Encore Healthcare and Rehabi of Malvern

In the surveyor’s words

From the most serious findings on record at Encore Healthcare and Rehabi of Malvern, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Nov 21, 2024

  Based on observation, interview, record review, and facility policy review, the facility failed to ensure dietary staff thoroughly washed their hands and changed gloves when contaminated and before handling food and clean equipment when contaminated; food items stored in the refrigerator, freezer and dry storage area were covered, sealed or dated; expired food items and spices were promptly removed/discarded on or before the expiration or use by date, and hot food items were maintained at 135 degrees Fahrenheit or above for 2 of 2 meals observed. The findings are: 1. On [DATE] at 8:59 AM, an opened box of sausage was observed on a shelf in the walk-in refrigerator. The box was not covered or sealed. 2. […]

• No harm, potential for more than minimal, widespreadF812Nov 9, 2023

  Based on observation and interview, the facility failed to ensure foods stored in the freezer were covered to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; ensure dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen, and failed to ensure 1 of 2 ice scoop holders was maintained in clean and sanitary condition to prevent contamination of airborne particles. These failed practices had the potential to affect 83 residents who received meals from the kitchen, (total census: 83) as documented on a list provided by the Dietary Supervisor on 11/07 /2023 at 11:56 AM The findings are: 1. […]

• No harm, potential for more than minimal, widespreadF812Jun 11, 2021

  Based on observation and interview, the facility failed to ensure food items stored in the refrigerators and freezer were dated, labeled and discarded before spoilage, and one of two ice machines was maintained in clean condition to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen and food stored in the 400-hall nourishment room refrigerator. These failed practices had the potential to affect 71 residents who received meals and ice, and 8 residents who received puree meals from the kitchen (total census: 73), as documented on a list provided by Dietary Employee #1 on [DATE]. The findings are: 1. On [DATE] at 10:16 a.m., the following observations were made in the beverage area outside the kitchen door, near the activity room: a. […]

• No harm, potential for more than minimal, patternF609Nov 18, 2025

  Based on interview and record review, the facility failed to report allegations of abuse within the required 2-hour time frame for three (Resident #1, #3, and #4) of four residents involved in incidents reported to the state agency. The findings include: Incident #1 Review of an Incident and Accident (I&A) Report of alleged abuse that was discovered by the facility on March 10th, 2025, at 11:30 AM, was not submitted to the state agency until March 10th, 2025, at 3:56 PM. The incident involved Resident #1 and Resident #7. The alleged incident included Resident #7 threatening Resident #1 due to Resident #1 playing their television too loud and keeping their light on, which agitated Resident #7. […]

• No harm, potential for more than minimal, patternF600Mar 7, 2025

  Based on document review, record review, interviews, and facility policy review, the facility failed to ensure a resident was free from resident-to-resident abuse for 1 (Resident #1) of 4 residents reviewed for abuse. Specifically, Resident #2 verbally abused Resident #1 by commenting I am going to kill [pronoun] (Resident #2) on 10/30/2024. Resident #2 was not moved to another room until 11/01/2024 after a second verbal abuse, that resulted in physical abuse. 1. Resident #1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 01/31/2025 documented a Brief Interview for Mental Status (BIMS) score of 08, which identified the resident as having moderate cognitive impairment. […]