Pennsylvania Department of Health
 GREEN RIDGE CARE CENTER
Patient Care Inspection Results

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GREEN RIDGE CARE CENTER
Inspection Results For:

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GREEN RIDGE CARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance survey completed on November 14, 2025, it was determined that Green Ridge Care Center was not in compliance with the following requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation: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.
§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

§483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:

Based on a review of clinical records, the facility's abuse prohibition policy and information provided by the facility it was determined the facility failed to conduct an investigation into an injury of an unknown source to rule out abuse and/or neglect and failed to implement corrective actions, and submit the results of the completed investigation to the State Survey Agency within five working days of the incident as evidenced by one of 18 residents reviewed (Resident 44).


Findings included:

A review of the facility's "Pennsylvania Resident Abuse Policy" last reviewed by the facility on October 21, 2025, indicated that it was the facility's policy to investigate all allegations, suspicions, and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation of residents, misappropriation of resident property and injuries of unknown source. The facility classified an injury as an "injury of an unknown source" when the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident and if the injury was suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular point in time, or the incidence over time.

Further review of the facility's abuse policy indicated all allegations of abuse, neglect, injuries of an unknown source, etc. must be reported immediately to the Nursing Home Administrator (NHA), Director of Nursing (DON), and to the applicable State Agency. If the event that caused the allegation involves an allegation of abuse or serious bodily injury, it should be reported to the Department of Health (DOH) immediately, but not later than two hours after the allegation is made. All serious incidents involving a resident will be reported to the DOH field office within twenty-four hours. Once the NHA and DON are notified, an investigation of the allegation or suspicion will be conducted, and the investigation must be completed within five working days from the alleged occurrence. Investigating injuries of an unknown source should include talking with both the shift on duty when the injury was discovered and prior shifts. Additionally, the investigation should include witness statements, obtain all medical reports and statements from physician and/or hospitals, and review the resident's record. Evidence of the investigation should be documented, and the final report will be submitted to the applicable State agency, after the investigation is completed, but no later than five working days from the occurrence.

A review of Resident 44's clinical record revealed the resident was admitted to the facility on December 29, 2023, with diagnoses that included unspecified dementia (a term that encompasses various neurological disorders characterized by cognitive decline, memory loss, and changes in behavior and mental health), unspecified fracture (a break in a bone) of lower end of left femur (thigh bone) with routine healing, left acute impact to left distal femur fracture, and presence of unspecified artificial knee joint.

A review of Resident 44's Quarterly Minimum Data Set Assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 26, 2025, the resident could not complete the BIMS (Brief Interview for Mental Status). The BIMS is a standardized interview used to assess memory and thinking skills. Because the resident was unable to participate in the interview, the BIMS was coded as "99," meaning the assessment could not be conducted. The MDS documented severe cognitive impairment and a need for total assistance of two or more staff for bed mobility and transfers.

A progress note completed by Employee 1 (LPN) on April 8, 2025, at 6:45 AM, documented that the resident's left knee was noted to be swollen and painful during routine foot care. Vital signs were within normal limits, and the supervisor was notified.

A progress note completed by Employee 2 (LPN) on April 8, 2025, at 12:35 PM, documented that the Certified Registered Nurse Practitioner (CRNP) assessed the resident and ordered an x-ray (medical imaging using radiation to create internal images) of the left knee. New orders included acetaminophen (a non-opioid pain reliever) 1000 mg orally every eight hours as needed for mild pain, and tramadol (an opioid pain reliever for moderate to severe pain) 50 mg orally twice daily for pain rated 710. The responsible party was notified.

A progress note completed by Employee 2 (LPN) on April 8, 2025, at 12:35 PM, indicated that the Certified Registered Nurse Practitioner (CRNP) assessed the resident and ordered an x-ray (medical imaging using radiation to create internal images) of the left knee. New orders included acetaminophen (a non-opioid pain reliever) 1000 mg orally every eight hours as needed for mild pain, and tramadol (an opioid pain reliever for moderate to severe pain) 50 mg orally twice daily for pain rated 7-10 (pain scale ratings indicate 0 least amount of pain and 10 being worst amount of pain). The responsible party was notified.

A review of the April 8, 2025, x-ray report, timed 10:19 AM, revealed a new but subacute angulated fracture (a bone break where it comes out of alignment, and tilts at an angle) of the distal left femur with partial healing. The report noted possible insufficiency fracture (a stress-related fracture occurring in weakened bone), moderate osteopenia (medical definition for bone density loss), degenerative joint disease (osteoarthritis most common type of arthritis and can occur in any joint, it usually affects the hands, knees, hips or spine), mild soft tissue swelling, and no significant joint effusion (joint swelling). Clinal correlation was suggested and follow up radiographs to confirm healing.

The facility was unable to provide documentation that an investigation into this injury of unknown source was conducted, including interviews, review of shifts prior to discovery, or completion of the required investigation report. The facility was also unable to provide evidence that investigation results were submitted to the State Survey Agency within five working days as required by the facility's abuse policy.

During an interview with the Director of Nursing on November 13, 2025, at 1:30 PM, it was stated that an investigation was not initiated because the facility's CRNP determined the swelling was related to an old fracture.

During an interview with the Nursing Home Administrator on November 14, 2025, at 10:10 AM, the above information was reviewed. The Nursing Home Administrator indicated that an investigation should have been completed due to the presence of an injury of unknown source, in accordance with the facility's policy to rule out potential abuse or neglect.


28 Pa. Code 201.14 (a) Responsibility of licensee.

28 Pa. Code 201.18(e)(1) Management.

28 Pa. Code 201.29(a)(c) Resident Rights.

28 Pa. Code 211.10(d) Resident care policies.

28 Pa. Code 211.12(c)(d)(5) Nursing Services







 Plan of Correction - To be completed: 12/09/2025

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. This statement applies to all observations listed below.

The facility cannot retroactively correct deficient practice for Resident 44.

To identify other residents that have the potential to be affected, the clinical team will Review incident and accidents reports for the past 30 days to verify any injuries of unknown origin to ensure the investigation was managed according to the facility policy and procedure on PA Resident Abuse Policy.

To prevent this from re-occurring, the new Acting Director of Nursing will re-educate the licensed nurses on the facility policy and procedure on PA Resident Abuse Policy. Incident and accidents will be reviewed at morning and afternoon clinical meetings to ensure the any injuries of unknown origin were investigated by facility policy and will be reported by regulation if required.

To monitor and maintain compliance audits will be conducted on incidents with injuries by the DON/designee weekly x 4 weeks and then monthly times 3. The results of the audits will be forwarded to QAPI committee for further review and recommendations.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records: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.
§483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(f). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

§483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

§483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

§483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

§483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.
Observations:

Based on a review of select facility policy. controlled sub stance shift to shift count records, and staff interview, it was determined the facility failed to implement procedures to promote accurate controlled medication records on three of three medication carts observed.

Findings include:

A review of facility policy entitled "Inventory Control of Controlled Substances" (a controlled substance is a medication regulated by federal or state law because it has a risk for abuse, diversion which is misuse for non-medical purposes, or addiction).last reviewed by the facility on October 21, 2025, revealed the facility is to maintain separate individual controlled substance records on all Schedule II medications and any medication with a potential for abuse or diversion in the form of a declining inventory using the "Controlled Substances Declining Inventory Record". The policy further revealed that the facility should ensure the incoming and outgoing nurse count all Schedule II controlled substances and other medications with a risk of abuse or diversion at the change of each shift.

A review of the facility "Shift Verification of Controlled Substances Count" record from the 500-unit medication cart revealed the following:

August 27, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.
August 31, 2025, the first shift off going nurse failed to sign that the narcotic count was completed and correct.
August 31, 2025, the third shift off going nurse failed to sign that the narcotic count was completed and correct.
September 1, 2025, the first shift off going nurse failed to sign that the narcotic count was completed and correct.
September 1, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.
September 1, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.
September 2, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.
September 2,2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.
September 2, 2025, the third shift on coming nurse failed to sign that the narcotic count was completed and correct.
September 4, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.
September 4, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.
September 9, 2025, the night shift on coming nurse failed to sign that the narcotic count was completed and correct.
September 9, 2025, the night shift off going nurse failed to sign that the narcotic count was completed and correct.
September 12, 2025, the night shift off going nurse failed to sign that the narcotic count was completed and correct.
September 14, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.
September 14, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.
September 17, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.
September 17, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.
September 22, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.
September 24, 2025, the third shift on coming nurse failed to sign that the narcotic count was completed and correct.
September 24, 2025, the third shift off going nurse failed to sign that the narcotic count was completed and correct.
September 27, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.
October 1, 2025, the third shift on coming nurse failed to sign that the narcotic count was completed and correct.
October 1, 2025, the third shift off going nurse failed to sign that the narcotic count was completed and correct.
October 4, 2025, the first shift off going nurse failed to sign that the narcotic count was completed and correct.
November 9, 2025, the third shift off going nurse failed to sign that the narcotic count was completed and correct.
November 13, 2025, the first shift on coming nurse failed to sign that the narcotic count was completed and correct.

An interview completed on November 13, 2025, at 08:25AM with employee 4 (Licensed Practical Nurse) revealed she did not complete the shift-to-shift narcotic count with the off going night shift nurse. Employee 6 stated she forgot to sign the book, then proceeded to sign the shift-to-shift narcotic count sheet without completing a complete count of the controlled medications stored in 500 Hall Cart.

A review of the facility "Shift Verification of Controlled Substances Count" record from the 500 Private Hall medication cart revealed the following:

August 15, 2025, the first shift off going nurse failed to sign that the narcotic count was completed and correct.
August 17, 2025, the first shift off going nurse failed to sign that the narcotic count was completed and correct.
August 19, 2025, the third shift off going nurse failed to sign that the narcotic count was completed and correct.
August 22, 2025, the first shift off going nurse failed to sign that the narcotic count was completed and correct.
August 23, 2025, the first shift off going nurse failed to sign that the narcotic count was completed and correct.
August 24, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.
August 24, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.
August 25, 2025, the first shift off going nurse failed to sign that the narcotic count was completed and correct.
August 25, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.
August 30, 2025, the third shift on coming nurse failed to sign that the narcotic count was completed and correct.
August 30, 2025, the third shift off going nurse failed to sign that the narcotic count was completed and correct.
September 2, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.
September 2, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.
September 4, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.
September 6, 2025, the first shift off going nurse failed to sign that the narcotic count was completed and correct.
September 7, 2025, the first shift off going nurse failed to sign that the narcotic count was completed and correct.
September 8, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.
September 8, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.
September 12, 2025, the first shift on coming nurse failed to sign that the narcotic count was completed and correct.
September 12, 2025, the first shift off going nurse failed to sign that the narcotic count was completed and correct.
September 15, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.
September 15, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.
September 16, 2025, the first shift off going nurse failed to sign that the narcotic count was completed and correct.
September 16, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.
September 16, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.
September 23, 2025, the first shift on coming nurse failed to sign that the narcotic count was completed and correct.
September 23, 2025, the first shift off going nurse failed to sign that the narcotic count was completed and correct.
September 23, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.
September 23, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.
September 24, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.
September 24, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.
September 24, 2025, the third shift on coming nurse failed to sign that the narcotic count was completed and correct.
September 24, 2025, the third shift off going nurse failed to sign that the narcotic count was completed and correct.
October 2, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.
October 2, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.
October 3, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.
October 3, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.
October 13, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.
October 13, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.
October 15, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.
October 15, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.
October 17, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.
October 17, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.
October 22, 2025, the first shift off going nurse failed to sign that the narcotic count was completed and correct.
October 22, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.
October 23, 2025, the first shift off going nurse failed to sign that the narcotic count was completed and correct.
October 23, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.
October 24, 2025, the first shift on coming nurse the second shift off going nurse failed to sign that the narcotic count was completed and correct.
October 25, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.
October 25, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.
October 28, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.
October 28, 2025, the third shift on coming nurse failed to sign that the narcotic count was completed and correct.
October 29, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.
October 29, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.
November 3, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.
November 3, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.
November 7, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.
November 7, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.


A review of the facility "Shift Verification of Controlled Substances Count" record from the 200-unit medication cart revealed the following:

November 12, 2025, the first shift off going nurse failed to sign that the narcotic count was completed and correct.

During an interview on November 13, 2025, at 08:05 AM, Employee 3 (Licensed Practical Nurse) confirmed that the count on the 200-unit cart for the above date was incomplete.

On November 13, 2025, at 12:45 PM, the surveyor reviewed the above findings with the Nursing Home Administrator and the Director of Nursing.

28 Pa Code 211.9 (c)(k) Pharmacy services.

28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing service.

28 Pa Code 211.10 (c) Resident care policies.

28 Pa Code 211.5(f)(x) Clinical records.


 Plan of Correction - To be completed: 12/09/2025

The narc count was completed on the 3-medication carts for correct count.

The other medication carts had the narc counts completed for the correct count.

To prevent this from re-occurring the DON/designee will educate licensed staff on the Inventory Control of Controlled Substances policy and procedure to ensure that licensed staff follow the process.

To monitor and maintain compliance the DON/designee will audit narcotic count sheets weekly x 4 weeks then monthly times 3. The results of the audits will be forwarded to the QAPI committee for further review and recommendations.

§ 211.12(i)(2) LICENSURE Nursing services.:State only Deficiency.
(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:

Based on a review of nurse staffing and resident census and staff interview, it was determined the facility failed to consistently provide minimum general nursing care hours to each resident daily on 10 out of 21 days reviewed.

Findings include:

A review of the facility's staffing levels revealed that on the following dates the facility failed to provide minimum nurse staffing of 3.2 hours of general nursing care to each resident:


June 30, 2025 -3.18 direct care nursing hours per resident.
July 1,2025 -3.11 direct care nursing hours per resident.
July 2, 2025 -3.17 direct care nursing hours per resident.
July 3, 2025 -3.13 direct care nursing hours per resident.
July 4, 2025 -3.07 direct care nursing hours per resident.
July 5, 2025 -3.08 direct care nursing hours per resident.
July 6, 2025 -3.10 direct care nursing hours per resident
September 2, 2025 -3.19 direct care nursing hours per resident
September 5, 2025 -3.17 direct care nursing hours per resident
November 8, 2025- 3.02 direct care nursing hours per resident

The facility's general nursing hours were below the minimum required levels on the dates noted above.

An interview was conducted with the Nursing Home Administrator November 14,2025, at 11:30 AM to review the above findings related to the facility's failure to consistently provide minimum general nursing care hours to each resident daily.


 Plan of Correction - To be completed: 12/09/2025

Facility cannot retroactively correct the cited deficient practice; no residents were adversely affected.

Staffing meetings will be held 5 days a week with the scheduler, Director of Nursing and Nursing Home Administrator, to review the current day nursing of minimum state care hours each day of 3.20 and review the upcoming days of the week and following week to ensure appropriate nursing minimum care hours each day of 3.20.

To prevent this from re-occurring the facility is focusing on retention of existing nurse aides and recruitment of new nurse aides through the efforts of the Human Resources manager and the Administrator working on facility recruitment and retention plan to maintain required minimum state daily nursing hours of 3.2 PPD. If the projected daily state minimum staffing ratios do not meet minimum, then the facility will reach out to current staff and staffing agencies using as needed bonuses to enlist staff or agency staff to meet the state minimum hours required. The facility will continue to recruit staff through all platforms to hire and retain staff to meet the state daily nursing care hours of 3.2.

To monitor and maintain compliance the NHA / designee will audit the daily minimum state nursing care hours weekly times 4 weeks and then monthly times 3. The results of the audits will be forwarded to QAPI committee for further review and recommendations.


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