Inspection visit
Health inspection
6 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0578
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
Based upon clinical record review, it was determined that the facility failed to ensure appropriate advance
directives regarding code status were in place for one of 33 residents reviewed. (Resident 114)Findings
include:Review of Resident 114's clinical record revealed a physician's order dated October 18, 2025,
stating Resident 114 was a Full Code.Review of Resident 114's current care plan revealed Resident 114
had a Full Code Status.Review of a Physician's Order for Life Sustaining Treatment (POLST) signed by
Resident 114 and dated November 7, 2025, revealed Resident 114's wishes to have a Do Not Resuscitate
status.Interview with the Director of Nursing on December 11, 2025, at 10:00 a.m. confirmed that Resident
114's clinical record did not concur with the POLST signed by Resident 114. 28 Pa. Code 201.14(a)
Responsibility of LicenseePreviously cited 10/9/202428 Pa. Code 211.12(c)(d)(3) Nursing
ServicesPreviously cited 10/9/2024, 4/30/2025
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 6
Event ID:
395519
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395519
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/11/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Green Meadows Nursing & Rehabilitation Center
283 East Lancaster Avenue
Malvern, PA 19355
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
Based on clinical record review and staff interview, it was determined that the facility failed to ensure
accurate assessments for one of 33 residents reviewed (Resident 29)Findings include:Review of Resident
29's admission MDS (Minimum Data Assessment - periodic assessment of resident needs) dated
November 30, 2025, section H, Bladder and Bowel, indicated that the resident had an indwelling catheter
(flexible tube that carries fluids into or out of the body).Further review of the clinical record no evidence that
the resident had an indwelling catheter.Interview with the licensed staff E3 on December 11, 2025, at 10:45
a.m. confirmed that the resident did not have an indwelling catheter and that the MDS was coded
incorrectly.28 Pa. Code 211.12(d)(1)(5) Nursing services
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395519
If continuation sheet
Page 2 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395519
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/11/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Green Meadows Nursing & Rehabilitation Center
283 East Lancaster Avenue
Malvern, PA 19355
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0692
Provide enough food/fluids to maintain a resident's health.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations and staff interviews it was determined that the facility failed to provide hydration for fifteen of
thirty-two rooms on the 1st floor dementia care unit.Observations made of resident rooms on December 8,
2025, December 9, 2025, and December 10, 2025, revealed rooms 100 through 115 had no cups of fresh
water for resident's hydration or the cups were dated between November 14, 2025, and December 1, 2025.
Rooms 116 through 132 were observed to have currently dated cups with fresh water.Observations made
on December 8, 2025, December 9, 2025, and December 10, 2025, of rooms [ROOM NUMBERS] revealed
cups of water dated November 14, 2025. Observations made on December 8, 2025, December 9, 2025,
and December 10, 2025, of room [ROOM NUMBER] revealed a cup of water dated December 1, 2025.All
remaining rooms between 100 and 115 had no water cups.Interview on December 10, 2025, at 12:43 p.m.,
with Registered Nurse Employee E4, E4 confirmed knowledge of rooms 100 through 115 not having fresh
water with properly dated cups. Interview conducted with Nursing Home Administrator (NHA) and Director
of Nursing (DON) on December 10, 2025, at 1:30 p.m., when the above information was presented, the
NHA and DON denied knowledge of residents not receiving fresh hydration daily and stated they would
investigate the matter.28 Pa. Code 211.10 (c) Resident care policies28 Pa Code 201.18 (b)(1) Management
28 Pa Code 211.12(d)(1)(5) Nursing services
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395519
If continuation sheet
Page 3 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395519
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/11/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Green Meadows Nursing & Rehabilitation Center
283 East Lancaster Avenue
Malvern, PA 19355
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0757
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Level of Harm - Minimal harm
or potential for actual harm
Based upon clinical record review, it was determined that the facility failed to ensure appropriate monitoring
for side effects and effectiveness were completed for the use of an anti-depressant medication for one of 33
records reviewed (Resident 35).Findings include:Review of Resident 35's diagnosis list revealed a
diagnosis of major depressive disorder.Review of Resident 35's physician's orders dated November 27,
2025, revealed an order for Mirtazapine (antidepressant) to be administered for treatment of Resident 35's
depression.Further review of Resident 35's clinical record failed to reveal evidence of monitoring for side
effects of the anti-depressant medication and failed to reveal documented evidence of the effectiveness of
the anti-depressant medication.Interview with the Director of Nursing on December 11, 2025, at 11:00 a.m.
confirmed that no monitoring for side effects of the anti-depressant medication was conducted and further
that no monitoring of the effectiveness of the medication was conducted. 28 Pa. Code 211.12(c)(d)(3)
Nursing ServicesPreviously cited 10/9/2024, 4/30/2025
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395519
If continuation sheet
Page 4 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395519
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/11/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Green Meadows Nursing & Rehabilitation Center
283 East Lancaster Avenue
Malvern, PA 19355
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0810
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews and record reviews it was determined that the facility failed to provide an assistive
device for one of seven residents investigated, (Resident 7).Review of Resident 7's physician orders
revealed an order for regular diet, regular texture, thin consistency [NAME] Cup (a spill-proof drinking cup
with a secure lid and J-shaped handle) built up fork and spoon dated May 21, 2025.Review of Resident 7's
care plan revealed a care plan for nutritional problem or potential nutritional problem related to need for
assist with meals, intellectual disability, and weight stable.Review of Resident 7's face sheet revealed
medical diagnoses that include Encephalopathy (a group of conditions that cause brain
dysfunction).Observations made of Resident 7 on December 8, 2025, December 9, 2025, and December
10, 2025, during lunch service revealed the resident drinking from a regular cup with a straw.Interview on
December 10, 2025, at 12:43 p.m., with Unit Manager Registered Nurse Employee E4, E4 confirmed
knowledge of resident not drinking from a Kennedy cup as per physician order.Interview conducted with
Nursing Home Administrator (NHA) and Director of Nursing (DON) on December 10, 2025, at 12:48 p.m.,
when the above information was presented, the NHA and DON denied knowledge of the resident not
utilizing a Kennedy cup. Interview conducted on December 11, 2025, at 10:58 a.m., with the DON who
stated that a new order of Kenndy cups had been received and were now available for Resident 7's use. 28
Pa Code 201.18 (b)(1) Management 28 Pa Code 211.10 (d) Resident care policies 28 Pa Code
211.12(d)(1)(5) Nursing services
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395519
If continuation sheet
Page 5 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395519
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/11/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Green Meadows Nursing & Rehabilitation Center
283 East Lancaster Avenue
Malvern, PA 19355
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0910
Ensure resident rooms meet each resident's needs.
Level of Harm - Minimal harm
or potential for actual harm
Based on observations and staff interviews it was determined that the facility failed to provide privacy
curtains for three of thirty-two resident rooms and failed to provide clean privacy curtains for eighteen of
thirty-two resident rooms located on the 1st floor dementia care unit.Observations made on December 8,
2025, December 9, 2025, and December 10, 2025, of resident rooms on the 1st floor dementia care unit
revealed 3 rooms with missing privacy curtains. Observations made on December 8, 2025, December 9,
2025, and December 10, 2025, of resident rooms on the 1st floor dementia care unit revealed 18 rooms
with privacy curtains that were soiled or had brown stains on them.Interview conducted with Nursing Home
Administrator (NHA) and Director of Nursing (DON) on December 11, 2025, at 10:58 a.m., when the above
information was presented, the NHA stated the facility was in the process of remodeling the 1st floor and
new privacy curtains have already been ordered for all rooms. 28 Pa Code 201.18 (b)(1) Management 28
Pa Code 211.10 (d) Resident care policies 28 Pa Code 211.12(d)(1)(5) Nursing services
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395519
If continuation sheet
Page 6 of 6
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Back to topCitations
6 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
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.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
F810 - Assistive devices
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
F910 - Resident Rooms
Ensure resident rooms meet each resident's needs.
FAQ · About this visit
Common questions about this visit
What happened during the December 11, 2025 survey of GREEN MEADOWS NURSING & REHABILITATION CENTER?
This was a inspection survey of GREEN MEADOWS NURSING & REHABILITATION CENTER on December 11, 2025. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at GREEN MEADOWS NURSING & REHABILITATION CENTER on December 11, 2025?
Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate ..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.