Green Acres Nursing and Rehab

Inspectors wroteBased on an investigation into a complaint, record review, and staff interviews, it was determined that the facility failed to ensure a resident remained free from abuse. This deficient practice was evident for 1 (Resident #5) of 5 residents reviewed for abuse during the complaint survey.

Inspectors wroteBased on investigation into a complaint, record review, and staff interviews, it was determined that the facility failed to ensure allegations of abuse were reported to the Office of Health Care Quality (OHCQ) as required. This deficient practice was evident for 1 (Resident #5) of 5 residents reviewed for abuse during the complaint survey.

Inspectors wroteBased on observations and staff interviews it was determined the facility failed to store food in accordance with professional standards for food safety and failed to ensure that the facility dishwasher provided safe heat sanitization.

Inspectors wroteBased on observation and staff interview during facility environmental observations, it was determined that the facility failed to ensure a safe, clean, comfortable, homelike environment. This was evident for 13 (rooms 102, 103, 104, 107, 111, 112, 115, 116, 118, 117, 119, 120, and 122) out of 24 resident rooms observed for Homelike Environment during the annual survey.

Inspectors wroteBased on observation, record review and interview, it was determined that the facility failed to develop and implement a baseline care plan for a resident, requiring patient-centered Dementia Care, that meets the professional standards of quality care. This was evident for 1 (resident #4) out of 7 residents investigated for Care Planning during the annual survey.

Inspectors wroteBased on observation, record review and interview, it was determined that the facility failed to develop and initiate a comprehensive person-centered care plan for residents residing in the facility. This was evident for 1 (resident #4) out of 7 residents investigated for Care Planning during the annual survey.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to: 1) ensure that each member of the interdisciplinary team was involved in updating the residents' care plans. This was evident for 2 residents (Resident #16 and Resident #65) out of 14 residents reviewed; and 2) develop and implement person-centered care plans with specific, individualized interventions to address residents' diagnosed conditions. This deficient practice was evident for 2 (Residents #10, #109) of 7 residents reviewed.

Inspectors wroteBased on observation, record review and interview, it was determined that the facility failed to ensure nursing services were provided in accordance with professional standards of practice related to medication preparation and administration. This deficient practice was evident for 1 of 5 residents reviewed (Resident #122) and had the potential to affect resident safety and clinical outcomes.

Inspectors wroteBased on observations, record reviews, and interviews, it was determined that the facility failed to document that informed consent was obtained and retained from residents and/or their resident representatives prior to the use of bedrails. This was evident for 6 out of 6 residents observed (Resident #83, #103, # 118, #10, #13 and #14) during the survey conducted at the facility. 1) On 01/14/2026 at 08:25 AM the surveyor observed that the beds in room [ROOM NUMBER] A and B both had 1/4 length bedrails in place on both sides of the bed. The residents, # 83 and # 118 agreed to be interviewed by the surveyor. On 01/15/2026 at 1:30 PM a review of the electronic medical record of both residents #83 and #118 failed to reveal a consent form for bedrail installation. [...]

Inspectors wroteBased on observation, record review, and interview, it was determined that the facility failed to ensure medications were properly removed and disposed of when no longer appropriate for use, including after resident discharge and upon expiration. This deficient practice was evident for 2 of 3 medication rooms reviewed.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure medications were administered in accordance with professional standards of practice, resulting in an overall medication administration error rate of 11.54%. This deficient practice was evident for 3 of 26 medication administrations observed.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to maintain medical records on each resident in accordance with accepted professional standards and practices that are accurately documented the resident current medical diagnosis. This was evident for 1 (resident #4) out of 7 residents' Care Plans reviewed during the annual survey.

Inspectors wroteBased on observation and interviews, it was determined that the facility failed to: 1) maintain infection prevention and control by not ensuring a sanitary and comfortable environment within the resident care areas. This was evident for 6 (rooms 101. 102, 108, 119, 121, and 123) out of 24 resident rooms observed; and 2) ensure staff performed appropriate hand hygiene during medication administration, placing residents at risk for cross-contamination. This deficient practice was evident for 1 of 5 medication administration observations.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to post required nurse staffing ratio information in a visible and accessible location on resident units. This deficient practice was evident for 3 of 4 units reviewed (Units 100, 200, and 300) during the recertification survey.

Inspectors wroteBased on clinical record review and staff interview it was determined that the facility staff failed to ensure a resident had an Advance Directive or was offered the opportunity to create one. This was evident for 5 residents (#21, #98, # 286, # 287, and # 296) out of 52 in the survey sample.

Inspectors wroteBased on observation and interviews it was determined the facility failed to respect the resident's dignity as evidenced by the resident meal tray taken away before the meal was finished. This was evident for 1 out of 1 resident (resident #50) reviewed for dignity.

Inspectors wroteBased on resident interview, staff interview, and clinical record review it was determined that the facility staff failed to honor resident choices with showering. This was evident for 2 (#21 and #73) out of 52 residents in the survey sample.

Inspectors wroteBased on interviews and record review it was determined that the facility failed to ensure the Power of Attorney (POA) was notified of a pressure ulcer. This was found to be evident for 1 (Resident #29) out of 1 resident reviewed for notification.

Inspectors wroteBased on family interview, staff interview, and clinical record reviews, it was determined that the facility failed to ensure that allegations of missing money was reported to the State Survey Agency (Maryland Department of Health - Office of Healthcare Quality) and neglect were reported within the required time frame. This was evident for 2 (#7, #136) out of the 52 residents reviewed for reporting of alleged violations.

Inspectors wroteBased on facility record review and interviews it was determined that the facility failed to ensure that thorough investigations were conducted for alleged violations. This was found to be evident for 2 (Resident #72 and #136) out of 2 Residents reviewed for investigation of alleged violations.

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility staff failed to ensure the local Ombudsman was notified of a facility initiated resident discharge or transfer. This was evident for 2 (#19 and #108) of 7 residents reviewed for hospitalizations during the annual survey.

Inspectors wroteBased on staff interview and clinical record review it was determined that the facility staff failed to ensure a bed hold policy was provided to the resident upon hospitalization. This was evident for 1 (#88) out of 52 residents that were part of the survey sample.

Inspectors wroteBased on resident interview, clinical record review and staff interview it was determined that the facility staff failed to ensure that the resident had care plan meetings. This was evident for 2 (#4 and #21) out of 52 residents that were part of the survey sample.

Inspectors wroteBased on record review and interview it was determined that the facility failed to ensure that a Resident received care in a timely manner. This was found to be evident for 1 (Resident #57) out of 1 Resident reviewed for Quality of Care during the recertification survey.

Inspectors wroteBased on resident interview, staff interview, observation, and clinical record review it was determined that the facility staff failed to ensure a resident wore an ordered brace. This was evident for 1 (#73) out of 3 residents reviewed for range of motion in the survey sample.

Inspectors wroteBased on clinical record review, observation and staff interview, it was determined that the facility staff failed to ensure that additional water ordered for flushes via gastrostomy tube (G-tube) was administered according to the prescriber's orders and notify the physician of a change in the color of the tubing. This was evident for 2 (Resident #6, #73) of 4 residents reviewed for tube feeding during the annual survey.

Inspectors wroteBased on observations, review of facility documentation, clinical record review, and staff interview it was determined that the facility failed to maintain oxygen therapy equipment according to facility policy and physician orders. This was found to be evident for 2 (# 62, #286) out of 4 residents reviewed for respiratory care during the annual survey.

Inspectors wroteBased on clinical record review and staff interview it was determined that the facility staff failed to administer medications according to physician's orders. This was evident for 1 (#53) of the 5 residents reviewed for unnecessary medications. A review of Resident #53's clinical record on 8/13/24 revealed the resident's primary physician ordered Novolog pen 100 unit/ml 16 units before meals and to be held if blood sugar is less than 150. A review of the resident's Medication Administration Record (MAR) revealed that the resident's blood sugar was below 150 on those days but the insulin was still administered. The blood sugars were 8/1 = 143, 8/3 = 145, 8/5 = 117 and 140, 8/6 = 143, and on 8/9 = 142. This represents 6 times out of 43 opportunities that the resident received insulin when it should have been held. [...]

Inspectors wroteBased on observation, interview, and medical record review, it was determined that the facility failed to provide dental services and assessments. This was found to be evident for 1 out of 1 resident (Resident #97) reviewed for dental care.

Inspectors wroteBased on resident interview, staff interview and observation it was determined that the facility staff failed to ensure a resident's meals matched their preferences. This was evident for 1 out of 52 residents in the survey sample.

Inspectors wroteBased on observation and staff interview it was determined that the facility staff failed to ensure food items in the kitchen were maintained in a safe and appropriate manner.

Inspectors wroteBased on observation and interviews it was determined the facility staff failed to have the most recent survey results in a place readily accessible to residents, family members, and legal representatives of residents. This has the potential to affect all the residents and visitors within the facility.

Inspectors wroteBased on facility investigations, record reviews, interviews and observations, the facility failed to protect residents from abuse and neglect. This was found to be evident for 5 (# 7, # 27, # 50, # 62, # 82) out of 38 residents investigated during the annual survey for abuse and neglect.

Inspectors wroteBased on clinical record review, a review of intake MD00166696, and staff interview it was determined that the facility staff failed to ensure a resident's assessment was accurate. This was evident for 1 (#142) out 52 records as part of the survey sample.

Inspectors wroteBased on clinical record review and an investigation of Intake MD00166696 it was determined that the facility staff failed to ensure that a resident wore their eyeglasses. This was evident for 1 (#142) out of 52 residents reviewed as part of the survey sample. The evidence includes: A review of complaint Intake #MD00166696 revealed family was concerned that the resident was not wearing his/her eyeglasses. A review of the clinical record revealed that on 3/24/21 at 2:24 PM nursing wrote: Resident's sister phoned requesting resident's glasses. This author stated that she had never seen resident wearing glasses or glasses in resident's room. The Minimum Data Set (MDS) is a federally mandated assessment tool that helps nursing home staff gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. [...]

Inspectors wroteBased on interview and record review it was determined that the facility staff failed to promptly provide or obtain visit/appointments for routine dental care or treatment. This was found to be evident for 1 (Resident # 49) out of 1 resident reviewed for dental services during an annual survey.

Inspectors wroteBased on medical record review, observations, and staff interview it was determined the facility failed to keep complete and accurate medical records related to: 1) documenting oxygen administration without valid orders for 2 (#158, #75) of 2 residents reviewed for respiratory care, 2) failing to document the administration of a prescribe medication, for 1 (#158) of 2 residents reviewed for respiratory care, and 3) failed to transcribe medication for administration with progress note documentation that is receiving medication as ordered for 1(#44) of 9 residents reviewed for nutrition.

Inspectors wroteBased on observations and staff interviews during environmental tours. It was determined that the facility staff failed to provide maintenance services necessary to maintain a sanitary, orderly, and comfortable building interior.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (#158) of 2 residents reviewed for respiratory care.

Inspectors wroteBased on observation, medical record review and resident and staff interview it was determined that the facility failed to develop and implement comprehensive person-centered care plans. This was exemplified for 2 (#75, #158) of 2 residents reviewed for nutrition.

Inspectors wroteBased on review of the medical record it was determined the facility failed to perform appropriate revisions to the care plan goals and interventions as resident care needs became apparent or changed over time. This was exemplified for 2 (#158, #75) of 2 for 2 residents reviewed for respiratory care.

Inspectors wroteBased on observation, medical record review, resident and staff interview it was determined the facility staff failed to provide respiratory care that was consistent with professional standards as evidenced by 1) failing to have a valid order for administering oxygen, and documenting resident was receiving oxygen without a valid order, failing to implement the written plan of care, and failing to label and date oxygen/nebulizer tubing for a resident; This was identified for 2 (#158, #75) of 2 residents reviewed for Respiratory Care.

Inspectors wroteBased on medical record review and interview with staff it was determined that the facility failed to ensure that the physician fully evaluated and addressed a resident with significant weight loss. This was evident for 1 (#44) of 9 residents reviewed for nutrition.

Inspectors wroteBased on medical record review and staff interview it was determined that the facility failed to assure that residents are seen by a physician at least once every 30 days for the first 90 days following admission to the facility. This was evident for 1 (#44) of 9 residents reviewed for nutrition.

Inspectors wroteBased on observations, review of daily staffing records, and staff interview it was determined the facility failed to post the total number and actual hours worked by categories of Registered nurses, Licensed practical nurses, and Certified nursing aides per shift and failed to have the staff data requirements available in an accurate, clear and readable format. This was identified that the facility did not have staffing information readily available in a readable format for residents and visitors for any given time.