Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aviata At Greenacres during CMS and state inspections, most recent first.
Two residents were not treated with dignity during care activities. A post-surgical resident who was cognitively intact and required substantial/max assistance with ADLs reported that urine splashed on the floor and on her body while using a bedside commode at the bedside, which appeared to lack the correct collection container; multiple commodes in storage areas were later observed without buckets or drainage collection. Another resident with mild cognitive impairment and dependent in ADLs was observed near the nurses’ station, slouched in a wheelchair and calling for help to be repositioned, and was then handled roughly by two staff members while being repositioned in front of others.
Surveyors identified multiple failures including nonfunctioning call lights in five rooms without a written protocol for timely response, missed wound and catheter care for a cognitively impaired resident with a right hip wound and indwelling catheter, and numerous omissions in medication and treatment administration for two other residents. One resident with complex conditions and heart failure did not consistently receive ordered daily weights, diuretics, IV antifungal therapy, diabetes injectables, vital sign monitoring, PICC/MID line measurements, or Hepatitis A and B vaccines as documented on the MAR. Another post‑surgical resident with a pain management care plan received PRN Naproxen for moderate to severe pain, but there was no documentation explaining why ordered PRN Oxycodone was not offered or given, nor whether the pain medication administered was effective.
A resident who was cognitively intact but required substantial to maximum assistance with ADLs following knee replacement surgery was discharged home with orders for OT, PT, home health, and DME including a standard walker. Although the SSD faxed home health orders to an agency, there was no confirmation that services were accepted or scheduled, and no documentation in the record regarding the status of home health arrangements at discharge. The resident later reported still waiting for home health treatment, indicating the resident was discharged without verified home health services in place.
The facility failed to secure medications as required by its own policy and professional standards. A resident with acute respiratory failure, incomplete quadriplegia, dysphagia, and moderate cognitive impairment had hydrocortisone and clobetasol creams stored in an open bedside nightstand drawer without any documented assessment or MD order for self‑administration; staff acknowledged the creams were intentionally kept at the bedside for CNA application. At one nursing station, two unopened bottles of melatonin were left on the counter with no staff present and residents nearby, and at another station an enema saline laxative was found unsecured with no staff present and several residents in the area; a RN manager confirmed medications are required to be secured at all times.
A resident with severe cognitive impairment and an order for a dysphagia mechanical soft diet was observed coughing in the hallway while eating a chewy granola bar, with staff passing by without intervening until prompted by a surveyor. The resident’s care plan identified risk of malnutrition and the need for a mechanically altered diet, including monitoring for dysphagia symptoms. In the resident’s room, a breakfast tray labeled for another resident contained remnants of hard scrambled eggs and crispy hashbrowns, and the CNA present could not explain the tray. The ST and RD later confirmed that the granola bar and crispy hashbrowns were not appropriate for the ordered mechanical soft diet.
Two residents with cognitive and physical impairments were fed by CNAs who stood at the bedside rather than sitting, despite staff awareness of proper feeding protocols. This practice failed to uphold resident dignity during meals.
A resident who was unable to perform activities of daily living independently did not receive the necessary care and assistance from facility staff.
A resident with dementia, Parkinson's disease, and bipolar disorder was prescribed multiple psychotropic and antipsychotic medications, but there was no documented behavior monitoring for these drugs in the MAR. The DON was unable to locate any records of behavior monitoring, resulting in a deficiency related to the lack of interventions to ensure the resident's drug regimen was free from unnecessary medications.
The facility failed to provide adequate portion sizes for the main lunch entree, affecting 46 residents on Regular diets. Three residents reported insufficient food portions, and an observation revealed that dietary staff used a 6-ounce scoop instead of the required 8-ounce scoop for serving Shrimp & Sausage Jambalaya.
A resident with a moderate cognitive deficit and known elopement risk managed to leave the facility undetected by loosening a window lock. The resident traveled three miles along a busy roadway before being found by an off-duty staff member. Lapses in communication and supervision, including a delay in initiating the elopement protocol, contributed to the incident.
A facility failed to adequately monitor a resident identified as an elopement risk. Initially, interventions included electronic monitoring and identifying wandering patterns. When the resident exhibited active exit-seeking behavior, additional measures like checking the Wanderguard were added. However, more frequent monitoring and one-to-one observation were only implemented after the resident eloped, highlighting a delay in addressing the risk.
A resident with cognitive impairment and identified as an elopement risk managed to leave the facility and travel 1.3 miles along a busy roadway. Despite being placed on 1:1 observation after showing exit-seeking behavior, the resident exited through a door, climbed a fence, and was found running along a main road. The staff's failure to maintain proper supervision and adhere to the facility's elopement risk policy led to this incident.
Failure to Maintain Resident Dignity During Toileting and Repositioning
Penalty
Summary
The deficiency involves failures to treat residents with dignity and respect for their rights. For one resident admitted post–knee replacement surgery, a comprehensive assessment documented that the resident was cognitively intact and required substantial to maximum assistance with ADLs. During a phone interview, the resident reported that while using a bedside commode placed next to her bed, urine splashed onto the floor and her body, which she described as humiliating. She stated it appeared the bedside commode did not have the correct bottom or collection container attached. Subsequent observation of the facility’s supply closet and shower room revealed multiple bedside commodes stored without attached buckets or drainage collection containers, and the Nursing Home Administrator (NHA) acknowledged these findings. A second resident with mild cognitive impairment and dependence for ADLs was observed sitting in a wheelchair next to the nursing station, slouched over to the right side, and yelling for help to be repositioned. The resident was then observed being handled roughly by two staff members as they attempted to reposition and adjust the resident in the wheelchair in front of others who were watching. This interaction occurred in a public area near the nursing station, and the NHA was made aware of the observation.
Nonfunctioning Call System, Missed Wound/Catheter Care, and Medication Administration Failures
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, resident preferences, and goals, including failure to ensure timely staff response to call lights due to a nonfunctioning call system in multiple rooms. The facility’s policy on inoperable call bell systems required immediate notification of Maintenance and the Executive Director of Clinical Services, placement of hand or tap bells within reach of affected residents, education on their use, and 15‑minute checks with documentation when a large number of residents were affected. During a tour of the South unit, surveyors observed that call lights were not functioning in five specific rooms at various times, and the Director of Maintenance later stated he had only been made aware of the nonfunctioning call lights the previous day. The DON also stated there was no written policy or protocol for answering call lights timely, despite having referenced a call light policy in a grievance response. The facility also failed to provide ordered wound care and catheter care for a resident with significant medical conditions. This resident had diagnoses including metabolic encephalopathy, type 2 diabetes mellitus, and cognitive communication deficit, with a BIMS score indicating severe cognitive impairment. Physician orders included catheter care every shift and right hip wound care with betadine and a bordered dressing three times weekly and as needed. Record review showed no documentation of right hip wound care from 02/19/26 to 02/24/26, and the DON acknowledged that wound care orders were not entered until 02/24/26 and that there was no documentation of wound care on 02/23/26. On observation, the resident was disheveled, partially uncovered, with a visible darkened area on the right hip under a brief, and the indwelling urinary catheter tubing was not secured, with the call light on the floor and out of reach. The ADON acknowledged the need to cover the resident, the presence of the right hip wound without a dressing, and the unsecured catheter tubing, and the wound care nurse acknowledged that wound care was not completed on one of the ordered days. The facility further failed to administer medications and treatments as ordered for two other residents. For one resident with discitis, type 2 diabetes mellitus, and heart failure, physician orders included daily weights for congestive heart failure, Bumex, Micafungin IV, Ozempic weekly, Victoza daily, vital signs every shift, PICC/MID line measurements, and Hepatitis A and B vaccines. The MAR showed multiple omissions, including missing daily weights on two days, missed doses of Bumex, Micafungin, Ozempic, and Victoza, lack of documented vital signs and PICC/MID line measurements on a specified date, and non‑administration of ordered Hepatitis A and B vaccines on several dates. The DON acknowledged that this resident had several medications that were not given in the month and also acknowledged that all medications had to be locked at all times. For another resident admitted post‑knee replacement surgery, with a care plan for pain medication therapy, orders included PRN Naproxen every six hours for pain and PRN Oxycodone every four hours for moderate to severe pain levels 5–10. The MAR documented administration of Naproxen on several occasions for pain levels of 5–6, but the record did not show why the ordered Oxycodone was not administered or offered for moderate to severe pain, nor did it document whether the administered medication was effective. The DON acknowledged these findings.
Failure to Arrange Ordered Home Health Services at Discharge
Penalty
Summary
The facility failed to ensure ordered home health services were arranged for a resident at discharge, resulting in the resident returning home without confirmed home health care. The resident had been admitted after knee replacement surgery, was cognitively intact, and required substantial to maximum assistance with activities of daily living. A comprehensive assessment documented these needs, and a physician’s order dated 01/30/26 directed discharge home with OT, PT, home health services, and DME including a standard walker. The Social Services Director reported that the resident’s discharge was initially delayed because the ordered walker had not been delivered, and stated she faxed the home health orders to an agency on 01/29/26 but did not obtain or document confirmation that services were accepted or scheduled. The resident reported in a phone interview nearly a month after discharge that she was still waiting to receive home health treatment, and record review showed no documentation regarding the status of home health arrangements or follow-up on the referral at the time of discharge. Record review and interviews confirmed that the resident was discharged home without verified home health services in place, and the facility’s documentation lacked any evidence of confirmation or tracking of the home health referral, despite the resident’s identified need for substantial assistance and ordered post-acute services.
Unsecured Medications at Bedside and Nursing Stations
Penalty
Summary
The deficiency involves the facility’s failure to secure medications in accordance with its own policy and accepted professional standards. The facility’s undated Medication Storage policy stated that, with the exception of emergency drug kits, all medications must be stored in a locked cabinet, cart, or medication room accessible only to authorized personnel. For one resident, identified as having acute respiratory failure with hypoxia, incomplete C5–C5 quadriplegia, dysphagia, and a Brief Interview of Mental Status score indicating moderate cognitive impairment, surveyors found hydrocortisone 2.5% cream and clobetasol propionate 0.05% cream in an open nightstand drawer at the bedside. Record review showed no assessment or physician order authorizing this resident to self-administer medications. Nursing staff, including an RN and a CNA, acknowledged during a side‑by‑side observation that the creams were kept at the bedside so the CNA could apply them during care. Additional unsecured medications were observed at both nursing stations. At one nursing station, surveyors observed two bottles of melatonin (3 mg and 5 mg, 200‑count) left on the nursing counter with no staff present and three residents nearby; the ADON acknowledged the medications had been left at the station, noting they were unopened. At another observation of the North nursing station, an enema saline laxative containing dibasic sodium phosphate 7 g and monobasic sodium phosphate 19 g was found unsecured with no staff present and four residents nearby. A RN Unit Manager confirmed that medications should be secured at all times and stated she did not know who left the enema at the station before removing it.
Failure to Provide Diet Consistent With Ordered Mechanical Soft Requirements
Penalty
Summary
The deficiency involves the facility’s failure to provide food in a form consistent with an ordered dysphagia mechanical soft diet for a resident with severe cognitive impairment and high assistance needs for ADLs. The resident had a care plan identifying risk of malnutrition related to the need for a therapeutic and mechanically altered diet, with interventions to explain and reinforce the importance of maintaining the ordered diet and to monitor, document, and report signs and symptoms of dysphagia such as pocketing, choking, coughing, and drooling. Despite these orders and care plan interventions, the resident was observed sitting in the hallway near the nursing station, coughing, while holding and eating a chewy granola bar. During this observation, staff walked past the coughing resident without intervening until the surveyor inquired about what was in the resident’s hand, at which point the resident revealed the chewy granola bar. A CNA stated the resident had obtained the granola bar from a drawer and commented that it was the last one. When the surveyor checked the resident’s room, no food was found in the drawer, but a breakfast tray labeled with another resident’s name was present on the bedside table, containing remnants of scrambled hard eggs and hashbrowns with crispy, crunchy edges. When questioned about this tray, the CNA, who was assisting the roommate, shrugged her shoulders. In a subsequent interview, the speech therapist and registered dietician both agreed that the resident should not have had the chewy granola bar or the crispy hashbrowns, confirming that these items were inconsistent with the ordered mechanical soft diet.
Failure to Maintain Dignity During Dining
Penalty
Summary
Staff failed to ensure dignity during dining for two residents with significant medical needs. One resident, who was severely cognitively impaired and dependent on assistance for eating, was observed being fed by CNAs while the staff stood at the bedside on two separate occasions. The resident's diet required special considerations due to dysphagia and other medical conditions. Despite being aware of proper feeding protocols, staff continued to feed the resident while standing. Another resident, who had mild cognitive impairment and required a dysphagia puree diet with honey thickened fluids, was also observed being fed by a CNA while the staff member stood. Upon noticing the surveyor, the CNA retrieved a chair and sat down. These observations were confirmed through interviews and record reviews, indicating a failure to maintain resident dignity during mealtime.
Failure to Assist Resident with Activities of Daily Living
Penalty
Summary
A deficiency was identified in the facility's provision of care and assistance with activities of daily living (ADLs) for residents who are unable to perform these tasks independently. The report notes that care and assistance were not provided as required for at least one resident who was unable to complete ADLs without help. This failure to provide necessary support directly affected the resident's ability to perform essential daily activities.
Failure to Monitor Behaviors for Psychotropic and Antipsychotic Medications
Penalty
Summary
The facility failed to implement interventions to monitor behaviors related to the use of antidepressant and antipsychotic medications for one resident. The resident, who was admitted with diagnoses including dementia, Parkinson's disease, and bipolar disorder, was prescribed multiple psychotropic and antipsychotic medications, such as Zonegran for agitation, Venlafaxine for depression, Nuplazid for hallucinations, and Mirtazapine for major depressive disorder. Review of the resident's Medication Administration Record (MAR) for July 2025 showed a lack of documentation regarding behavior monitoring associated with these medications. During interviews, the Director of Nursing (DON) was unable to locate any behavior monitoring records for the resident, either on paper or within the MAR. The absence of documented behavior monitoring for the administration of antipsychotic and psychotropic medications constituted a failure to ensure the resident's drug regimen was free from unnecessary drugs, as required by regulation.
Inadequate Portion Sizes for Regular Diets
Penalty
Summary
The facility failed to provide adequate portion sizes for the main lunch entree for residents on Regular diets, potentially affecting 46 residents. During the survey, three residents expressed concerns about inadequate food portions. Resident #3, who has diabetes and potential nutritional problems, stated that the facility did not provide enough food. Resident #8, diagnosed with brain neoplasm, also reported insufficient food portions. Resident #9, with a cutaneous abscess, mentioned that he often had to order food from outside due to inadequate portions provided by the facility. An observation of the lunch tray line service revealed that the dietary staff was serving only 6 ounces of Shrimp & Sausage Jambalaya instead of the 8 ounces specified in the menu. Staff B, responsible for plating the food, used a 6-ounce scoop instead of the correct 8-ounce scoop. This discrepancy was confirmed by Staff A, the food service manager, and further verified by examining prepared trays, which all contained only 6 ounces of the entree.
Resident Elopement Due to Inadequate Supervision and Communication
Penalty
Summary
The facility failed to provide appropriate supervision to prevent an elopement, resulting in a resident leaving the facility and traveling along a busy roadway. The resident, identified as having a moderate cognitive deficit and diagnosed with conditions such as encephalopathy and anxiety disorder, was known to be at risk for elopement. Despite being identified as an elopement risk upon admission and re-evaluated as such when exhibiting exit-seeking behavior, the resident managed to exit the facility undetected. The resident was able to leave the facility by loosening the screws on a window lock, removing the device, and climbing out. This incident occurred between late at night and early morning, and the resident walked approximately three miles before being found by a staff member off duty. The staff member, a housekeeper, noticed the resident walking along a busy roadway and managed to convince him to return to the facility. Interviews with staff revealed lapses in communication and supervision. The primary nurse on duty did not notice the resident's absence until early morning, and a CNA who noticed the resident's bed was empty did not report it. The facility's elopement protocol was not initiated until the resident was reported missing, indicating a delay in response. The lack of communication between shifts and inadequate monitoring contributed to the resident's ability to leave the facility unnoticed.
Failure to Adequately Monitor Elopement Risk
Penalty
Summary
The facility failed to appropriately care plan for a resident identified as an elopement risk. The resident was admitted to the facility and identified as an elopement risk due to exit-seeking behavior. A comprehensive care plan was initiated, which included interventions such as electronic monitoring every shift and identifying patterns of wandering. However, when the resident was determined to be actively exit-seeking, additional interventions like checking the Wanderguard every shift and monitoring its expiration date were implemented. Despite these measures, it was not until after the resident eloped that more frequent monitoring every 30 minutes and one-to-one observation were added. The deficiency lies in the delay of implementing adequate monitoring measures despite clear indications of the resident's exit-seeking behavior.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent an elopement incident involving a resident identified as an elopement risk. The resident, who had a cognitive impairment with a BIMS score of 6 out of 15, was able to leave the facility and travel approximately 1.3 miles along a busy roadway. The resident had been evaluated as an elopement risk upon admission and had an elopement bracelet placed. Despite these precautions, the resident was able to exit the facility between 8:12 PM and 8:18 PM, after showing exit-seeking behaviors earlier in the evening. The incident occurred when the resident was agitated and attempted to leave through the exit doors, triggering the alarm. Staff members attempted to redirect the resident back to his room and were instructed to place the resident under 1:1 observation. However, the resident managed to leave the facility, climb a 6-foot-high fence, and run along a main roadway. The staff's failure to maintain 1:1 eye contact with the resident, who was actively seeking to exit, was identified as a root cause of the incident. Interviews with staff and residents revealed that the resident was agitated and seeking to leave the facility, and despite efforts to contain him, he was able to exit and travel a significant distance before being located by staff. The facility's policy on elopement risk was not effectively implemented, leading to the resident's unsupervised departure and subsequent risk of harm. The Immediate Jeopardy was ongoing at the time of the facility exit, indicating a serious deficiency in the facility's supervision and safety protocols.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Green Acres
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aviata At West Palm Beach | 2.2 mi | ★★★★★ | 18 | 2 |
| Aviata At Coral Bay | 2.2 mi | ★★★★★ | 0 | 0 |
| Beach Breeze Rehab And Care Center | 3 mi | ★★★★★ | 0 | 0 |
| Palm Beach Nursing Center | 3.3 mi | ★★★★★ | 13 | 0 |
| Pine Trail Nursing And Rehab Center | 3.7 mi | ★★★★★ | 0 | 0 |
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