Encore Healthcare Malvern: Care Quality Cited - AR
The resident, identified only as Resident #6 in federal inspection records, had a cognitive assessment score of three out of 15 — indicating severe impairment. Medical records showed diagnoses including memory and thinking disorders, anxiety, and depression.
The problems began escalating in early May. On May 5, an Advanced Practice Registered Nurse referred the resident to the psychiatric team after the resident "initiated physical aggression toward another resident" and showed "increased confusion and hallucinations."
Four days later, nursing staff documented that the resident experienced "increased paranoia and confusion at night and on weekends." They noted the resident needed both dementia care and mental health consultation as a new patient.
The consultation never happened.
Federal inspectors found no evidence that mental health or psychiatric team consultations were ever completed for Resident #6, despite clear documentation of the referrals and the resident's deteriorating condition.
During the November inspection, the Advanced Practice Registered Nurse explained the facility's standard process: making rounds, entering orders electronically, then providing handwritten lists to Licensed Practical Nurses about new orders.
The nurse said she first needed to rule out physical causes for the resident's behavioral changes by ordering a urinalysis. When that test came back negative on May 12, she entered a new order for behavioral health consultation.
The nurse provided inspectors with a scanned copy of her handwritten note from May 12, which clearly listed the new order for Resident #6 to be referred to behavioral health consultants for "dementia and hallucinations."
But the order disappeared into the facility's system.
When inspectors interviewed the Director of Nursing on November 18, she admitted the facility could not produce the behavioral health consultation order for Resident #6. She confirmed "the order for the behavioral health consultation was not followed."
The facility's own job description for Licensed Practical Nurse supervisors specifically states they are responsible for making "requisitions and arrangements for therapeutic services per physician orders."
Six months passed between the initial psychiatric referral and the federal inspection. During that time, Resident #6 continued living with untreated psychiatric symptoms that had already led to physical aggression against other residents.
The inspection report provides no indication that alternative mental health interventions were attempted or that the resident's psychiatric symptoms improved without professional consultation.
Federal inspectors classified the violation as causing "minimal harm or potential for actual harm," but noted it affected the facility's ability to provide appropriate treatment according to medical orders and resident needs.
The case illustrates a breakdown in the facility's order-tracking system. Medical staff identified a clear need for psychiatric intervention, documented it properly, and entered the order into the system. Yet somehow between the electronic order entry and actual service delivery, the consultation request vanished.
Encore Healthcare and Rehabilitation of Malvern operates under regulations requiring facilities to ensure all physician orders are implemented promptly and completely. The facility's failure to track and complete the behavioral health referral violated these federal care standards.
For Resident #6, the consequences extended beyond missed appointments. The resident's documented symptoms — physical aggression, paranoia, confusion, and hallucinations — went without specialized psychiatric evaluation or treatment recommendations that might have improved quality of life and safety for both the resident and others in the facility.
The inspection occurred following a complaint, though the report does not specify whether the missed psychiatric consultation was the subject of that complaint or discovered during the investigation of other concerns.
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 violations during a health inspection on November 18, 2025.
Medical records showed diagnoses including memory and thinking disorders, anxiety, and depression.
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.