Green Meadow Haven

In the surveyor’s words

From the most serious findings on record at Green Meadow Haven, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 18, 2021

  Based on observations, record reviews, and interviews, the facility failed to ensure the residents remained free of accident hazards for 1 of 1 (#77) residents, who was transported in the facility's van via wheelchair, out of a total sample of 3 (#19, #77 and #78) residents reviewed for accidents. The deficient practice resulted in an Immediate Jeopardy situation for Resident #77 on 1/28/2021 at 8:00 am, when she was being transported to a doctor's appointment in the facility's van. During transport, Resident #77 slid out of her wheelchair and onto the van floor. S13 CNA (Certified Nursing Assistant) and S14 CNA picked Resident #77 up off the floor, placed her back in her wheelchair, and continued to transport the resident to her doctor's appointment. […]

• Immediate jeopardy, isolatedF835May 18, 2021

  Based on observations, record reviews and interviews, the facility failed to be administered in a manner that used resources effectively and efficiently to ensure a resident's environment remained as free of accident hazards for 1 of 1 (#77) residents, who was transported in the facility's van via wheelchair, out of a total sample of 3 (#19, #77 and #78) residents reviewed for accidents. The deficient practice resulted in an Immediate Jeopardy situation for Resident #77 on 1/28/2021 at 8:00 am, when she was being transported to a doctor's appointment in the facility's van. During transport, Resident #77 slid out of her wheelchair and onto the van floor. […]

• Actual harm, isolatedF689Aug 20, 2025

  Based on observations, record reviews and interviews the facility failed to have a system in place to prevent accident hazards for 1 (#67) of 4 (#4, #46, #67, #84) sampled residents investigated for accidents. The facility failed to ensure coffee was served at a safe temperature to prevent burn injuries.The deficient practice resulted in an actual harm on 08/13/2024 at approximately 8:40 a.m. when Resident #67 spilled her breakfast coffee onto her lap. Resident #67 was not aware she had a burn to her left anterior thigh until S6 CNA (Certified Nursing Assistant) came to help her clean up and her left anterior thigh had a reddened area with blisters. […]

• No harm, potential for more than minimal, patternF558Aug 20, 2025

  Based on record review, observations, and interviews the facility failed to ensure a resident received reasonable accommodation of needs by failing to have an assistive device accessible to 1 (#3) of 19 sampled residents.Findings:Review of Resident #3's medical record revealed an admission date of 05/16/2025 with diagnoses including, in part, spinal stenosis, lumbar region without neurogenic claudication; adult failure to thrive; contracture, right knee; and contracture, left knee.Review of Resident #3's Quarterly MDS (Minimum Data Sheet) assessment dated [DATE] revealed, in part, Resident #3 had a BIMS (Brief Interview for Mental Status) score of 7 indicating severe impaired cognition. […]

• No harm, potential for more than minimal, patternF605Aug 20, 2025

  Based on record review and interviews, the facility failed to ensure a resident with an order for psychotropic medication as needed (PRN) was not subjected to chemical restraints for 1 (#4) of 6 (#1, #2, #4, #9, #12, and #51) residents reviewed for unnecessary medications. The facility failed to ensure Resident #4's PRN order for psychotropic medication was limited to 14 days. Findings:Review of Resident #4's medical record revealed an admit date of 01/04/2025 with diagnoses of but not limited to Alzheimer's disease, anxiety disorder, and schizophrenia.Review of Resident #4's physician orders revealed an order dated 07/07/2025 for Ativan Oral Tablet 1 MG (milligram) (Lorazepam); Give 1 tablet by mouth every 6 hours as needed for anxiety, end date indefinite. […]