Green Acres Health And Rehabilitation
Inspection Findings
F-Tag F0677
F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
- 2. Review of the EMR for Resident R55 revealed he was admitted to the facility with diagnoses to include Alzheimer's
disease with early onset, unspecified disorientation, cognitive communication deficit, and major depressive disorder.
Review of the Quarterly Minimum Data Set assessment, dated 5/10/2025, for Resident R55 revealed Section C (Cognitive Patterns) documented a BIMS score of 4 (indicating severe cognitive impairment). Section GG (Functional Abilities and Goals) documented the resident was dependent on staff for oral hygiene, toileting hygiene, showers/bathing, and personal hygiene.
Review of the care plan for Resident R55 revealed a “Care Area/Problem” related to self-care deficit, last reviewed and continued on 8/12/2025. The goal was for Resident R55 to accept assistance with ADLs, and needs will be met during the next review period, last reviewed and continued on 8/12/2025. Interventions included assistance with ADLs as needed, reviewed, and continued on 8/12/2025.
Review of the EMR revealed Resident R55 resided in room [ROOM NUMBER].
Review of the “Bath Schedule” revealed room [ROOM NUMBER] (Resident R55) was scheduled for showers on Tuesdays, Thursdays, and Saturdays.
Review of the “Point of Care” data sheets, dated 7/14/2025 through 8/14/2025, revealed that out of 14 shower opportunities, Resident R55 received six showers on 7/19/2025, 7/26/2025, 7/31/2025, 8/2/2025, 8/9/2025, and 8/14/2025. There was no documentation to indicate that Resident R55 refused his scheduled showers
during the specified time period. In an interview on 8/14/2025 at 3:30 pm, CNA AA confirmed that Resident R55 had 14 opportunities for showers from 7/14/2025 through 8/14/2025, but only six showers were documented.
CNA AA stated that if the shower was not documented, the shower did not happen.
In an interview on 8/14/2025 at 3:45 pm, CNA BB stated he was not sure why showers for Resident R55 were not documented.
In an interview on 8/14/2025 at 4:20 pm, the DON stated she expected showers to be completed as scheduled or as needed, and should include nail care and grooming needs. She stated the documentation of ADL care needed to be consistent and reflect the care and services provided. She stated she was unable to determine if the showers were given during the identified period and confirmed that, without documentation, she would assume they were not.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Green Acres Health and Rehabilitation
313 Allen Memorial Drive,sw Milledgeville, GA 31061
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0760
F 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and review of the facility's policy titled Medication Administration-General,
the facility failed to ensure medications were administered as ordered by the physician to one of nine residents (R) (Resident R20) observed for medication administration. This deficient practice had the potential to place Resident R20 at an increased risk of adverse effects from the medication and a diminished quality of life. Findings include:Review of the facility's policy titled Medication Administration-General, review date 4/15/2025, revealed the Intent section stated, To facilitate that medications are administered as prescribed, in accordance with good nursing principles. The Guidelines section included, . Prior to medication administration, the Nurse or Certified Medication Aide (CMA): . Reads the administration directions on the MAR [medication administration record] and verifies correct medication, dose, and directions for use.Review of the Face Sheet for Resident R20 revealed admission on [DATE REDACTED]. Diagnoses included, but were not limited to, spastic diplegic cerebral palsy, anxiety disorder, essential hypertension, and muscle weakness.Review of the physician's orders for Resident R20 revealed an order dated 5/9/2025 for amlodipine 5 milligrams (mg) tablet [a medication used to treat high blood pressure], one tablet by mouth one time per day. Hold if blood pressure (BP) is less than 110/60. Hold if systolic BP less than 110. Hold if diastolic BP less than 60. Review of the MedAid (medication aide) MAR dated 8/1/2025 to 8/14/2025 for Resident R20 revealed amlodipine 5 mg tablet was administered on 8/3/2025, and the BP was documented as 90/67, and on 8/13/2025, and the BP was documented as 88/77.In an interview on 8/14/2025 at 4:09 pm, the Director of Nursing (DON) confirmed that the MedAid MAR for Resident R20 documented that amlodipine 5 mg oral tablet was administered when the resident's BP was below the ordered parameters for holding the medication on 8/3/2025 and 8/13/2025. The DON stated the charge nurse should have been notified, and a follow-up should have been completed. In an interview on 8/14/2025 at 4:19 pm, Licensed Practical Nurse (LPN) CC verified that the MedAid MAR for Resident R20 documented that amlodipine 5 mg oral tablet was administered when
the resident's BP was below the ordered parameters for holding the medication on 8/3/2025 and 8/13/2025.
She stated that the CMA should have notified her, she would have notified the physician, and the resident would have been monitored for changes.
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
GREEN ACRES HEALTH AND REHABILITATION in MILLEDGEVILLE, GA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MILLEDGEVILLE, GA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from GREEN ACRES HEALTH AND REHABILITATION or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.