Encore Healthcare Malvern: Abuse Reporting Failures - AR
Resident #6 scored three on a cognitive assessment in September, indicating severe impairment. The resident carried diagnoses for memory and thinking disorders, anxiety, and depression.
The problems started surfacing in early May. On May 5, an Advanced Practice Registered Nurse referred Resident #6 to the psychiatric team after the resident physically attacked another resident. The nurse noted increased confusion and hallucinations.
Four days later, another nurse documented the referral to mental health services. The same day, a dementia and mental health consultation was ordered as staff observed increased paranoia and confusion during nights and weekends.
Nobody followed through.
The nurse practitioner told state inspectors on November 18 that new orders followed a specific process: making rounds, entering orders electronically, then providing handwritten lists to licensed practical nurses. Before placing the behavioral health referral, she wanted to rule out physical causes for the behavior change through a urinalysis.
When the urine test came back negative on May 12, she entered a new order for behavioral health consultation. Her handwritten note from that date, provided to inspectors, clearly listed the new order for Resident #6 to be referred to behavioral health consultants for dementia and hallucinations.
The order sat untouched for six months.
During the November inspection, the Director of Nursing admitted the facility could not provide the behavioral health consultation order and acknowledged it was never followed. State inspectors found no evidence the mental health or psychiatric team consultation ever occurred.
The facility's own job description for Licensed Practical Nurse supervisors states they must make requisitions and arrangements for therapeutic services per physician orders. Despite this clear responsibility, the May 12 order for Resident #6 fell through the cracks.
Resident #6's condition had deteriorated significantly by the time of the original referral. The May 5 incident involved physical aggression toward another resident, a concerning escalation for someone already struggling with cognitive impairment. Staff documented increasing paranoia and confusion, particularly during nights and weekends when fewer personnel were available.
The Advanced Practice Registered Nurse had followed proper protocol by first ruling out medical causes through urinalysis before pursuing psychiatric consultation. When that test returned normal results, the path was clear for mental health evaluation.
Yet the system failed at the most basic level. The handwritten order existed. The electronic order was entered. The Licensed Practical Nurse supervisor had explicit job duties to arrange such consultations.
Six months passed with no action.
Mental health consultations for nursing home residents with severe cognitive impairment serve critical functions. They can identify medication adjustments to reduce agitation, recommend behavioral interventions to manage confusion, and provide strategies for staff to handle episodes of paranoia or hallucinations.
For Resident #6, those potential benefits remained unrealized from May through November. The resident continued experiencing symptoms that prompted the original referral: physical aggression, increased confusion, and hallucinations that disrupted daily care.
The inspection revealed a breakdown in the facility's order-following process. While the nurse practitioner properly assessed the resident's needs and wrote appropriate orders, the implementation system failed completely.
Resident #6 represents what inspectors classified as "few" residents affected by this violation. But for someone already struggling with severe cognitive impairment, anxiety, and depression, six months without ordered psychiatric consultation represents a significant gap in care.
The facility received a citation for failing to provide appropriate treatment according to provider orders. State inspectors found minimal harm or potential for actual harm, but the violation highlights how administrative failures can leave vulnerable residents without needed mental health services.
Resident #6's case illustrates the consequences when nursing homes fail to follow through on psychiatric orders for residents experiencing behavioral changes and cognitive decline.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Encore Healthcare and Rehabi of Malvern from 2025-11-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
ENCORE HEALTHCARE AND REHABI OF MALVERN in MALVERN, AR was cited for abuse-related violations during a health inspection on November 18, 2025.
Resident #6 scored three on a cognitive assessment in September, indicating severe impairment.
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.