Inspection Reports for
Encore Healthcare and Rehab of Malvern
1820 W. Moline St, Malvern, AR, 72104
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
15% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
77% occupied
Based on a November 2023 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 18, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to timely report allegations of abuse and failure to ensure staff initiated and completed provider orders for psychiatric consults.
Complaint Details
The complaint investigation found that the facility failed to report allegations of abuse within the required 2-hour timeframe for three residents (Resident #1, #3, and #4) and failed to follow through on psychiatric consult orders for Resident #6.
Findings
The facility failed to report allegations of abuse within the required 2-hour timeframe for three of four residents involved in incidents reported to the state agency. Additionally, the facility failed to ensure staff initiated and completed provider orders for psychiatric consultation for one resident.
Deficiencies (2)
Failure to timely report allegations of abuse within the required 2-hour timeframe for three residents.
Failure to ensure staff initiated and completed provider orders for psychiatric consult for one resident.
Report Facts
Residents involved in abuse reporting incidents: 4
Residents with delayed abuse reporting: 3
Dates of incidents: Incidents occurred on 03/10/2025, 05/05/2025, and 04/29/2025.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Indicated the facility was unable to provide the order for the Behavioral Health consult and that the order was not followed. |
| Advanced Practice Registered Nurse | APRN | Provided notes and interviews regarding psychiatric consult orders and processes for Resident #6. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 7, 2025
Visit Reason
The inspection was conducted to investigate complaints related to resident-to-resident abuse and failure to implement a physician's order for a fall mat, resulting in injury and safety concerns for residents.
Complaint Details
The complaint investigation focused on incidents of resident-to-resident abuse involving Resident #1 and Resident #2, including verbal threats and physical assault occurring between 10/30/2024 and 11/05/2024. The investigation also addressed failure to implement a fall mat order for Resident #5, who sustained brain hematomas after a fall on 01/15/2025.
Findings
The facility failed to protect a resident from resident-to-resident abuse, with documented verbal and physical abuse incidents between two residents. Additionally, the facility failed to revise a care plan to include an intervention for a fall mat, resulting in a resident sustaining bifrontal subdural hematomas after a fall.
Deficiencies (3)
Failed to protect a resident from resident-to-resident abuse, including verbal threats and physical assault.
Failed to revise care plan to include intervention for a fall mat after a resident sustained injuries from a fall.
Failed to ensure a physician's order for a fall mat was implemented, contributing to a resident's fall and injury.
Report Facts
Residents reviewed for abuse: 4
Residents sampled for falls care plans: 3
BIMS score: 8
BIMS score: 1
Fall mat order date: Dec 14, 2024
Fall incident date: Jan 15, 2025
Hematoma size left: 5.5
Hematoma size right: 2.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #4 | Certified Nursing Assistant | Removed Resident #2 from area during abuse incident and reported threats |
| CNA #10 | Certified Nursing Assistant | Witnessed physical abuse incident between Resident #1 and Resident #2 and separated residents |
| LPN #9 | Licensed Practical Nurse | Observed injuries after abuse incident and provided assessment |
| Director of Nursing | Director of Nursing | Interviewed regarding procedures following resident-to-resident altercations and care plan revisions |
| Treatment Nurse #3 | Treatment Nurse | Observed verbal and physical abuse incident and provided statements |
| Administrator | Facility Administrator | Interviewed regarding actions taken to protect residents from abuse and care plan policies |
| LPN #12 | Licensed Practical Nurse | Entered order for fall mat and informed CNAs but not other nursing staff or MDS Coordinator |
| MDS Coordinator #14 | MDS Coordinator | Reviewed care plans and confirmed fall mat intervention was not included |
| CNA #1 | Certified Nursing Assistant | Found Resident #5 on floor after fall and reported observations |
| CNA #11 | Certified Nursing Assistant | Interviewed about Resident #5's fall risk and bed controls |
| CNA #15 | Certified Nursing Assistant | Interviewed about Resident #5's fall risk and bed controls |
Inspection Report
Routine
Deficiencies: 4
Date: Nov 21, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, medication management, nutritional services, and food safety in the nursing home.
Findings
The facility was found deficient in several areas including improper use of mechanical lifts risking resident safety, failure to label medications with expiration dates, incorrect meal portion sizes served to residents on pureed diets, and inadequate food handling and hygiene practices by dietary staff.
Deficiencies (4)
Failed to ensure residents were lowered and raised in a mechanical lift with the rear casters/wheels in the unlocked position to prevent accidents or injury for 1 sampled resident.
Failed to label an anti-anxiety medication stored in the refrigerated narcotic box with the open and use by date to prevent expired medication administration.
Failed to ensure meals were prepared and served according to the planned written menu to provide nutritionally balanced meals for residents on pureed diets.
Failed to ensure dietary staff washed hands and changed gloves when contaminated, stored food items properly, removed expired food, and maintained hot food at required temperatures.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: Many
Temperature: 121
Temperature: 122
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #5 | Certified Nursing Assistant | Observed locking mechanical lift casters improperly |
| CNA #6 | Certified Nursing Assistant | Observed locking mechanical lift casters improperly and trained on lift |
| Director of Nursing | Director of Nursing | Interviewed regarding mechanical lift procedures and medication expiration |
| LPN #7 | Licensed Practical Nurse | Unable to confirm medication opening date and expiration |
| DA #1 | Dietary Aide | Served incorrect portion sizes and handled food improperly |
| DA #2 | Dietary Aide | Handled plates without washing hands |
| DC #3 | Dietary Cook | Handled clean equipment with contaminated hands and gloves |
| DC #4 | Dietary Cook | Served food at improper temperature and handled food with contaminated gloves |
Inspection Report
Routine
Census: 83
Deficiencies: 9
Date: Nov 9, 2023
Visit Reason
The inspection was conducted as a routine regulatory oversight visit to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including bowel care, accident hazard prevention, catheter care, feeding tube management, oxygen therapy signage, medication administration errors, meal temperature and palatability, food safety and hygiene practices, and infection control related to glucometer disinfection. Deficiencies had potential to affect multiple residents with minimal harm noted.
Deficiencies (9)
Failed to ensure bowel movements were occurring to prevent possible complications for Resident #18.
Failed to ensure potentially hazardous chemicals were stored securely, fall prevention interventions were implemented, and sharps containers were changed timely.
Failed to maintain indwelling catheter tubing to prevent infection complications for Resident #8.
Failed to flush and auscultate PEG feeding tube prior to administration of nutritional supplements for Resident #18.
Failed to post precautionary oxygen sign outside Resident #21's room indicating oxygen use.
Medication errors occurred including wrong medication administration and missed doses affecting Residents #15 and #66.
Meals served at temperatures below acceptable levels and cold food was often served cold, affecting palatability.
Failed to ensure foods stored in freezer were covered, dietary staff washed hands before handling clean equipment, and ice scoop holder was clean.
Failed to properly disinfect multi-resident glucometers between uses, risking infection spread among Residents #51, #56, and #17.
Report Facts
Residents affected by hazardous chemical storage and fall prevention failures: 42
Medication error rate: 9.68
Number of medication errors detected: 3
Number of residents with indwelling catheters sampled: 3
Number of residents with enteral feeding tubes sampled: 4
Number of residents receiving oxygen therapy sampled: 13
Number of residents affected by meal temperature issues: 81
Facility census: 83
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in glucometer disinfection deficiency and sharps container observations |
| LPN #4 | Licensed Practical Nurse | Named in bowel care, fall prevention, and feeding tube flushing deficiencies |
| LPN #5 | Licensed Practical Nurse | Named in medication error deficiency |
| CNA #4 | Certified Nursing Assistant | Named in fall prevention deficiency |
| CNA #5 | Certified Nursing Assistant | Named in bowel care deficiency |
| CNA #6 | Certified Nursing Assistant | Named in catheter care deficiency |
| Dietary Employee #1 | Dietary Staff | Named in food safety and hygiene deficiencies |
| Housekeeping Supervisor | Housekeeping Supervisor | Named in hazardous chemical storage deficiency |
| Director of Nursing | Director of Nursing (DON) | Named in multiple deficiencies including bowel care, fall prevention, catheter care, feeding tube, oxygen signage, medication errors, and glucometer disinfection |
| Administrator | Facility Administrator | Named in bowel care, feeding tube, oxygen signage, and medication error deficiencies |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Oct 27, 2023
Visit Reason
The document is a statement of deficiencies related to the facility's failure to ensure pureed food items were blended to a smooth, lump-free consistency to meet individual resident needs.
Findings
The facility failed to ensure pureed food items were properly prepared for 2 of 2 meals observed, posing a choking hazard to 5 residents requiring pureed diets. Observations and interviews confirmed thick, lumpy, and pasty pureed foods served at breakfast and lunch.
Deficiencies (1)
Failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize choking risk for residents requiring pureed diets.
Report Facts
Residents affected: 5
Meals observed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Supervisor | Reviewed pictures of breakfast and confirmed eggs were lumpy | |
| C.N.A #1 | Noted pureed rice and bread was a choking hazard and refused to feed resident | |
| LPN #1 | Stated pureed food (rice) looked too thick and gummy |
Inspection Report
Routine
Census: 81
Deficiencies: 5
Date: Aug 25, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident transfers, weight loss prevention, respiratory care, medication management, and food safety at Encore Healthcare and Rehab of Malvern.
Findings
The facility failed to notify representatives in writing of hospital transfer reasons for some residents, failed to prevent significant weight loss in one resident, did not ensure oxygen flow rates and CPAP mask storage met orders, stored unlabeled medications at bedside, and improperly cooled potentially hazardous foods in the kitchen.
Deficiencies (5)
Failed to notify representatives of hospital transfer reasons in writing for 3 residents.
Failed to identify and intervene to prevent significant weight loss for 1 resident.
Failed to ensure oxygen flow rate was set as ordered for 1 resident and CPAP mask was not bagged and dated for 1 resident.
Stored unlabeled medications at bedside for 1 resident.
Failed to properly cool potentially hazardous foods before refrigeration.
Report Facts
Residents affected by transfer notification deficiency: 3
Residents sampled for transfer notification: 12
Resident census: 81
Weight loss percentage: 8.98
Residents affected by weight loss deficiency: 1
Residents affected by oxygen/CPAP deficiency: 23
Residents affected by CPAP mask storage deficiency: 3
Residents affected by unlabeled medication deficiency: 1
Residents potentially affected by unlabeled medication: 17
Residents potentially affected by food safety deficiency: 78
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Responsible for transfer notification process; interviewed regarding transfer documentation and weight loss interventions |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Called Life Net for hospital transfer of Resident #77; interviewed about weight loss identification process |
| Admissions Coordinator | Admissions Coordinator | Responsible for sending out notice of transfers with reason for transfer in writing; interviewed about transfer documentation |
| Licensed Practical Nurse #1 | LPN | Observed oxygen flow rate discrepancy for Resident #65 and CPAP mask storage for Resident #1 |
| Licensed Practical Nurse #2 | LPN | Observed and corrected CPAP mask storage for Resident #1 |
| MDS Coordinator | Minimum Data Set Coordinator | Provided transfer/discharge notices and nutritional screening data |
| Dietary Employee #1 | Dietary Employee | Observed storing hot foods in refrigerator |
| Dietary Employee #2 | Dietary Employee | Interviewed about leftover food usage |
| Dietary Employee #3 | Dietary Employee | Interviewed about safe storage of leftover food |
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