Green Acres Care Center LLC

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on observation, staff interview, record review, and review of the facility's policy titled Fall Prevention Program, the facility failed to provide an environment free from accident hazards for one of three Residents (R) (R1) reviewed for accidents. On 11/18/2025, actual harm occurred when R1 attempted to use her bathroom, which was under renovation, and her sock became stuck to the glue on the bathroom floor, resulting in an unwitnessed fall. R1 sustained a right humerus shaft fracture, right open distal femur fracture, and a hematoma over the right inferior frontal scalp. R1 was hospitalized on [DATE] and underwent an operative fixation (a surgical repair for broken bones) on 11/20/2025 as a result of the fall.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.