #3 experienced fourteen (14) unwitnessed falls from January 2021 through June 2022, with the resident experiencing serious injuries as a result of the fall on 10/27/2021. […]

• Actual harm, isolatedF657Jun 30, 2022

  Based on observation, interview, record review and review of the facility's policies, it was determined the facility failed to ensure each resident's care plan was revised and updated; and, failed to provide the necessary supervision and assistive devices for each resident to prevent accidents for two (2) of eighteen (18) sampled residents (Resident #3 and Resident #5). The facility assessed Resident #3 as a high risk for falls on admission, quarterly and with any falls. However, the facility failed to review and revise Resident #3's care plan and failed to implement the necessary supervision and assistive devices to prevent accidents. The facility repeatedly care planned Resident #3 to ask for assistance when picking items up off the floor and with transfers. […]

• No harm, potential for more than minimal, isolatedF580Nov 19, 2025

  Based on record review, interview, and facility policy review, the facility failed to inform the resident representative when there was a significant change a resident's status for 1 of 4 residents sampled for notification, out of 6 total sampled residents (Resident (R)1). The findings include:Review of the facility policy titled, Notification of Changes, reviewed [DATE], revealed when there was a change in a resident's condition requiring notification, the facility was to promptly inform the resident, consult the resident's physician, and notify the resident's representative (ex. […]

• No harm, potential for more than minimal, isolatedF655Nov 19, 2025

  Based on record review, interview, and facility policy review, the facility failed to develop and implement a baseline care plan with instructions to provide effective and person-centered care for 1 of 6 sampled residents, (Resident (R)1). The findings include: Review of the facility policy titled, Baseline Care Plan, reviewed [DATE], revealed the facility was to develop and implement a baseline care plan for each resident that included the instructions needed to provided effective and person-centered care of the resident to meet professional standards of quality of care. Review further revealed the baseline care plan was to be developed within 48 hours of a resident's admission. […]