Green Meadows Nursing & Rehabilitation Center

Based on clincal record review, observations, and staff and resident interviews it was determined the facitliy failed to provided services that meet professional standards for one of one residents reviewed. (Resdient 1)Findings include:Review of facility's policy Medication Administration, stated .18 Administer medications as ordered in accordance with manufacturer specifications.19 Observe resident consumption of medication.Review of Resident 1's diagnosis sheet revealed diagnoses type 2 diabetes (insufficient production of insulin, causing high blood sugar) and chronic systolic(congestive)heart failure (excessive body/lung fluid caused by a weakened heart muscle).Observations were made in Resident 1's room on June 29, 2026, at 9:43 am, of a cup filled with medications set on the table in front of Resident 1.Interview with Resident 1 on June 29, 2026, at 9:43am, stated I did not know the medication was there.Review of Resident 1's active care plan failed to reveal a care plan for self-administration of medication.Observations made with the Director of Nursing on June 29, 2026, at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews it was determined that the facility failed to provide hydration for fifteen of thirty-two rooms on the 1st floor dementia care unit.Observations made of resident rooms on December 8, 2025, December 9, 2025, and December 10, 2025, revealed rooms 100 through 115 had no cups of fresh water for resident's hydration or the cups were dated between November 14, 2025, and December 1, 2025. Rooms 116 through 132 were observed to have currently dated cups with fresh water.Observations made on December 8, 2025, December 9, 2025, and December 10, 2025, of rooms [ROOM NUMBERS] revealed cups of water dated November 14, 2025. Observations made on December 8, 2025, December 9, 2025, and December 10, 2025, of room [ROOM NUMBER] revealed a cup of water dated December 1, 2025.All remaining rooms between 100 and 115 had no water cups.Interview on December 10, 2025, at 12:43 p.m., with Registered Nurse Employee E4, E4 confirmed knowledge of rooms 100 through 115 not having fresh water with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and staff interviews it was determined that the facility failed to provide privacy curtains for three of thirty-two resident rooms and failed to provide clean privacy curtains for eighteen of thirty-two resident rooms located on the 1st floor dementia care unit.Observations made on December 8, 2025, December 9, 2025, and December 10, 2025, of resident rooms on the 1st floor dementia care unit revealed 3 rooms with missing privacy curtains. Observations made on December 8, 2025, December 9, 2025, and December 10, 2025, of resident rooms on the 1st floor dementia care unit revealed 18 rooms with privacy curtains that were soiled or had brown stains on them.Interview conducted with Nursing Home Administrator (NHA) and Director of Nursing (DON) on December 11, 2025, at 10:58 a.m., when the above information was presented, the NHA stated the facility was in the process of remodeling the 1st floor and new privacy curtains have already been ordered for all rooms. 28 Pa Code 201.18 (b)(1) Management 28 Pa Code 211.10 (d) Resident care policies 28 Pa Code…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based upon clinical record review, it was determined that the facility failed to ensure appropriate advance directives regarding code status were in place for one of 33 residents reviewed. (Resident 114)Findings include:Review of Resident 114's clinical record revealed a physician's order dated October 18, 2025, stating Resident 114 was a Full Code.Review of Resident 114's current care plan revealed Resident 114 had a Full Code Status.Review of a Physician's Order for Life Sustaining Treatment (POLST) signed by Resident 114 and dated November 7, 2025, revealed Resident 114's wishes to have a Do Not Resuscitate status.Interview with the Director of Nursing on December 11, 2025, at 10:00 a.m. confirmed that Resident 114's clinical record did not concur with the POLST signed by Resident 114. 28 Pa. Code 201.14(a) Responsibility of LicenseePreviously cited 10/9/202428 Pa. Code 211.12(c)(d)(3) Nursing ServicesPreviously cited 10/9/2024, 4/30/2025

Based on clinical record review and staff interview, it was determined that the facility failed to ensure accurate assessments for one of 33 residents reviewed (Resident 29)Findings include:Review of Resident 29's admission MDS (Minimum Data Assessment - periodic assessment of resident needs) dated November 30, 2025, section H, Bladder and Bowel, indicated that the resident had an indwelling catheter (flexible tube that carries fluids into or out of the body).Further review of the clinical record no evidence that the resident had an indwelling catheter.Interview with the licensed staff E3 on December 11, 2025, at 10:45 a.m. confirmed that the resident did not have an indwelling catheter and that the MDS was coded incorrectly.28 Pa. Code 211.12(d)(1)(5) Nursing services

Based upon clinical record review, it was determined that the facility failed to ensure appropriate monitoring for side effects and effectiveness were completed for the use of an anti-depressant medication for one of 33 records reviewed (Resident 35).Findings include:Review of Resident 35's diagnosis list revealed a diagnosis of major depressive disorder.Review of Resident 35's physician's orders dated November 27, 2025, revealed an order for Mirtazapine (antidepressant) to be administered for treatment of Resident 35's depression.Further review of Resident 35's clinical record failed to reveal evidence of monitoring for side effects of the anti-depressant medication and failed to reveal documented evidence of the effectiveness of the anti-depressant medication.Interview with the Director of Nursing on December 11, 2025, at 11:00 a.m. confirmed that no monitoring for side effects of the anti-depressant medication was conducted and further that no monitoring of the effectiveness of the medication was conducted. 28 Pa. Code 211.12(c)(d)(3) Nursing ServicesPreviously cited 10/9/2024,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews it was determined that the facility failed to provide an assistive device for one of seven residents investigated, (Resident 7).Review of Resident 7's physician orders revealed an order for regular diet, regular texture, thin consistency [NAME] Cup (a spill-proof drinking cup with a secure lid and J-shaped handle) built up fork and spoon dated May 21, 2025.Review of Resident 7's care plan revealed a care plan for nutritional problem or potential nutritional problem related to need for assist with meals, intellectual disability, and weight stable.Review of Resident 7's face sheet revealed medical diagnoses that include Encephalopathy (a group of conditions that cause brain dysfunction).Observations made of Resident 7 on December 8, 2025, December 9, 2025, and December 10, 2025, during lunch service revealed the resident drinking from a regular cup with a straw.Interview on December 10, 2025, at 12:43 p.m., with Unit Manager Registered Nurse Employee E4, E4…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview it was determined that the facility failed to ensure that the pharmacy provided medications timely for two of four residents reviewed (Residents 1 and 3). Findings include: Review of Resident 1's clinical record revealed Resident 1 was admitted [DATE], with diagnoses of but not limited to hypertension (high blood pressure), hyperlipidemia (high levels of fats in the blood), COPD (chronic obstructive pulmonary disease - progressive lung disease characterized by chronic respiratory symptoms and airflow limitation), and surgical aftercare following aortocoronary bypass graft (heart bypass surgery - procedure to restore blood flow to areas of the heart), Review of physician's admissions orders revealed a start date of March 30, 2025, for the following medications: Metoprolol Succinate ER (extended release) 50 MG (milligrams), one tablet by mouth twice a day for hypertension (high blood pressure), Spironolactone Oral Tablet 25 MG, one tablet by mouth one time a day…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on policy review, observation, and staff interview, it was determined that the facility failed to properly store food in the dry storage located next to the main kitchen. Findings include: Review of the facility's policy entitled, Labeling and storage, dated 2017, revealed that All food should be dated upon receipt before stored, food labels must include the food item name, and the use-by date . Observations during the tour of the main kitchen on October 6, 2024, at 9:12 a.m., revealed the following: Observation of the dry storage 2 area, noting eight opened bags of uncooked pasta without a label and use-by date and were nor properly sealed. Interview conducted on October 6, 2024, at 9:15 a.m., with the Dietary Director E3 confirmed the eight bags of uncooked pasta should have had a label with the name of the item and a use-by date. E3 also stated the above items should have been properly sealed. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of facility policy, observation, and clinical record review, it was determined that the facility failed to provide documented evidence that consisted, adequate catheter care was provided to one of seven residents reviewed for catheters (Resident 94). Findings include: Review of facility policy, Catheter Care, implemented March 1, 2024, revealed: Catheter care will be performed every shift and as needed by nursing personnel .Document care and report any concerns noted to the nurse on duty. Observation of Resident 94 on October 7, 2024, at approximately 12:30 p.m. revealed the resident had a suprapubic catheter (tube that drains urine from the bladder through a small incision in the abdomen). Review of Resident 94's clinical record failed to reveal documented evidence that staff were providing catheter care. Interview with the Director of Nursing on October 9, 2024, at approximately 11:15 a.m. confirmed there was no documented evidence of catheter care for Resident 94's suprapubic catheter. 28 Pa Code 211.12(d)(5) Nursing Services

Based on clinical record review and staff interview it was determined the facility failed to report results for laboratory studies to the ordering physician timely for one of 40 residents reviewed. (Resident 22) Findings Include: Review of Resident 22's Physician orders revealed an order dated September 11, 2024 for a UA C+S (test of urine to determine if there is a Urinary Tract Infection). Review of Resident 22's Laboratory report for the UA C+S revealed the report was final and was reported on September 15, 2024. Review of Resident 22's Progress Notes revealed a nursing entry on September 18, 2024 stating the results were posted and reported to the physician who ordered antibiotics to treat the urinary tract infection. Interview with the DON on October 9, 2024 at 11:30 a.m. confirmed the results were final on September 15, 2024 but not reported to the physician for orders to begin treatment until September 18, 2024. 28 Pa. Code 211.12(c)(d) (1)(3)(5) Nursing services

Based on clinical record and facility documentation review and resident/staff interview, it was determined that the facility failed to timely treat a burn and failed to follow a physician medication parameter for two of 33 residents reviewed (Residents 32 and 58). Findings include: Interview with Resident 32 on November 28, 2023, at 9:10 a.m. revealed the resident had a burn on her abdomen from spilling coffee in September. Review of Resident 32's progress notes revealed a nurse's note dated September 10, 2023, at 10:31 a.m. which stated: notified by aide that resident had a skin area on upper abdomen. Upon arrival to room, this nurse noted 4x4 gauze pad on abdomen and once removed, a slightly red non-opened area noted (measured 4cm W x 4 ½ L). Resident stated 'I burnt myself with coffee on [September 8] a blister appeared and it popped [September 9, 2023.]' Nursing supervisor notified. Cleansed area with [normal saline], applied [triple antibiotic ointment], and covered with bordered gauze. Review of facility documentation revealed on September 8, 2023, at approximately 11:00 a.m.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical records facility documentation review and staff interview, it was determined that the facility failed to timely assess a resident's skin impairment and inform the physician of a newly found skin impairment for one of six residents reviewed (Resident 58). Findings include: Review of Resident 58's clinical records revealed resident was admitted to the facility with a diagnosis of Malignant Prostate Cancer, Diabetes, and Severe Protein Calorie Malnutrition. The admission skin assessment dated [DATE], revealed no skin impairment in the resident's midback area. Review of facility documentation, and staff statement dated November 7, 2023, revealed that on November 3, 2023, a bandage gauze dressing was observed on the resident's upper back which was not present during initial assessment. Review of Resident 58's clinical records failed to reveal a completed skin assessment of the mid-upper back upon observing a bandage gauze dressing on November 3, 2023. Review of Resident 58's clinical records,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review, it was determined that the facility failed to ensure one of 33 residents reviewed was free of unnecessary medications (Resident 137). Findings include: Review of Resident 137's physician's orders revealed an order dated May 20, 2021, to evaluate for verbal and non-verbal signs and symptoms of pain every shift. Review of Resident 137's July 2023 Medication Administration Record (MAR) revealed the resident reported no pain a total of 78 times. Review of Resident 137's August 2023 MAR revealed the resident reported no pain a total of 48 times. Review of Resident 137's September 2023 MAR revealed the resident reported no pain a total of 42 times. Review of Resident 137's October 2023 MAR revealed the resident reported no pain a total of 50 times. Review of Resident 137's November 2023 MAR revealed the resident reported no pain a total of 50 times. Review of Resident 137's clinical record revealed a nurse's note on November 24, 2023, at 8:39 a.m. which stated that the resident approached this writer stating she will not take any of her prescribed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.