Cycle 1
Health 2025-12-11 · Fire 2025-12-11
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Malvern, PA
Green Meadows Nursing & Rehabilitation Center
4-star overall rating with 3-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
283 East Lancaster Avenue, Malvern, PA
(610) 296-4170
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
184
Certified beds
Average residents
167
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Prestige Healthcare Administrative Services
Operator or chain grouping
Approved since
1982-02-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
15 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.40
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.91
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.08
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.39
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.31
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.21
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.28
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.44
CMS adjusted RN staffing hours
Adjusted total hours
3.75
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,472
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
44.16
Composite VBP score used to determine payment impact.
Payment multiplier
0.9972
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.65
Baseline 18.35% · Performance 18.81% · Measure score 5.65 · Achievement 5.65 · Improvement 0
Healthcare-associated infections
6.30
Baseline 4.76% · Performance 5.95% · Measure score 6.30 · Achievement 6.30 · Improvement 0
Total nurse turnover
3.25
Baseline 47.75% · Performance 50.41% · Measure score 3.25 · Achievement 3.25 · Improvement 0
Adjusted total nurse staffing
2.46
Baseline 3.65 hours · Performance 3.78 hours · Measure score 2.46 · Achievement 2.46 · Improvement 0.12
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.53% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 219 · Observed rate 12.79% · Lower 95% interval 8.64% |
| Discharge to community | 54.57% |
50.57%
4 pts better
|
No Different than the National Rate · Eligible stays 165 · Observed rate 44.85% · Lower 95% interval 46.99% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 46.67% |
95.27%
48.6 pts worse
|
Numerator 84 · Denominator 180 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 180 |
| Discharge self-care score | 66.42% |
53.69%
12.7 pts better
|
Numerator 91 · Denominator 137 |
| Discharge mobility score | 60.58% |
50.94%
9.6 pts better
|
Numerator 83 · Denominator 137 |
| Pressure ulcers or injuries, new or worsened | 0.56% |
2.29%
1.7 pts better
|
Numerator 1 · Denominator 179 · Adjusted rate 0.49% |
| Healthcare-associated infections requiring hospitalization | 5.95% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 118 · Observed rate 5.08% · Lower 95% interval 3.72% |
| Staff COVID-19 vaccination coverage | 6.25% |
8.2%
1.9 pts worse
|
Numerator 12 · Denominator 192 |
| Staff flu vaccination coverage | 31.71% |
42%
10.3 pts worse
|
Numerator 39 · Denominator 123 |
| Discharge function score | 72.99% |
56.45%
16.5 pts better
|
Numerator 100 · Denominator 137 |
| Transfer of health information to provider | 97.56% |
95.95%
1.6 pts better
|
Numerator 40 · Denominator 41 |
| Transfer of health information to patient | 98.7% |
96.28%
2.4 pts better
|
Numerator 76 · Denominator 77 |
| Resident COVID-19 vaccinations up to date | 19.61% |
25.2%
5.6 pts worse
|
Numerator 20 · Denominator 102 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.7
About the same
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.3 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.2
0.2 pts worse
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.1 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 61.5% |
86.9%
25.4 pts worse
|
93.4%
31.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 64.5% · Q2 62.3% · Q3 55.7% · Q4 63.6% · 4Q avg 61.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.2% |
93.5%
2.7 pts better
|
95.5%
0.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.4% |
3.2%
0.2 pts worse
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 4.6% · Q3 2.7% · Q4 2.1% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 17.2% |
6.5%
10.7 pts worse
|
11.4%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 10.6% · Q3 23.5% · Q4 28.7% · 4Q avg 17.2% |
| Percentage of long-stay residents who lose too much weight | 4.8% |
6.5%
1.7 pts better
|
5.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.2% · Q3 6.0% · Q4 8.3% · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.7% |
19.9%
5.8 pts worse
|
19.6%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.4% · Q2 27.1% · Q3 25.5% · Q4 23.5% · 4Q avg 25.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 26.1% |
18.7%
7.4 pts worse
|
16.7%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.2% · Q2 26.7% · Q3 27.4% · Q4 22.9% · 4Q avg 26.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 3.4% |
19.6%
16.2 pts better
|
16.3%
12.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.6% · Q3 3.3% · Q4 3.3% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.4% |
18.3%
12.9 pts better
|
14.9%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 4.4% · Q3 9.0% · Q4 3.8% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.9%
0.6 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.4% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.8% |
26.4%
2.4 pts worse
|
19.8%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.1% · Q2 28.4% · Q3 28.5% · Q4 26.0% · 4Q avg 28.8% |
| Percentage of long-stay residents with pressure ulcers | 0.4% |
5.3%
4.9 pts better
|
5.1%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.9% · Q3 0.0% · Q4 0.8% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 20.3% |
68.9%
48.6 pts worse
|
81.7%
61.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 11.7% · Q2 21.8% · Q3 25.2% · Q4 20.0% · 4Q avg 20.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.0% |
9.8%
2.2 pts worse
|
12.0%
About the same
|
Short Stay · 20240701-20250630 · Adjusted 12.0% · Observed 12.2% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 32.2% |
68.7%
36.5 pts worse
|
79.7%
47.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 32.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.1% |
23.1%
1 pts better
|
23.9%
1.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.1% · Observed 21.2% · Expected 22.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-09 · Fire 2024-10-09
3 health deficiencies
Top issue: Administration (1 deficiency)
7 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2023-11-30 · Fire 2023-11-30
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-12-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-02-16
C · Minimal harm
2025-12-11
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2026-02-16
F · Potential for more than minimal harm
2024-10-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-28
E · Potential for more than minimal harm
2024-10-09
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-12-28
E · Potential for more than minimal harm
2024-10-09
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-12-28
E · Potential for more than minimal harm
2024-10-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-28
E · Potential for more than minimal harm
2024-10-09
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-12-28
D · Potential for more than minimal harm
2024-10-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-12-28
C · Minimal harm
2024-10-09
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-12-28
E · Potential for more than minimal harm
2023-11-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-01-02
D · Potential for more than minimal harm
2023-11-30
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-01-30
D · Potential for more than minimal harm
2023-11-30
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-01-02
D · Potential for more than minimal harm
2023-11-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-02
D · Potential for more than minimal harm
2023-11-30
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-01-02
C · Minimal harm
2023-11-30
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-01-02
C · Minimal harm
2023-11-30
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-01-02
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-11
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2026-01-26
E · Potential for more than minimal harm
2025-12-11
F910 · Environmental Deficiencies
Health
Ensure resident rooms meet each resident's needs.
Corrected 2026-01-26
D · Potential for more than minimal harm
2025-12-11
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2026-01-26
D · Potential for more than minimal harm
2025-12-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2026-01-26
D · Potential for more than minimal harm
2025-12-11
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2026-01-26
D · Potential for more than minimal harm
2025-12-11
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2026-01-26
D · Potential for more than minimal harm
2025-04-30
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-05-27
E · Potential for more than minimal harm
2024-10-09
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-11-12
D · Potential for more than minimal harm
2024-10-09
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-11-12
D · Potential for more than minimal harm
2024-10-09
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2024-11-12
D · Potential for more than minimal harm
2023-11-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-16
D · Potential for more than minimal harm
2023-11-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-16
D · Potential for more than minimal harm
2023-11-30
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-01-16
Penalties and ownership
What sits behind the stars
Ownership
Cpsh Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Stern, Moshe
5% Or Greater Indirect Ownership Interest · Individual
Berger, Yaakov
W-2 Managing Employee · Individual
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#3
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