Pennsylvania Department of Health
GREEN MEADOWS NURSING & REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

GREEN MEADOWS NURSING & REHABILITATION CENTER
Inspection Results For:

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GREEN MEADOWS NURSING & REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Findings of an Abbreviated Complaint Survey completed on August 4, 2026, at Green Meadows Nursing &; Rehabilitation Center, identified deficient practice, related to the reported complaint allegations, under the requirements of 42 CFR Part 483, Subpart B Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey process.\~

Plan of Correction:

483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors:

This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.

The facility must ensure that its-
�483.45(f)(2) Residents are free of any significant medication errors.

Observations:

Based upon review of facility policy and procedure, review of facility documentation and clinical record review, it was determined that the facility failed to ensure residents were free from significant medication errors, resulting in actual harm to one resident (Resident R1), who required treatment with Narcan and hospitalization. This was identified as past non-compliance for Resident R1.

Findings include:

Review of undated facility policy and procedure titled "Medication Administration" revealed "identify resident by photo in the MAR (medication administration record)".

Review of Resident R1's diagnosis list revealed diagnoses including Pulmonary Fibrosis (lung disease where tissue deep in the lungs becomes thick, stiff, and scarred over time), Transient Cerebral Ischemic attack (temporary blockage of blood flow to part of the brain that causes sudden stroke-like symptoms), Thyrotoxicosis (serious health condition caused by too much thyroid hormone in the blood), and type 2 Diabetes Mellitus (chronic condition where the body resists insulin or does not make enough of it, causing high blood sugar).

Review of facility documentation titled, "Medication Error Reporting Form" dated July 7, 2026, reveals on July 7, 2026, at 10:00 a.m., Resident R1 was "not properly identified" during a medication pass.

Further review of facility documentation revealed medications were given to Resident R1 as:
Norvasc 5 mg (prescription calcium channel blocker used to treat high blood pressure and chest pain)ASA 81 mg (Aspirin; over the counter medication used to prevent blood clots, heart attacks, and ischemic strokes)Cymbalta 60 mg (prescription medication that works by increasing specific natural chemicals in the brain and spinal cord that regulate mood and pain signals)Metformin 500 mg (prescription medication used primarily as a first-line treatment for type 2 diabetes to lower blood sugar levels)Eliquis 5 mg (prescription blood thinner used to prevent and treat dangerous blood clots)Keppra 750 mg (prescription anticonvulsant medication used to treat various types of seizures)Ativan 0.5 mg (prescription benzodiazepine medication that slows the central nervous system to treat anxiety disorders, insomnia caused by stress, acute seizures, and alcohol withdrawal, or to provide sedation before surgery)Metoprolol 50 mg (prescription beta-blocker used to lower blood pressure, treat chest pain, manage heart failure, and improve survival after a heart attack)Oxycodone 10 mg (strong prescription opioid medicine used to treat moderate to severe pain when other non-opioid treatments do not work well enough)Tylenol 1000 mg (over the counter medication that acts as a pain reliever and fever reducer to treat headaches, muscle aches, arthritis, and cold symptoms)Gabapentin 500 mg (prescription medication used to treat partial seizures and nerve pain from shingles)Pantoprazole 40 mg (prescription proton pump inhibitor used to decrease stomach acid production)

Further review of facility documentation revealed statement by Nursing Orientee Employee E1, "I was passing medications during training, and my trainer handed me the residents medication. I approached the resident sitting by the window who I believed was (Resident R2) and introduced myself saying hey (Resident R2) I have your meds the resident noded as I proceeded to pas her the meds, I came to realize I gave the wrong meds and reported the incident to my trainer immediately."

Further review of facility documentation dated July 7, 2026, revealed statement by Nursing Preceptor Employee E2, "Nurse trainer gave nurse trainee medication for a resident. Medication was given in medication cup poured by trainer. Trainee gave the medication to the wrong resident. Nurse trainer stood by med cart as trainee gave medication."

Review of facility documentation "Additional Questions for Statements," revealed statement by Nursing Preceptor Employee E2, "Why did you pour the medications and not administering them?I was showing the orientee how to pour the meds and going over each medication. What direction did you give the orientee? I showed her the medications, the name of the resident, and the area in the room where the resident was at. Did you tell the orientee who the resident was prior to giving the medications? Yes, I told her the name and pointed to the door side of the room. What did you do after the med error was discovered? I told the unit manager, then I took vital signs."

Further review of facility documentation "Additional Questions for Statements", revealed statement by Nursing Orientee Employee E1, "Why didn't you pull your own medications to administer? She was pouring the medications and showing me each medication. I didn't question it. Did you check patient identifiers prior to giving medications? I asked the resident's name and she said nothing. I had looked at the door and saw the resident's name. I thought the resident was at the window."

Review of Nurse Practitioner Progress Note dated July 7, 2026, at 9:09 a.m., revealed, "LATE ENTRY: Today the patient was urgently evaluated for an acute change in mental status after nursing reported decreased responsiveness. Upon arrival to the room, the patient was found lying in bed, markedly lethargic, difficult to arouse, and unable to answer questions or follow commands. She was drifting in and out of sleep with minimal response to verbal and tactile stimulation. At the time of assessment, respirations were even and unlabored with a respiratory rate of 16 breaths/min, and heart rate was 66beats/min. Due to concern for possible opioid-induced CNS (central nervous system)depression [occurs when opioid drugs slow down brain activity], a verbal order was given for immediate administration of Narcan [prescription rescue medication that rapidly reverses the effects of opioid overdose]. Following the initial dose, the patient demonstrated partial improvement by opening her eyes spontaneously and briefly tracking staff; however, she remained significantly lethargic, nonverbal, and unable to meaningfully interact or follow commands. Respiratory status and vital signs were closely monitored while the patient remained under continuous nursing observation. The PCP [Primary Care Physician] arrived at the facility subsequently and was provided a verbal report regarding the patient's acute change in condition, assessment findings, and response to the initial dose of Narcan."

Review of Nurses Note dated July 7, 2026, at 2:19 p.m., revealed, "Received report resident was lethargic. This nurse went to assess resident with MD [Doctor of Medicine]. Vital signs taken and WNL [within normal limits]. Resident AAOx1 [alert and oriented to person] and lethargic, eyes opening to verbal commands but resident nonverbal. Neurochecks [assessment of neurological systems] were initiated. Resident had emesis [vomiting] and MD ordered to send resident to ER [emergency room] for further evaluation. 911 was called and daughter notified."

Review of hospital documentation titled "Discharge Summary," dated July 10, 2026, revealed,
"Problem List on the Day of Discharge:
1. Toxic metabolic encephalopathy [brain dysfunction caused by systemic illness, organ failure, toxins, drugs, or chemical and electrolyte imbalances in the body]. This is secondary to medications (Resident R1) wrongly received as well as pneumonia [infection that inflames the air sacs in one or both lungs, causing them to fill with fluid or pus]...
2. Sepsis [medical emergency that occurs when the body has an extreme, harmful response to an infection] present on admission associated with acute hypoxemic respiratory failure [sudden, life-threatening condition where the lungs cannot transfer enough oxygen into the blood] from aspiration pneumonia [lung infection that occurs when food, liquid, vomit, or saliva enters your airways or lungs]...
...4. Nausea and vomiting. This is likely secondary to ingestion of multiple medications that were given to her mistakenly..."

Further review of hospital documentation dated July 10, 2026, revealed a brief hospital course stating, "(Resident R1)... was admitted on 7/7/2026 for altered mental status [sudden or gradual change in thinking, awareness, attention or level of consciousness] following inadvertent administration of another resident's morning medications at (Resident R1's) skilled nursing facility. (Resident R1's) acute presentation included encephalopathy [disease, damage, or malfunction of the brain], vomiting, and subsequent aspiration, leading to right lower lobe pneumonia and acute hypoxic respiratory failure. Diagnosis was supported by CT (computed tomography scan, a medical imaging test that combines specialized x-ray equipement with computer processing to generate detailed, cross-sectional "slice" images of bones, blood vessels, and soft tissues inside the body) chest showing right lower lobe and right middle lobe airspace disease consistent with pneumonia (infection that inflames the air sacs in one or both lungs, causing them to fill with fluid or pus), and chest x-ray revealing patchy airspace opacity at the right lung base. Pulmonary and infectious disease consultants confirmed aspiration pneumonia... Altered mental status was attributed to toxic metabolic encephalopathy from the medication error and pneumonia... experienced nausea and vomiting, likely related to the medication ingestion..."

Review of Nurses Note dated July 10, 2026, at 1:40 p.m., revealed, "Resident returned from [local] hospital with dx (diagnosis) of RLL (right lower lobe) PNA (pneumonia)."

Interview with the Nursing Home Administrator and Director of Nursing on August 4, 2026, at 1:30 p.m. confirmed Employee E1 and Employee E2 failed to ensure Resident R1's was free from significant medication errors by verifying the identity of the resident prior to medication administration, resulting in subsequent transfer to the emergency room and admission to the hospital.

The facility self-identified deficient practice at the time of the incident on July 7, 2026. The facility implemented a corrective action plan of staff education regarding the 9 Rights of Medication Administration.

The facility's immediate action plan included:
The Director of Nursing provided one-on-one education to the involved and preceptor and orienting nurse regarding the rights of medication administration.
The Director of Nursing completed one-on-one medication administration competency assessment with both nurses.
Facility policies and procedures related to 9 rights of medication administration were reviewed.
The Director of Nursing and designee(s) will educate LPN/RN's about the 9 rights of medication administration, and to ensure no medications are left at bedside.
Director of Nursing/Designee and/or pharmacy consultant will conduct random medication administration observations to ensure that licensed nurses are following the 9 rights of medication administration which includes the right resident, x 7 days, then the following will be weekly x4 then monthly audit x2 then quarterly until compliance is sustained.
Audit report will be submitted to QA committee.

The corrective action plan was completed on July 8, 2026, and verified through review of education documentation, interviews, and observation.

The facility failed to ensure residents were free from significant medication errors, resulting in actual harm to Resident R1, who required treatment with Narcan and subsequent hospital admission for antibiotics and supplemental oxygenation. This was identified as past non-compliance for Resident R1, based on facility self-identification of deficient practice and subsequent completion of a corrective action plan.

28 Pa. Code 211.9 (a)(1)(c)(d) Pharmacy Services

28 Pa. Code 211.10 (c) Resident Care Policies

Plan of Correction - To be completed: 08/20/2026

Past noncompliance: no plan of correction required.

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