Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Green Acres Care Center Llc during CMS and state inspections, most recent first.
Expired and unlabeled food items were found throughout the kitchen, including dairy, meat, dry goods, and opened condiments without required open or discard dates. Surveyors also observed a black-like substance inside the ice machine, and staff gave inconsistent accounts of who cleaned it and whether the assigned DA had been trained. Raw fish was also observed thawing on a countertop/sink in standing water, with staff describing differing thawing methods.
Staff failed to knock before entering a resident’s room, including when entering behind another CNA, and the resident stated staff did not acknowledge him before coming in. The resident had moderate cognitive impairment with a BIMS score of 11. Additional observations showed two CNAs entering another resident room without knocking to retrieve meal trays, and both CNAs confirmed they did not knock. The DON stated staff are expected to knock before entering a resident’s room.
A resident who was not approved to self-administer medications had Tylenol, antibiotic ointment, an herbal supplement, and an unlabeled medication cup left on the overbed table. The resident said her son brought some items in and that she had been using them, while the RN/UM and DON confirmed there was no physician order or care plan for self-administration and that medications should not have been left at the bedside.
A resident with severely impaired cognition had his call light repeatedly found under his bed and out of reach, despite care plan interventions stating it should be within reach. Another resident with a history of falls and no cognitive impairment was observed using a wheelchair with a missing left armrest cushion, leaving his arm resting on bare metal. Staff interviews confirmed the wheelchair issue had not been formally tracked and the chair required repair or replacement.
Care Plan Not Timely Updated for Code Status Change: A resident’s EMR, physician orders, and POLST reflected DNR/allow natural death status, but the care plan still listed full code with CPR and emergency response interventions. The MDS Coordinator confirmed the code status changed from full code to DNR, and the DON stated code status changes are communicated in morning meetings and the care plan is expected to be updated in real time as possible.
A resident with chronic respiratory failure with hypoxia was observed receiving oxygen at 2 LPM, and the care plan and MDS indicated oxygen therapy was in use. However, review of the physician orders found no order for oxygen therapy, and an LPN and the DON both confirmed the EHR contained no such order.
A resident with intact cognition and cirrhosis had a pair of scissors kept on the overbed table beside her bed and used them to cut condiment packets. Surveyors observed the scissors in the room on multiple occasions, and staff including RN, UM, ADON, and DON stated residents were not allowed to have scissors in their rooms and that they should be kept in the med cart with the resident's name.
Medication carts and resident medications were left unsecured in the South Wing. One RN left two medication carts unlocked and unattended, and during a medication pass another RN placed a resident’s medications on top of the cart, locked the cart, and walked away to take the resident’s BP while the medications remained unsecured and visible in the mall area. The DON stated nurses were expected to lock the carts and secure medications when not in use.
A resident with severe cognitive impairment did not have a privacy curtain in his room after curtains were taken down for deep cleaning and his curtain was not put back up. Observations confirmed the bed-A area lacked a privacy curtain, and the HKS acknowledged the curtain was missed.
A resident with Alzheimer’s disease, dementia, parkinsonism, osteoarthritis, and moderate cognitive impairment, who was ambulatory and independent with toileting, fell while attempting to use a shared bathroom that was under renovation. The facility’s fall prevention policy required a clear pathway to the bathroom, but the bathroom floor was incomplete and had glue on it, and residents were not reassigned rooms during remodeling. The resident, known to wear socks and not assisted to the restroom because staff considered her independent, entered the partially finished bathroom, where her sock or foot became stuck in glue on the floor, causing an unwitnessed fall. Staff and EMS found her on the bathroom floor with head, arm, and leg pain, and imaging later confirmed a right humerus shaft fracture, a right open distal femur fracture, a scalp hematoma, knee contusion, and facial swelling.
Surveyors found that food items in the kitchen and resident pantries were not properly labeled, dated, or securely wrapped, and staff food was stored with resident food. The Dietary Manager confirmed that food was not checked for expiration, and that facility policies for food storage and separation were not followed.
A resident with an active personal funds account did not receive required written quarterly statements about their account balance. The facility's policy did not address the need to provide these statements, and the Business Office Manager confirmed that no statements had been sent out due to a transition between fund management providers, resulting in the resident being uninformed of their account status.
Expired and Unlabeled Food Items; Unsanitary Ice Machine
Penalty
Summary
The facility failed to discard expired food items and failed to properly label and date multiple food products in the kitchen and storage areas. During the initial tour, surveyors found two 5-lb boxes of vanilla creme icing with an expiration date of 11/28/2025, five 5-lb boxes of butterflakes biscuit mix with an expiration date of 04/23/2026, one 1/8 pan of pudding with an expiration date of 04/21/2026, one 5-lb container of heavy sour cream with an expiration date of 03/16/2026, one 48-lb box of chicken with an expiration date of 04/16/2026, and milk products with expiration dates of 02/21/2026 and 04/22/2026 still in storage. The Assistant Dietary Manager confirmed the expired items were present. Surveyors also observed several opened food items without open dates, including seasoning sauce, teriyaki marinade and sauce, spaghetti noodles, tri-color rotini pasta, egg noodles, Italian dressing, dill pickle relish, sweet and sour sauce, and ranch dressing. In addition, 50 red tomatoes and 24 yellow onions were found in facility containers without labeling or dating, and the Dietary Manager confirmed these items. The facility’s policy required date marking with the day/date of opening and the day/date the item must be consumed or discarded, but the observed items were not marked in that manner. The facility also failed to maintain sanitary practice with the ice machine. Surveyors observed a black-like substance inside the ice machine near the ice, on the bolt and screw, and at the top interior of the machine. The Assistant Dietary Manager stated that Dietary Aid LL was tasked with cleaning the ice machine, but he was unsure whether LL had been trained to clean it. Maintenance JJ stated he cleaned the ice machine after being told about the black-like substance, and DA LL stated he had not been trained on cleaning the ice machine. The report also noted that raw fish was thawing on the countertop/sink covered with parachute paper and submerged in shallow standing water, and staff gave differing descriptions of thawing practices.
Failure to Knock Before Entering Resident Rooms
Penalty
Summary
The facility failed to protect and value one resident’s right to dignity and privacy by not ensuring staff knocked before entering the resident’s bedroom. R88 had a BIMS score of 11 on the quarterly MDS, indicating moderate cognitive impairment. During an observation and interview, R88 stated there was a lack of acknowledgement from staff knocking on his door before entering, and while in the room, CNA FF entered without knocking. CNA GG then entered behind CNA FF without knocking as well. Additional observations showed the same issue in another resident room when CNA HH walked in without knocking to retrieve a meal tray, and CNA MM also entered without knocking to retrieve a meal tray. CNA HH confirmed she did not knock before entering and said she forgets to knock if the room door is open. CNA MM confirmed she did not knock and stated she is supposed to announce herself prior to entering a resident room. The DON stated this is the resident’s home and staff are expected to knock prior to entering a resident’s room.
Medications Left at Bedside for Resident Not Approved to Self-Administer
Penalty
Summary
The facility failed to remove medications from the bedside of a resident who was not approved to self-administer medications. The resident had been admitted and readmitted with cirrhosis of the liver, had a BIMS score of 15 indicating intact cognition, and had no care plan or physician order for self-administration. Review of the facility’s policy stated that bedside medication storage is only permitted when the interdisciplinary team determines it is safe and when the conditions for bedside storage are met. Observation of the resident’s room revealed one bottle of Tylenol 500 mg tablets, one tube of first aid antibiotic ointment, one bottle of 175 mg herbal supplement tablets, and one medication cup with an unlabeled white creamy substance on the overbed table beside the bed. The resident stated her son brought the Tylenol and antibiotic ointment to her several days earlier, that she had been taking the herbal supplement since admission, and that the ointment had been left for her to use whenever needed. The RN/UM confirmed the medications were in the room and stated they should not have been there because the resident was not ordered to self-administer medications. Other nursing staff and the DON also confirmed there was no order or care plan for self-administration and that medications should not be left at the bedside unattended.
Call Light Not Accessible and Wheelchair Not Properly Maintained
Penalty
Summary
The facility failed to ensure that R53’s call device was within reach. R53 was admitted with diagnoses including dementia, muscle weakness, unsteadiness on feet, abnormalities of gait and mobility, lack of coordination, and symptoms involving cognitive functions and awareness. His admission MDS showed a BIMS score of 03, indicating severely impaired cognition, and his care plan identified him as at risk for falls with interventions to anticipate and meet his needs and ensure his call light was within reach and used for assistance as needed. During multiple observations on 04/24/2026 and 04/25/2026, R53’s call light was found on the floor under his bed and inaccessible to him. On several occasions, the call light remained under the bed during repeated observations throughout the day. During an observation and interview, a CNA entered the room, and the surveyor and CNA confirmed the call light was not visible or accessible; the CNA pulled the cord from under the bed. R53 stated he did not know where his call light was and said he would use it to ask staff for assistance, but he could not find it. The facility also failed to ensure proper accommodation of R70’s wheelchair device. R70 had diagnoses including cervical disc disorder with radiculopathy, a history of falls, and a BIMS score of 15 indicating no cognitive impairment. OT documentation noted nursing requested an OT screen to ensure fitting of a new wheelchair due to falls. During observation, R70 stated the cushion on the left armrest had been absent for at least two months, and he was resting his left arm on bare metal. Staff interviews showed there was no formal process to audit resident equipment, and the Regional Therapy Manager and Maintenance staff confirmed the chair needed repair or replacement. The DON stated she had frequently seen R70 in the wheelchair but had not observed the missing armrest.
Care Plan Not Timely Updated for Code Status Change
Penalty
Summary
The facility failed to ensure one of 39 sampled residents, R52, had a care plan revised in a timely manner related to code status. The facility policy titled, Comprehensive Care Plan, stated the comprehensive care plan is to be developed and implemented for each resident and reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. Review of the EMR showed R52 was documented as DNR, and the physician orders and POLST also reflected allow natural death and do not attempt resuscitation. Despite those records, the care plan still listed R52 as full code with interventions to initiate CPR, contact emergency services, and notify the NP or MD and family in the event of cardiac or respiratory arrest. During interview, the MDS Coordinator confirmed the full code status was discontinued and a DNR order was initiated on 02/09/2026, and stated there should be more efficient communication when code statuses are switched. The DON stated that when code status is updated or changed it is communicated in morning meetings and the care plan is expected to be updated in real time as possible.
Failure to Obtain Physician Order for Oxygen Therapy
Penalty
Summary
The facility failed to obtain a physician's order for oxygen therapy for one resident receiving oxygen out of 13 residents on oxygen. The resident was admitted with diagnoses including chronic respiratory failure with hypoxia, and the care plan documented that the resident required oxygen therapy and medications as ordered by the physician. The quarterly MDS indicated the resident was receiving oxygen therapy, and observations on 04/24/2026 and 04/26/2026 showed the resident receiving oxygen at 2 liters per minute. Review of the physician's orders found no order for oxygen therapy, and both an LPN and the DON confirmed there was no physician order in the EHR.
Scissors Left at Resident Bedside
Penalty
Summary
The facility failed to remove one pair of scissors from the bedside of one resident, R35, during multiple observations. On 04/25/2026 and 04/26/2026, surveyors observed the scissors on the overbed table beside R35's bed several times. R35 confirmed the scissors belonged to her and stated she used them to cut ketchup and condiment packets for meals. She also stated the scissors had always remained on her overbed table and that no nurse or other staff had removed them. Record review showed R35 was admitted and re-admitted to the facility with cirrhosis of the liver, had a BIMS score of 15 indicating intact cognition, and had a care plan addressing ADL self-care performance deficit related to activity intolerance. Staff interviews showed RN staff were not aware of the scissors in the room or of any process for residents having scissors. The UM and ADON stated residents were not allowed to have scissors in their rooms and that scissors should be kept in the medication carts with the residents' names, available to the resident upon request. The DON stated she preferred not to have scissors in residents' rooms and that scissors should be kept in the medication carts.
Medication carts and resident medications left unsecured
Penalty
Summary
Medication storage was not maintained in locked and secure conditions for multiple medication carts. Based on observations and staff interviews, one medication cart in the South Wing mall area was observed unlocked and unattended while residents were wandering nearby, and the RN confirmed it had been unlocked since 7:00 AM after the medication count. A second medication cart on the South Wing was also observed unlocked and unattended, and the RN acknowledged she thought she had locked it but knew the cart was supposed to be locked when not in use. The DON stated she expected nurses to lock the medication carts. During a medication pass in the South area, an RN removed multiple medications for a resident, placed the medications on top of the cart, locked the cart, and then walked away to take the resident’s blood pressure while the resident was eating breakfast. The medications remained unsecured on top of the cart while the RN was away and facing away from the cart, with staff and residents passing by. The RN acknowledged she had left the medications unsecured and stated she should have locked them in the cart before taking the blood pressure. The DON stated she expected nursing staff to secure medications if they needed to leave them unattended or plan to administer them later.
Missing Privacy Curtain in Resident Room
Penalty
Summary
The facility failed to ensure a privacy curtain was in place for one resident in room [ROOM NUMBER], bed-A, despite the resident’s need for privacy. The resident, who had a BIMS score of 3 on the annual MDS indicating severe cognitive impairment, stated during interview that he had not had a privacy curtain for a while and reported that a staff member had removed the curtains for cleaning but did not put his curtain back up. Observations on 04/24/2026 and 04/25/2026 confirmed that bed-A in room [ROOM NUMBER] did not have a privacy curtain. The Housekeeping Supervisor acknowledged that the privacy curtain was missing, explained that curtains are taken down for deep cleaning, and stated that bed-A’s curtain was missed and that rounds should be conducted to identify missing privacy curtains.
Resident Fall and Fractures Due to Unfinished Bathroom Floor With Glue Hazard
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision during bathroom renovations, resulting in an unwitnessed fall with major injury for one resident. The facility’s Fall Prevention Program policy required universal environmental interventions, including a clear pathway to the bathroom, and routine rounding. At the time of the incident, remodeling was underway in the resident’s room and shared bathroom, and the bathroom floor was not yet completed, with glue still present on part of the floor. Residents were not reassigned rooms during the remodeling of their rooms and bathrooms, and the resident continued to use the bathroom that was under construction. The resident involved had diagnoses including Alzheimer’s disease, dementia with anxiety, parkinsonism, and osteoarthritis, and had a BIMS score of 8/15, indicating moderate cognitive impairment. According to the MDS and staff interviews, the resident was ambulatory, independent with toileting, and had not had a fall in over two years. Staff, including the DON and unit manager, stated that the resident did not require assistance with toileting and was considered independent and cognitively fit, so she was not assisted to the restroom during the renovation period. However, the Director of Maintenance confirmed that glue remained on the bathroom floor prior to the fall, and that the resident was known to wear socks. On the day of the incident, a contractor alerted a CNA to the shared bathroom, where the CNA found the bathroom door half open and the resident lying on the floor. EMS and hospital records documented that the resident’s sock or foot became stuck in glue on the bathroom floor, causing her to fall. Multiple staff, including an LPN, RN, and another LPN, confirmed that the bathroom floor was under construction and not completed at the time of the fall. The resident reported pain in her right arm and leg and stated she had hit her head. Assessments and imaging revealed a right humerus shaft fracture, a right open distal femur fracture, a hematoma over the right inferior frontal scalp, a contusion of the knee, and facial swelling, and she subsequently underwent operative fixation for both fractures.
Failure to Properly Store, Label, and Separate Food Items
Penalty
Summary
Surveyors observed multiple failures in food storage and labeling practices within the facility's kitchen and resident pantries. In the main kitchen refrigerator, hamburger patties, hot dogs, and breaded chicken tenders were found in open, undated containers. The kitchen pantry contained rice and sugar stored in large, open, and undated bags. These practices were not in accordance with the facility's policies, which require food to be stored in a manner that maintains quality and safety, including proper labeling and dating. Further inspection of the nutrition pantries on both the North and South units revealed additional deficiencies. Resident refrigerators contained food items such as bean dip, pineapple chunks, green grapes, watermelon, deli meat, and iced tea that were either undated, unlabeled, or not identified with a resident's name. Staff food items were also found stored alongside resident food in these refrigerators. The Dietary Manager confirmed these findings, acknowledging that food products were not being properly checked for expiration, labeled, or separated as required by facility policy.
Failure to Provide Timely Quarterly Resident Fund Statements
Penalty
Summary
The facility failed to provide written quarterly statements of personal funds to a resident and/or their representative within 30 days of the end of the quarter, as required. Review of the facility's policy on management of residents' personal funds revealed that it did not address the requirement to provide these statements. Documentation showed that the resident had an active account with the facility, with transactions recorded during the relevant period. Interviews confirmed that the resident had not received any statements about their account, and the Business Office Manager acknowledged that no quarterly statements had been sent out since the end of December due to a transition between resident fund management providers. The March statements, which should have been provided in April, were not distributed, leaving the resident uninformed of their account balance.
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What surveyors actually found near you
We read the 37 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Nursing homes near Lagrange
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Peachtree Nursing And Rehabilitation Llc | 4 mi | ★★★★★ | 10 | 0 |
| Lagrange Trails Of Journey Llc | 5.1 mi | ★★★★★ | 2 | 0 |
| Pruitthealth - Greenville | 15.3 mi | ★★★★★ | 0 | 0 |
| Pruitthealth - Franklin | 16.1 mi | ★★★★★ | 5 | 0 |
| Diversicare Of Lanett | 18 mi | ★★★★★ | 0 | 0 |
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