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:

There are 251 surveys for this facility. Please select a date to view the survey results.

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

Initial comments:

of an Abbreviated Complaint Survey completed on June 29 2026,Green Meadows Nursing and 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:

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

�483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.

Observations:

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 10:12am confirmed the cup filled with medications set on the table should not have been left in front of Resident 1.

Interview with Director of Nursing on June 29, 2026, at 10:12am revealed that the nurses are expected to observe resident consumption of medication.

Review of physician orders revealed the following medications were administered on June 29, 2026:

Prednisone Oral Tablet 5mg (inflammatory, autoimmune, and allergic conditions)
Aspirin Low Dose Oral Tablet Delayed Release 81mg (used to treat pain and reduce fever or inflammation.)
Pantoprazole Sodium Oral Tablet Delayed Release 40 MG (used to reduce stomach acid);
Ezetimibe Oral Tablet 10mg (cholesterol medication)
Mycophenolate Mofetil Oral Capsule 250mg (prevent organ transplant rejection and treat certain autoimmune)
Clopidogrel Bisulfate Oral Tablet 75 mg (antiplatelet medication used to prevent blood clots)
Isosorbide Dinitrate Oral Tablet 10mg (medication used to prevent and treat angina by dilating blood vessels)
Tums Oral Tablet Chewable 500 mg (Antacid)
Lamotrigine Oral Tablet 150 mg (used to treat epilepsy and stabilize mood in bipolar disorder)
Tacrolimus Oral Capsule 1 mg (used to prevent organ rejection in transplant patients)
Amoxicillin-Potclavulanate Oral Tablet 875-125mg (prescribed to treat bacterial infections);
Doxycycline Hyclate Oral Capsule 100 mg (an antibiotic used to treat a wide range of bacterial infections)
Sertraline HCl Oral Tablet 100mg (treats depression, anxiety and other mental health conditions).

Review of Resident 1's Medication Administration Record (MAR) dated June 29, 2026, revealed that the Registered Nurse Employee 3 administered the above medication and failed to observe Resident 1's consumption of the medication.

Interview with the Nursing Home Administrator on June 29, 2026, at 2:00pm confirmed the above findings.

28 Pa. Code 211.12(d)(5) Nursing services.

Plan of Correction - To be completed: 07/30/2026

1. Resident 1 had no negative outcome and was discharged from facility on 7/1/26. Employee 3 was educated on the 9 rights of medication administration policy to ensure medications are administered and consumed in accordance with professional standards.

2. All Residents have the potential to be affected by this practice. An audit of resident rooms was done to ensure that medications are administered and consumed in accordance with professional standards.

3. Licensed nursing staff will be in-serviced by Staff Development/Designee on the 9 rights of medication administration policy to ensure medications are administered and consumed in accordance with professional standards.

4. Random Audits of resident rooms and medication administration will be done by DON/designee to ensure that medications are administered and consumed in accordance with professional standards. Audits will be done weekly for 4 weeks then monthly x 2 then quarterly or until compliance is sustained. Findings will be reported in the QAPI Committee meeting.

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