Green Meadows Skilled Nursing and Rehab

In the surveyor’s words

From the most serious findings on record at Green Meadows Skilled Nursing and Rehab, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Oct 24, 2022

  The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey. Based on observation, medical record review, review of a facility investigation, interviews with facility staff, Family Member #200, Physician #300, and review of the facility policy on elopement, the facility failed to provide adequate supervision to prevent Resident #1, who had moderately impaired cognition and a diagnosis of [CONDITION(S)], from leaving the facility unsupervised. This resulted in Immediate Jeopardy on 10/10/22 between 12:00 A.M. and 2:00 A.M. when Resident #1 was able to enter the key code to unlock the door at the main facility entrance, due to the code being taped to the code box and exit the facility unsupervised. […]

• Actual harm, isolatedF684Dec 20, 2023

  Based on review of resident photographs, facility fall log review, resident medical record review, facility policy review and staff interview, the facility failed to appropriately identify and assess an acute change in Resident #98's condition (including altered mental status/and increased falls) to provide timely medical intervention/treatment for the resident. This affected one resident (#98) of three residents reviewed for falls. The facility census was 98. Actual harm occurred on 11/29/23 when Resident #98, who experienced an acute change in condition including three falls within an hour (between 8:00 A.M. and 9:00 A.M.), was not comprehensively assessed or provided timely medical evaluation/intervention. […]

• No harm, potential for more than minimal, widespreadF725May 21, 2026

  Based on observations, record reviews and interviews, the facility failed to maintain sufficient levels of staff to meet the total care needs of all residents. This affected five residents (#109, #113, #114, and #184) of five residents reviewed for personal care services and had the potential to affect all 93 residents residing in the facility. The facility census was 93. Findings include: Observation and interview on 05/18/26 at 10:10 A.M. during the facility entry conference with Administrator and Licensed Practical Nurse (LPN) #213 revealed the facility Director of Nursing (DON) was on vacation this week and the facility did not currently have the assistant director of nursing (ADON) position filled. […]

• No harm, potential for more than minimal, widespreadF921May 21, 2026

  Based on observation and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This had the potential to affect all 93 residents of the facility. The facility census was 93.Findings include:On 05/18/26 at 12:48 P.M., an observation of the Men's Restroom in the main lobby revealed a sign stating the restroom was temporarily out of order. The inside of the restroom revealed a hole in the ceiling over the toilet with honeycomb-like rusted metal exposed. On 05/18/26 at 12:50 P.M., an interview with the Administrator confirmed the restroom off the main lobby was closed because the roof had a leak and was causing the ceiling to fall down. […]

• No harm, potential for more than minimal, widespreadF868Feb 10, 2025

  Based on review of Quality Assurance (QA) committee meeting attendance sheets, policy review and interview, the facility failed to ensure a QA meeting was held the first quarter of 2024. This had the potential to affect all 89 residents. Findings include: Upon entrance with the Administrator and Director of Nursing (DON), sign in sheets for quality assurance meetings held in the year 2024 were requested. There were no attendance sheets provided for a meeting in the first quarter of 2024. Review of the Quality Assessment and Assurance policy (dated September 2021) revealed the committee shall meet at least quarterly to identify quality assessment and assurance issues, and to develop and implement or oversee implementation of, appropriate plans for identified quality deficiencies. […]