Encore Healthcare And Rehabi Of Malvern

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

49.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 111 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 78.6% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 56 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.35 therapist hours per resident per day in 2026Q1 — more than 59% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 34% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 108 beds and averages 84.1 residents a day — about 78% occupied, or roughly 24 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.64 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.35 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.18 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.02 hrs/resident/day on weekends vs 3.89 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 0.41 to 0.19 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 49% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

19 citations, most serious first. The 10 most serious are shown; the remaining 9 are one tap away and print in full.

• Potential for harm · E2025-11-18 · tag F0609 — failed to report abuse allegations — pattern
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  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. The report indicated, [Resident #1] told [an LPN] that [Resident #1's] roommate had threatened [Resident #1]. Review of Resident #1's admission Record indicated the facility admitted Resident #1 with diagnoses which included cognitive communication deficit and recurrent depressive disorder. Review of Resident #1's significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD)…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-11-18 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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. The findings include:Review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/04/2025, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of three, which indicated severe cognitive impairment. The MDS also indicated Resident #6 had diagnoses that included a disorder affecting memory and thinking, anxiety disorder, and depression. A review of Resident #6's Progress Notes indicated the following: On 05/05/2025 at 11:13 AM, an Advanced Practice Registered Nurse's (APRN) note indicated the APRN referred Resident #6 to the Psych team after an incident where Resident #6 initiated physical aggression toward another resident, and Resident #6 had increased confusion and hallucinations. On 05/09/2025 at 2:26 PM, a Nurses Note indicated the resident was referred to Mental health. On 05/09/2025, a Nurses Note titled…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-03-07 · tag F0600 — failed to protect residents from abuse and neglect — pattern
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  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. Diagnoses included: diabetes mellitus (DM), chronic kidney disease, cerebrovascular accident (CVA), cognitive communication deficit, delirium, and obstructive and reflux uropathy. Resident #1 had an indwelling urinary catheter. a. Review of an Incident and Accident (I & A) Information Report, revealed the findings and actions taken documented: On 10/30/2024, the Assistant Director of Nursing…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-03-07 · tag F0684 — failed to provide proper treatment and quality of care — pattern
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings are: Review of a 7734 Incident and Accident Information form with a status date of 01/24/2025, revealed the prior Director of Nursing was reviewing Resident #5's medical records from a fall with a hospital encounter on 01/15/2025. A computer tomography (CT) scan showed small collections of blood between the brain and its outer covering in the front areas of the brain (bifrontal subdural hematomas). The left hematoma was 5.5 millimeters (mm) in maximum diameter (measurement from one side to the next) and the right hematoma was 2.5 mm in maximum diameter. Review of Resident #5's medical diagnosis screen revealed diagnoses…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-03-07 · tag F0657 — failed to keep the care plan current — isolated
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings are: Review of Resident #5's medical diagnosis screen revealed diagnoses of hemiparesis (partial muscle weakness on one side of the body) and hemiplegia (total paralysis on one side of the body), dementia (a decline in a person's mental thinking affecting daily life), fracture (break) of unspecified (not clear) part of neck or right femur (part of the thigh bone), and unspecified fracture of sacrum (break in the bone between the two hip bones). Review of the Order Summary Report revealed an order dated 12/14/2024 for a fall mat to the right (R) side of…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2024-11-21 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  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 11/18/24 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. On 11/18/24 at 9:15 AM, the following observations were made on a shelf in the walk-in freezer. a. An opened box of biscuits. The box was not covered or sealed. b. An opened box of chicken fried steak. The box was not covered or sealed. 3. On 11/18/24 at 9:19 AM, the following observations were made on a shelf in the storage room. a. One container of ground cloves with an expiration…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-11-21 · tag F0803 — failed to meet residents' dietary needs — pattern
  Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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. The findings are. 1. On 11/18//2024, the menu for noon meal indicated residents on pureed diets were to receive a #6 scoop (2/3 cup) of pureed chicken and dumpling and a #8 scoop (1/2 cup) of pureed cornbread. On 11/18/24 at 12:48 PM, the following observations were made during the noon meal service. a. Dietary Aide (DA) #1 used a #16 scoop (1/4 cup) to serve a single portion of pureed cornbread to the residents on pureed diets, instead of a #8 scoop (1/2 cup). On 11/19/24 at 8:45 AM, DA #1 when asked during an interview what spoon size she had used when serving pureed cornbread to the residents who required pureed diets. DA #1 stated she used the blue scoop (#16) which was equivalent to 1/4 cup to give a single serving to each resident. When asked if she looked at the menu DA #1 confirmed she did not. The kitchen staff always use…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-11-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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. Findings include: 1. A review of Medical Diagnoses revealed Resident #45 with diagnoses of Parkinson's, type II diabetes, and Alzheimer's. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/23/2024, indicated a Brief Interview for Mental Status (BIMS) score of 03 (0-7 suggest cognitively impaired). Resident #45 required total care for bathing, dressing, and personal care. a. A review of Resident #45's Care Plan, dated 07/31/2024, revealed Resident #45 was dependent on 2 or more helpers doing all the effort for toileting and transfers using a mechanical lift with a green lift pad. b. Review of the mechanical lift instruction manual page 2 indicated not to lock the casters during lifting. c. On 11/18/2024 at 11:28 AM, Certified Nursing Assistant (CNA) #5 and CNA…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-11-21 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings include: a. A review of an in-service titled, Narcotic Expiration, dated [DATE], revealed staff are to be mindful of the expiration dates on narcotics by dating bottles when opened, and lorazepam will expire 60 days from the date opened. Review of a policy titled, Medication Storage in the Facility, revised [DATE], revealed to ensure medication potency and purity, certain medications require an expiration date that is shorter than the manufacturers expiration date. The pharmacy will carry a beyond use date that is determined by regulations and the law. Multi dose packaging will have a beyond use date of 60 days. Medications should…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2023-11-09 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  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. On 11/06/23 at 12:33 PM, Dietary Employee (DE) #1 took a paper plate in the storage room. Without washing her hands, she picked up a clean blade from the clean side of the dish washing machine and placed it on a clean rack to air dry to be used in pureeing food items to be served to the residents for supper meal. 2. On 11/06/23 at 01:00…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to SOUTHERN ADMINISTRATIVE SERVICES — 35 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported $6.4M paid to related parties — landlords or management companies under common ownership — equal to about 71% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in AR