Green Acres Health And Rehabilitation
GREEN ACRES HEALTH AND REHABILITATION in MILLEDGEVILLE, GA — inspection on August 14, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the EMR for 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 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 R55 revealed a “Care Area/Problem” related to self-care deficit, last reviewed and continued on 8/12/2025.
The goal was for 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 R55 resided in room [ROOM NUMBER].
Review of the “Bath Schedule” revealed room [ROOM NUMBER] (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, 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 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 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 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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/14/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Green Acres Health and Rehabilitation
313 Allen Memorial Drive,sw Milledgeville, GA 31061
SUMMARY STATEMENT OF DEFICIENCIES
Review of the MedAid (medication aide) MAR dated 8/1/2025 to 8/14/2025 for 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 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 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.
Facility ID: