Ennis Care Center

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of eight residents (Resident # 32 and Resident #43) reviewed for ADL care. The facility failed to ensure Resident #32 and Resident #43's nails were cleaned on 05/18/2026. These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for three of seven residents (Resident # 5, Resident #47 and Resident #52) reviewed for activities. The facility failed to provide Resident #5, Resident #47 and Resident #52 in room activities three times per week, during the months of March 2026, April 2026 and May 2026. This failure could place residents at risk for boredom, depression, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. 1. The facility failed to ensure sanitation practices (cleaning the inside of the microwave, cleaning the mixer beater shaft, cleaning metal storage rack where clean sheet and muffin pans where stored and were free from food debris and food particles) 2. The facility failed to ensure all items were covered and stored properly. 4. The facility failed to label and date all food items in the kitchen. These failures could place residents at risk of foodborne illness and decreased quality of life.

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure the resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system for three of fifteen resident rooms on the 600 hall reviewed for working call lights. The facility failed to ensure Rooms 602 A, 603 A, 603 B, and 604 B had call lights that were functioning properly. These failures posed a risk for residents' care needs not being met, potential for falls and injuries or pain. [...]

Inspectors wroteBased on observation and interviews, the facility failed to ensure residents were treated with respect and dignity for one (Resident #47) of fifteen reviewed for respect and dignity. The facility failed to ensure Resident # 47's door was closed when she was being prepared for lift transfer exposing her lower body to the hallway. This failure could cause residents potential psychosocial harm and decreased self-worth. During an observation on 5/18/2026 at 9:20 am, CNA G and CNA H were in Resident #47's room with a mechanical lift preparing to transfer resident from her bed. Resident was lying uncovered in her bed, in a dress with her feet toward the doorway and hall. Resident #47's lower body from her upper legs to her feet were bare and visible from the hallway. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for two of six residents (Resident # 4 and Resident # 47) reviewed for care plans. The facility failed to develop a comprehensive care plan to reflect Resident #4's diagnosis and triggers of PTSD (Post Traumatic Stress Disorder). The facility failed to develop a comprehensive care plan to reflect Resident #47's activity preferences of receiving in-room activities. These failures could place residents at risk of not receiving appropriate interventions to meet their psychosocial and medical needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for two of seven residents (Resident #5 and Resident #52) reviewed for care plans. The facility failed to update the comprehensive care plan to reflect Resident #5 and Resident #52 received in room activity programs. This failure could place residents at risk for not having their needs identified and met.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure the resident environment remained as free of accident hazards as is possible for one of two housekeeping carts (Housekeeping Cart #1) reviewed for hazards. The facility failed to ensure Housekeeping Cart #1, with chemicals inside the compartments, was locked when unsupervised. This failure could place residents at risk for injuries, illness, and hospitalization.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 2 of 4 residents (Resident #4 and Resident #47) reviewed for trauma-informed care. The facility failed to ensure Resident #4 and Resident #47 had a trauma screening that identified possible triggers when Resident #4 and Resident #47 had a history of trauma. This failure could place residents at an increased risk for severe psychological distress due to re-traumatization.

Inspectors wroteBased on interview, and records review, the facility failed to determine that drug records were in order and that an account of all controlled drugs is maintained and periodically reconciled for one of two medication rooms (medication room [ROOM NUMBER]) reviewed for pharmacy services. The facility failed to ensure that LPN B and LPN C completed a narcotic count for Medication room [ROOM NUMBER] refrigerator on 5/12/2026, which lead to the facility not accounting for all narcotic medications. This failure had the potential for drug diversions and medication unavailability for the therapeutic care for residents. [...]

Inspectors wroteBased on observation and interview, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, for one of two medication rooms (medication room [ROOM NUMBER]) and one of six medication carts (medication cart #1) reviewed for storage of biologicals. The facility failed to ensure LPN C returned a liquid narcotic medication to the locked refrigerator box in Medication room [ROOM NUMBER] on 5/12/2026The facility failed to ensure Medication Cart # 1 was not left unlocked and unattended by LVN D on the 600 hall on 5/18/2026 These failures have the potential for missing medications, drug diversions and medication unavailability for the therapeutic care for residents. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents remained free from accidents, hazards and each resident received adequate supervision and assistance when being transferred for 1(resident #1) of 5 residents reviewed for accidents and hazards. The facility failed to ensure a safe transfer with a mechanical/Hoyer lift to assist in the transfer of Resident #1 on 11/7/2025 when CNA A did not follow the protocol of having two staff to operate the Hoyer lift resulting in Resident #1 falling and sustaining a fractured right humerus (upper arm) and a closed head injury. This failure could result in serious injuries to residents and potentially death. The noncompliance was identified as PNC. The facility was provided with the IJ template on 11/18/2025. The facility had corrected the non compliance before the survey began.

Inspectors wroteBased on record review and interviews the facility failed to ensure that two (2) residents (Resident #1 and Resident #2) of six residents reviewed for transfer or discharge had the required documentation in the resident's medical record made by the physician for a safe and effective transition of care. The facility discharged Resident #1 on 3/20/2025 and Resident #2 on 3/19/2025 without physician documentation in the EMR. This failure could put residents at risk for inappropriate discharge from the facility and cause psychological harm due to feelings of anger and sadness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide maintenance services necessary to maintain a safe, sanitary, orderly, and comfortable interior of three (Residents #32, #37, #48) of five residents reviewed for safe, clean, homelike environment. 1. The facility failed to ensure the ceiling A/C vent for Resident #32's room was clean and not dusty on 03/11/25. The facility failed to ensure the leaking pipe underneath Resident #32's sink was repaired on 03/11/25 instead of the resident using a trash can to catch the water. The facility failed to ensure that the dark gray container underneath Resident #32's sink was empty on 03/11/25 that was full of water from a leaking pipe. 2. The facility failed to ensure Resident #37's fluorescent lights had a cover, exposing metal fixtures and 2 light bulbs on 03/11/2025 that was located over his bed. 3. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen safety. 1. The facility failed to ensure food in the facility's dry storage, refrigerator, and freezer areas were labeled and dated according to guidelines on 3/11/2025. 2. The facility failed to seal open items in plastic bags in the dry storage pantry, refrigerator, and freezer areas on 3/11/2025. 3. The facility failed to ensure that expired items in the dry storage pantry, refrigerator and freezer areas were removed on 3/11/2025. These deficient practices could affect residents who received meals and/or snacks from the main kitchen and place them at risk for cross contamination and other air-borne illnesses. Findings Included: [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure that residents were free from abuse for one (Resident #29) of three residents reviewed for abuse and neglect. The facility failed to protect Resident #29 from abuse on 01/05/2025 when CNA E was witnessed calling Resident #29 an asshole. The noncompliance was identified as Past non-compliance. The noncompliance began on 1/5/25 and ended on 1/7/25. The failure placed residents at risk for abuse, neglect, and emotional and psychological harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure individuals with mental disorders were evaluated and received care and services in the most integrated setting appropriate to their needs for 1 of 3 residents (Resident #29) reviewed for Preadmission Screening and Resident Review Level I screenings. The facility failed to ensure Resident #29's Preadmission Screening and Resident Review Level One screening completed 07/02/24 and 02/11/25 on accurately reflected his diagnosis of mental illness. There was no evidence that Resident #29 was referred to a Level Two Preadmission Screening and Resident Review Screening. This failure could affect residents by placing them at risk for not receiving needed treatments and services.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #11) of 3 residents reviewed for care plans. The facility failed to develop interventions to address the goal on Resident #11's care plan to maintain nephrostomy tube care through the next review date. This failure could affect the facility's residents who were occasionally or frequently incontinent of bladder and/or with catheter or nephrostomy tube placement by placing them at risk of not receiving the necessary care and services to meet their needs.

Inspectors wroteBased on observation and interview, and record review, the facility failed to ensure a medication error rate less than 5 percent. There were 9 errors out of 25 opportunities which resulted in a 36% percent medication error rate for 1 (Resident #28) of 4 residents reviewed for medication errors. On 3/12/25, RN C administered 9 individual medications via Gtube (surgically placed tube used to administer nutrition, fluids, and medications) to Resident #28 by pushing the medications through a syringe without an order rather than by gravity as noted in their policy. This failure placed the resident at risk of Gtube complications, aspiration pneumonia, and not receiving the therapeutic effects of medications.

Inspectors wroteBased on interview and record review, the facility failed to notify a representative of the Office of the State Long-Term Care Ombudsman, for 1 of 1 resident (Resident #1) reviewed for discharge. The facility initiated a 30-day discharge for Resident #1 on 12/10/2024 and did not notify the State Long-Term Care Ombudsman by phone or in writing. This failure could place residents at risk of improper discharge planning and diminished quality of life.

Inspectors wroteBased on record review and interviews, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for one (1) of one resident reviewed for transfer and discharge rights. (Resident #1) The facility failed to make arrangements for a safe discharge for Resident #1. This failure could place residents at risk for not receiving care and services to meet their needs upon discharge.

Inspectors wroteBased on interviews and record review the facility failed to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #1) reviewed for comprehensive care plans. The facility failed to ensure Resident #1's comprehensive care reflected Resident #1's resolved at risk for elopement goal of the date initiated, revised, and target. Resident # 1's goal was left blank on the comprehensive care plan. This deficient practice could place residents at risk for not reaching their goals due to inaccurate care plans.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for three of three residents (Residents #23, #34, #41, #61, #65, #66 and #179) reviewed for supervision. The resident environment did not remain free of accident hazards in addition to the supervision failure because the courtyard contained mud-filled trenches approximately 40 feet long and 3-4 feet deep, mounds of dirt and debris that contained rocks and sharp shards of plastic piping, there were no fencing or warning signs around the affected construction areas. The courtyard also contained a laundry facility that was unlocked, with the door observed to be frequently open and lacking a self-closing mechanism. [...]

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 17 of 31 days reviewed for RN coverage. The facility failed to ensure they had an RN on duty on. 10/01/23 (SA); 10/02/23 (SU); 10/09/23 (SU); 10/22/23 (SA); 10/23/23 (SU); 10/29/23 (SA); 10/30/23 (SU); 11/05/23 (SA); 11/12/23 (SA); 11/13/23 (SU); 11/20/23 (SU); 11/26/23 (SA); 11/27/23 (SU); 12/18/23 (SU); 12/24/23 (SA); 12/25/23 (SU); 12/31/23 (SA) This failure placed residents at risk of missed nursing assessments, interventions, care, and treatment.

Inspectors wroteBased on observation, interviews and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. The facility failed to ensure the ice machine's filter was free from dust. The facility failed to ensure expired foods were discarded. The facility failed to discard items stored in the dry storage that were not properly labeled or past the best used by, consume by or expiration dates. The facility failed to ensure food preparation area was free from splash, dust, and other airborne contaminants. This failure could place all residents who receive food prepared in the facility's only kitchen at an increased risk of exposure to food-borne illnesses.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 3 (Residents #3, #5, and #6) of 6 residents reviewed for infection control in that: 1. LVN A failed to disinfect her hands between glove changes while providing wound care for Resident #64. 2. CNA B failed to change their soiled gloves and wash hands during incontinent care for Resident #3. 3. MA C failed to disinfect her hands while servicing food trays to the residents on Hall 200. 4. LVN H and LPN I failed to disinfect hands between assistance with feedings in the Dining Hall. These failures could place residents at-risk of cross contamination which could result in infections or illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for one (Hall 600) of three halls observed for environment, in that: The facility failed to ensure rooms, activity room, and shared bathrooms on Hall 600, were clean, safe, and in good repair for Rooms 615, 614, 613, 611, 612, 610, 608, 607, 605, 604, 606, and 609. These failures could place residents at risk for diminished quality of life due to the lack of a well-kept environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for three (Halls 100, 200, 600, nurse's station, and the main dining rooms), of three halls reviewed for pest control program. The facility had live water bugs (tree roaches) and gnats in areas of the facility including the nurse's station, Halls 100, 200, and 600, and the dining room. This failure could place residents at risk for spread of infection, cross-contamination, and decreased quality of life. Findings Include: Observation and interview 01/29/24 at 11:00 a.m., revealed 1-3 live gnats flying in the television room on Hall 600, the secured unit. There were six residents in the television room and one staff member. The residents did not seem to notice the gnats, but the CNA was swatting at the gnats. [...]