Enterprise Health & Rehabilitation Center

Inspectors wroteBased on interviews, resident's medical records, review of Facility Reported Incidents (FRIs) received by the State Agency, the facility's investigative files, and facility policies titled Abuse, Neglect, and Exploitation, Social Media Use, Cell Phones, and Confidentiality Statement, the facility failed to protect the residents' right to be free from sexual abuse perpetrated by other residents, physical abuse perpetrated by other residents, and exploitation/mental abuse perpetrated staff. Specifically:1. On 02/11/2025 the facility failed to protect Resident Identifier (RI) #168's right to be free from sexual abuse. On 02/11/2025 around 7:30 PM, Certified Nursing Assistant (CNA) #13 was making rounds on the Memory Care Unit (MCU) and observed RI #168 sitting on RI #97's bed. CNA #13 observed RI #97 fondling RI # 168's genitalia with his/her hand in RI #168's brief. [...]

Inspectors wroteBased on interviews, resident's medical records, review of Facility Reported Incidents (FRIs) received by the State Agency, the facility's investigative files, and the facility policy titled Abuse, Neglect, and Exploitation, the facility failed to ensure its abuse policy was implemented to establish a safe environment and implement protocols for preventing, identifying, and investigating an allegation of sexual abuse on 02/11/2025. On 12/18/2024 Resident Identifier (RI) #97 began having documented episodes of sexually inappropriate behaviors towards staff. Progress notes in RI #97's medical record included seven entries of sexually inappropriate behaviors documented by six different staff members from 12/18/2024 until 02/11/2025. [...]

Inspectors wroteBased on record review, interview, the facility's policy titled Abuse, Neglect, and Exploitation, and the facility plan titled Quality Assurance and Performance Improvement (QAPI) Plan the facility failed to implement an effective QAPI program related to a resident-to-resident sexual abuse incident. Specifically, the facility's Quality Assurance Committee failed to review the incident to verify that a thorough investigation was conducted, failed to the incident as abuse, and failed to analyze contributing risk factors including residents wandering without supervision on a unit with a resident who had a documented history of sexually inappropriate behavior toward staff. [...]

Inspectors wroteBased on observations, interviews and facility policies titled, Date Marking and Food Safety, Kitchen Hood Inspection and Cleaning, and Automated Ware Washing Policy, the facility failed to ensure food items in dry storage and the freezer were labeled with use by dates; the vents in the stove hood were free of dust and grease; and plates and bowls were dried properly before being used to serve food to residents. These deficient practices created the potential for cross-contamination and/or foodborne illnesses. These deficient practices had the potential to affect 162 of 162 residents who received meals from the kitchen. Findings Include: 1) A review of a policy titled, Date Marking for Food Safety, with a Reviewed/Revised: dated of 10/2025, revealed. Policy The facility adheres to a date marking system to ensure the safety to. food items. Procedure and Compliance Guidelines for Staffing: [...]

Inspectors wroteBased on interview, review of the Online report submitted to State Agency and facility policy, titled Abuse, Neglect and Exploitation the facility failed to report an allegation of sexual abuse on 02/11/2025 to local law enforcement when Resident Identifier (RI) #97 was found with his/her hands in RI #168's brief. This affected two out of six residents sampled for abuse.

Inspectors wroteBased on observations, interviews, and a review of facility policies titled: STORAGE OF FOOD AND SUPPLIES, DRYING OF DISHES & UTENSILS, TEMPERATURE OF WALK-IN FREEZER, WALK-IN COOLER, AND ICE CREAM FREEZER and a TEMPERATURE LOG document, the facility failed to ensure: 1. meats in the freezer were labeled and sealed; 2. the temperatures of the freezer and cooler were recorded on the temperature log; and 3. utensils were not wet in utensil bags and in a silverware holder. This had the potential to affect 184 of 184 residents who received meals from the kitchen. Findings Include: 1) A review of a policy titled, STORAGE OF FOOD AND SUPPLIES with a last revised date of 2/16 revealed: . PROCEDURE . G. Cover all cooked foods with plastic wrap or other covering prior to storage to protect from dripping or contamination. H. All left overs are to be labeled with the contents and date. [...]

Inspectors wroteBased on observation, interviews, review of a lab report and review of a facility policy titled, PERINEAL CARE POLICY AND PROCEDURE, the facility failed to ensure the Certified Nursing Assistant (CNA) cleaned Resident Identifier (RI) #63 in a manner to assure the perineal area was thoroughly cleaned of bowel movement and in a manner to reduce the potential for urinary tract infection. This was observed on 11/3/19 and affected one of two residents observed for incontinent care. Findings Include: A review of a facility policy titled, PERINEAL CARE POLICY AND PROCEDURE with a revised date of 10/24/12 revealed Purpose: To maintain skin integrity, reduce opportunity for urinary tract infection, promote comfort. B. Performance of Perineal Care . 2. Continue procedure until perineal area thoroughly cleaned. A review of a lab report document for RI #63 revealed . [...]

Inspectors wroteBased on observations, interviews, review of residents meal tray cards and review of facility policies titled, Main Dining Room Protocol and Resident Meal Tray Preparation, the facility failed to ensure residents received foods that were listed on their tray cards matched foods received on their meal trays. This was observed on 11/3/19 lunch and supper meals and affected three of 15 residents whose trays cards were reviewed for meals. This deficient practice was cited as a result of the investigation of complaint # AL00036218, and affected (Resident Identifier) RI #128, RI #132 and RI #139. Findings Include: A review of a facility document titled, Main Dining Room Protocolwith a revised date of 7/25/13, revealed . 3. Nutrition Services will place all food and beverage on meal try, following tray cards and selective menus for accuracy. [...]

Inspectors wroteBased on observation, interviews and review of a facility policy titled, Proper Linen Handling, the facility failed to ensure the Certified Nursing Assistant (CNA) did not place soiled linen she removed from Resident Identifier (RI) #63's bed, during incontinent care on the floor beside the bed. This was observed on 11/3/19 and affected one of two residents observed for incontinent care. Findings Include: A review of a facility policy titled, Proper Linen Handling with a revised date of 10/2017 revealed Purpose: To provide guidelines for handling of resident's soiled linens. In resident rooms: . 3. Deposit soiled laundry/linens . sheets . under pads in clear plastic bag . RI #63 was admitted to the facility on [DATE] and readmitted on [DATE]. Per departmental notes RI #63 had a personal history of urinary tract infections. [...]

Inspectors wroteBased on observation, interview and review of the facility policy titled, FOOD TEMPERATURES, the facility failed to ensure the temperature of Brussels sprouts was taken prior to serving for lunch on 10/30/2018. This had the potential to effect 130 residents who received Brussels sprouts for the lunch meal. Finding Include: A review of the facility policy titled, FOOD TEMPURATURES, with a last revised date of 07/2014, revealed, . PROCEDURE .B. Temperature of foods must be taken from the stream table 10 minutes before the first tray assembly and must be recorded. The acceptable temperature of hot food is greater than 135 degrees Fahrenheit . [...]

Inspectors wroteBased on observation, interview, record review and review of a facility policy Maintaining/ Promoting Resident Dignity and Respect, the facility failed to ensure Resident Identifier (RI) #19 was not on the porch, in the facility halls and in the dining area with the suprapubic catheter, drain tubing and catheter drain bag visible to residents and visitors. This was observed on 10/30/18 and 10/31/18 and affected three unsampled residents who preferred the catheter tubing and bag not be exposed. Findings Include: A review of facility policy titled, Maintaining/ Promoting Resident Dignity and Respect with a revised date of 3/2017 revealed: Policy Statement . Residents are appropriately covered by clothing/covers to avoid inappropriate exposure . RI #19 was admitted to the facility 11/7/17 with a diagnosis of Retention of Urine. [...]

Inspectors wroteBased on observation, interview, record review and review of a facility policy titled, Resident Smoking, the facility failed to ensure a safe smoking assessment was completed for Resident Identifier (RI) #145 in a timely manner. Findings Include: A review of a facility policy titled, Resident Smoking, with a revised date of 7/2/18 revealed: .Policy: .6. All residents will be asked about tobacco use during the admission process, during each quarterly or comprehensive MDS (Minimum Data Set) assessment process. 7. Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment, . RI #145 was admitted to the facility 1/8/18 with a diagnosis of Nicotine dependence. A review of RI #145's care plan dated 1/15/18 revealed, .is a smoker . Reassess residents' safety with smoking as indicated. [...]