Greenwood Center: Blood Pressure Medication Errors - PA
The inspection report, filed following a complaint investigation completed November 25, 2025, documents the same pattern across 19 separate dates. The medication carried a condition: do not administer if the resident's systolic blood pressure falls below 120 mm/Hg. The readings, logged in the resident's own chart, showed the systolic number sitting below that line each time the drug was given anyway.
October 27: 110/72. October 29: 118/70. October 30: 116/70. The readings continued through November, rarely budging. November 1: 116/70. November 4: 116/70. November 5: 118/68. The highest reading recorded across the entire span was 118, still short of the 120 threshold. On November 11, the systolic dropped to 118/60. On November 12: 118/64. The medication was given on those days too.
The numbers were there. The threshold was known. Nobody stopped.
Giving a blood pressure-lowering drug to a patient whose pressure is already beneath the safe floor for that drug carries real risk. Blood pressure that drops too low can cause dizziness, falls, fainting, and in vulnerable patients, organ damage. In a nursing home population, a fall from a medication-induced drop in pressure can mean a broken hip, a hospitalization, or worse. The inspection report classified the harm level as minimal harm or potential for actual harm, and noted that some residents were affected.
The administrator of Greenwood Center, interviewed by inspectors at 12:10 p.m. on the day of the survey, confirmed what the records already showed. Nursing staff, the administrator said, failed to follow acceptable standards of nursing practice during medication administration. The result was multiple medication errors.
That confirmation matters. This was not a disputed finding or a case where the facility pushed back on the inspector's read of the records. The person running the facility agreed: the nurses gave the medication when they should not have, and they did it repeatedly over the course of nearly three weeks.
What the report does not say is whether anyone caught the pattern while it was happening, whether the resident's physician was notified, or whether the resident experienced any symptoms during those weeks. It does not say whether the medication order included clear written instructions about the blood pressure threshold, or whether nursing staff were trained on how to apply hold parameters before giving cardiac medications. Those questions go unanswered in the four pages of the inspection document.
Greenwood Center for Nursing and Rehab sits at 149 Lafayette Avenue in Tamaqua, a small borough in Schuylkill County in eastern Pennsylvania. The complaint that triggered the November inspection is not described in the report.
What is described is a medication administration record that, read date by date, shows a drug being given against its own conditions of use. October 31: 118/70. November 3: 118/74. November 6: 116/70. November 8: 118/68. November 9: 116/70. November 10: 118/68. November 13: 116/66. November 14: 118/70. Each entry a day when someone checked the blood pressure, wrote down the number, and gave the medication anyway.
The inspection cites violations of Pennsylvania's pharmacy services regulations, nursing services standards, and resident care policy requirements.
For the resident whose readings fill those two pages of the report, the weeks between late October and mid-November are now a documented record of a safety check that existed on paper and failed in practice, day after day, until an inspector arrived and the administrator ran out of a different explanation to give.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Greenwood Center For Nursing and Rehab from 2025-11-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 23, 2026 · Our methodology
GREENWOOD CENTER FOR NURSING AND REHAB in TAMAQUA, PA was cited for violations during a health inspection on November 25, 2025.
The inspection report, filed following a complaint investigation completed November 25, 2025, documents the same pattern across 19 separate dates.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.