Green Ridge Care Center

In the surveyor’s words

From the most serious findings on record at Green Ridge Care Center, in the surveyor’s own words.

• Actual harm, isolatedF760Feb 2, 2024

  Based on review of clinical records and select facility policy and incident reports, and staff interviews it was revealed that the facility failed to assure that one of 18 residents reviewed was free of a significant medication error (Resident 81), which compromised the resident's clinical condition and required corrective treatment to reverse the effects of the error. Findings include: A review of the facility's current pharmacy policy and procedures last reviewed January 2024, revealed that facility staff should only prepare medications for one resident at a time. […]

• No harm, potential for more than minimal, widespreadF868May 14, 2021

  Based on review of facility QAPI meeting attendance records and staff interviews, it was determined that the facility failed to show evidence of committee members attendance at quarterly Quality Assurance Process Improvement (QAPI) Committee meetings conducted for four quarters out of four reviewed. Findings include: A review of QAPI Committee meeting sign-in sheets, for the last four quarters of meetings, revealed that the attendance sheets did not include a date when meeting attendees assembled for the meetings conducted during the last four quarters. Interview with the administrator on May 14, 2021, at 1:30 PM confirmed that the facility failed to identify the dates of that attendees had attended the facility's QAPI quarterly meetings. 28 Pa. Code 201.18(e)(1)(2)(3) Management

• No harm, potential for more than minimal, patternF658Sep 11, 2026

  Based on select facility policy, clinical record review, and staff interviews, it was determined the facility failed to ensure nursing services met professional standards of quality as required by the Pennsylvania Code Title 49, Professional and Vocational Standards, by failing to verify Licensed Practical Nurses possessed the required education, training, and competencies for the administration of an intravenous (IV) medication via peripheral inserted central venous catheter (PICC) for two of 19 residents reviewed (Resident 8 and Resident 6). […]

• No harm, potential for more than minimal, patternF694Sep 11, 2026

  Based on select facility policy, a review of clinical records, and staff interviews, it was determined the facility failed to ensure intravenous therapy was provided and monitored in accordance with physician orders and professional standards of practice for two of 19 residents reviewed (Residents 5 and Resident 6).Findings include: According to the Infusion Nurses Society (INS) (2024), Infusion Therapy Standards of Practice, the baseline circumference of an extremity with an intravenous catheter is measured upon insertion, noting location for future measurements to ensure consistent measurement. Facilities should assess circumference when edema or signs and symptoms of deep vein thrombosis (DVT) present, noting the location and characteristics of edema. […]

• No harm, potential for more than minimal, patternF697Jan 31, 2025

  Based on clinical record review, facility policy review, and staff interviews, the facility failed to provide effective pain management, administer pain medication as prescribed by the physician, and attempt non-pharmacological interventions prior to administering narcotic pain medication prescribed on an as-needed (PRN) basis for one (1) of three (3) residents sampled for pain (Resident 18). Findings include: A review of the facility's policy titled Pain Management, with a policy review date of December 2024, indicated that an evaluation of pain presence and severity should occur using the appropriate pain scale (numeric pain rating scale, face rating scale, or verbal descriptor scale). […]