Encore Healthcare and Rehabi of Malvern

Inspectors wroteBased 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.

Inspectors wroteBased on interview and facility document review, the facility failed to ensure staff initiated and completed provider orders for one (Resident #6) of two residents reviewed for implementation of psychiatric consult orders.

Inspectors wroteBased 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. Diagnoses included: diabetes mellitus (DM), chronic kidney disease, cerebrovascular accident (CVA), cognitive communication deficit, delirium, and obstructive and reflux uropathy. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure a physician's order for a fall mat was implemented as evidenced by a resident sustaining small collections of blood between the brain and outer covering in the front areas of the brain (bifrontal subdural hematomas) after a fall for 1 (Resident #5) of 3 (Residents #5, #6 and #7) sampled residents reviewed for falls.

Inspectors wroteBased on record review and interview, the facility failed to ensure a care plan was revised to include an intervention for a fall mat for a resident who had a fall which resulted in the resident sustaining injuries of small collections of blood between the brain and outer covering in the front areas of the brain (bifrontal subdural hematomas) for 1 (Resident #5) of 3 (Residents #5, #6 and #7) sampled residents whose care plans were reviewed for falls.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to ensure that nutritionally balanced meals were provided for the residents for 2 of 2 meals observed.

Inspectors wroteBased on observation, record review, and interview, the facility 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 #45) resident reviewed for accidents and injuries.

Inspectors wroteBased on observation, record review, interview, and facility policy review, it was determined that the facility nursing staff failed to label an anti-anxiety medication stored in the refrigerated narcotic box in the 300-hall medication room with the open and use by date to prevent expired medication from being administered to residents beyond the recommended use by date.

Inspectors wroteBased 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

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure potentially hazardous chemicals were stored in a secure location to prevent the potential access to hazardous items for residents who were independently mobile and cognitively impaired; failed to ensure interventions were in place to prevent further falls; and failed to ensure sharps containers were changed when reaching the full line to prevent possible needle sticks and/or removal of used sharps from the sharp's container. These failed practices had the potential to affect 42 residents who ambulated independently or propelled independently, as documented on a list provided by the Administrator on 11/08/23 at 05:07 PM.

Inspectors wroteSurveyor: [NAME], [NAME] Based on observation of medication pass and clinical record review, the facility failed to ensure physician orders were followed to maintain a medication error rate of less than 5%, to prevent potential complications for 2 (Residents #15 and #66) of 2 residents observed during the medication pass. The medication error rate was 9.68%, based on observation of 31 medications administered, plus 1 medication ordered but not administered when timed on the Medication Administration Record (MAR) for a total of 3 errors detected.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure meals were served in a method that maintained the appearance of cold products and at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. This failed practice had the potential to affect 15 residents who received meal trays in their rooms on the 100 Hall, 32 residents who received meal trays on the 200 Hall, 18 residents who received meal trays in their room on the 300/400 Halls, and 16 residents who received meal trays in their room on the Retreat Hall, as documented on a list provided by the Dietary Supervisor on 11/07/2023 at 11:56 AM.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a multi-resident use glucometer was properly disinfected between use to prevent potential spread of infection for 3 (Residents #51, #56 and #17) sampled residents who had physician orders for capillary blood glucose (CBG) monitoring from hall 200/300 medication cart, as documented on a list provided by the Administrator on 11/8/2023 at 4:29 PM.

Inspectors wroteBased on record review and interview, the facility failed to ensure bowel movements were occurring to prevent possible complications for 1 (Resident #18) of 1 sampled resident who required assistance with bowel elimination. The failed practice had the potential to affect 2 residents according to a list provided by the Administer on 11/9/23 at 1:45 PM.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure an indwelling catheter tubing was maintained in a fashion to prevent complications of infection for 1 (Resident #8) of 3 (Residents #8, #14, #33) sampled residents who had an indwelling catheter.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a percutaneous endoscopic gastrostomy (PEG) tube was flushed and or auscultated prior to the administration of nutritional supplements for 1 (Resident #18) of 4 (Residents #18, #27, #58, and #63) case mix residents who had enteral feeding tubes. This failed practice had the potential to affect 5 residents who had enteral feeding tubes, as documented on a list of residents provided by the Administrator on 11/08/23 at 5:07 PM.

Inspectors wroteBased on observation, interview and record review, the facility failed to post a precautionary oxygen sign outside the door indicating the use of oxygen for 1 (Resident #21) of 13 sampled residents. This had the potential to affect 22 residents receiving oxygen therapy.

Inspectors wroteBased on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 5 residents who received pureed diets as documented on the Diet List provided by the Food Service Supervisor on 10/26/23.