Deficiency Records for Green Acres Healthcare Center
Updated as of May 01, 2024
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Deficiency Records for Green Acres Healthcare Center
A list of the most recent deficiencies for Green Acres Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Green Acres Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-09 | 2024-04-15 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-02-09 | 2024-04-15 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-02-08 | 2024-03-27 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2024-02-08 | 2024-03-27 | N |
| Have exits that are accessible at all times. | Fire Safety | 2024-02-08 | 2024-03-27 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-02-08 | 2024-03-27 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-02-08 | 2024-03-27 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-02-08 | 2024-03-27 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2024-02-08 | 2024-03-27 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-02-08 | 2024-03-27 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2024-02-08 | 2024-03-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-08 | 2024-03-27 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-02-08 | 2024-03-27 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-02-08 | 2024-03-27 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-02-08 | 2024-03-27 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2024-02-08 | 2024-03-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-08 | 2024-03-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-02-08 | 2024-03-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-02-08 | 2024-03-27 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-02-09 | 2024-03-20 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-02-09 | 2024-03-20 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-02-09 | 2024-03-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-02-09 | 2024-03-20 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-02-09 | 2024-03-20 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-02-09 | 2024-03-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-09 | 2024-03-20 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-02-09 | 2024-03-20 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-02-09 | 2024-03-20 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-02-09 | 2024-03-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-02-09 | 2024-03-20 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-02-09 | 2024-03-20 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-02-09 | 2024-03-20 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2024-02-09 | 2024-03-20 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-02-09 | 2024-03-20 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-02-09 | 2024-03-20 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2024-02-09 | 2024-03-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-09 | 2024-03-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-02-09 | 2024-03-20 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2024-02-09 | 2024-03-20 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-02-09 | 2024-03-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-09 | 2024-03-20 | N |
| Provide enough space and equipment to meet each resident's needs | Health | 2024-02-09 | 2024-03-20 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2024-02-09 | 2024-03-20 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2024-02-09 | 2024-03-20 | N |
| Provide bedrooms that have direct access to an exit hallway. | Health | 2024-02-09 | 2024-03-20 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-02-09 | 2024-03-20 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-02-09 | 2024-03-20 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-15 | 2024-01-12 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-12-15 | 2024-01-12 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-06-16 | 2023-07-31 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-16 | 2023-07-31 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-19 | 2023-06-15 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-05-19 | 2023-06-15 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-05-19 | 2023-06-15 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-05-19 | 2023-06-15 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-05-19 | 2023-06-15 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-05-19 | 2023-06-15 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-12-15 | 2023-01-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-15 | 2023-01-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-22 | 2022-05-20 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-03-22 | 2022-05-20 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-01 | 2022-03-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-09 | 2022-02-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-21 | 2022-02-01 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-11-11 | 2022-01-26 | N |
| Construct fire resistant interior walls. | Fire Safety | 2021-11-11 | 2022-01-26 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-11-11 | 2022-01-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-11-11 | 2022-01-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-11 | 2022-01-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-11-11 | 2022-01-26 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-11-05 | 2021-12-23 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-11-05 | 2021-12-23 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-11-05 | 2021-12-23 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-11-05 | 2021-12-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-05 | 2021-12-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-05 | 2021-12-23 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-11-05 | 2021-12-23 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-11-05 | 2021-12-23 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-11-05 | 2021-12-23 | N |
| Post nurse staffing information every day. | Health | 2021-11-05 | 2021-12-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-11-05 | 2021-12-23 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-11-05 | 2021-12-23 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-11-05 | 2021-12-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-05 | 2021-12-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-05 | 2021-12-23 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2021-11-05 | 2021-12-23 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-11-05 | 2021-12-23 | N |
| Provide bedrooms that have direct access to an exit hallway. | Health | 2021-11-05 | 2021-12-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-25 | 2021-10-18 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-08-25 | 2021-10-18 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2019-06-06 | 2019-07-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-06-06 | 2019-07-08 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-06-06 | 2019-07-08 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-06-06 | 2019-07-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-06-06 | 2019-07-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-06 | 2019-07-08 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-06-06 | 2019-07-08 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-06-06 | 2019-07-08 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-06-06 | 2019-07-08 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2019-06-06 | 2019-07-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-06 | 2019-07-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-06 | 2019-07-08 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2019-06-06 | 2019-07-08 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-06-06 | 2019-07-08 | N |
| Provide bedrooms that have direct access to an exit hallway. | Health | 2019-06-06 | 2019-07-08 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-06-14 | 2019-07-08 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-06-14 | 2019-07-08 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2019-06-14 | 2019-07-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-06-14 | 2019-07-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-06-14 | 2019-07-08 | N |
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