Inspection Reports for
Ennis Care Center

The complaint investigation found that on 11/7/2025, CNA A did not follow protocol requiring two staff to operate the Hoyer lift, causing Resident #1 to fall and sustain a fractured right humerus and closed head injury. CNA A was removed from the facility and placed on a do not return list. The facility conducted in-services and competency checks for staff following the incident.

The facility failed to ensure adequate supervision and safe transfer protocols were followed, leading to Resident #1 falling from a Hoyer lift operated by a single staff member instead of two, resulting in a fractured right humerus and a closed head injury. The facility corrected the noncompliance before the survey began and implemented staff in-services and competency check-offs for mechanical lift use.

The visit was complaint-related, triggered by a resident-to-resident incident on 3/18/2025 involving Resident #1 and Resident #2. Both residents were discharged due to life-threatening aggressive behaviors affecting the safety of others. Family members expressed concerns about the discharges and lack of awareness of the appeal process. The physician acknowledged failure to document the discharges timely in the EMR.

The facility failed to ensure that two residents discharged due to aggressive behaviors had the required physician documentation in their medical records at the time of discharge. The discharges were issued following a resident-to-resident incident, but the physician did not timely document the reason for discharge in the EMR, which could put residents at risk for inappropriate discharge and psychological harm.

The complaint investigation was substantiated. The incident involved CNA E verbally abusing Resident #29 on 01/05/2025 by calling him an asshole. The resident was cognitively impaired and had behavioral health diagnoses. The facility conducted interviews, Safe Surveys, and staff training. CNA E was suspended, completed abuse prevention training, and received a final written warning before returning to work.

The facility failed to protect Resident #29 from verbal abuse when CNA E called the resident an inappropriate name during a heated incident. The investigation confirmed the allegation, and corrective actions including suspension, training, and disciplinary measures were taken. Resident #29 showed no lasting harm and reported feeling safe at the facility.

The facility was found deficient in maintaining a safe, clean, and homelike environment, protecting residents from abuse, ensuring accurate PASARR screening, developing comprehensive care plans, maintaining medication error rates below 5%, and following food safety standards. Specific issues included unclean A/C vents, unrepaired leaking pipes, missing light covers, holes in bathroom walls, verbal abuse by staff, inaccurate mental health screening, incomplete care plans for nephrostomy tube care, improper medication administration via G-tube, and improper food storage and labeling.

The complaint investigation revealed that Resident #1 was discharged to the hospital on 12/10/2024 without proper notification to the Ombudsman or the resident's representative. The facility issued a 30-day discharge notice on the same day as the discharge, which did not allow for safe and orderly discharge planning. Interviews with staff confirmed lack of notification and improper discharge procedures.

The facility failed to notify the Ombudsman and resident representative timely about the discharge of Resident #1, did not provide sufficient preparation and orientation for a safe discharge, and failed to maintain an accurate comprehensive care plan reflecting resolved goals for the resident. These failures could place residents at risk of improper discharge planning, diminished quality of life, and unmet care needs.

The visit was complaint-related due to concerns about resident safety, supervision failures, environmental hazards, infection control breaches, staffing shortages, food safety issues, and pest infestations. Immediate jeopardy was identified related to supervision and environmental hazards.

The facility was found to have immediate jeopardy related to inadequate supervision of residents at risk of elopement, unsafe environmental conditions including unsecured construction areas, improperly maintained wheelchairs, infection control lapses, insufficient RN coverage, food safety violations, unsanitary and unsafe living environments, and ineffective pest control. Corrective actions were initiated during the survey.

The complaint investigation revealed Resident #1 missed chemotherapy medication for 17 days (07/07/23 to 07/23/23) after medication was delivered to the facility. The error was discovered when the family member called to check medication supply. Immediate Jeopardy was identified on 08/09/23 and removed on 08/11/23 after corrective actions.

The facility failed to provide pharmaceutical services ensuring accurate medication administration for Resident #1, resulting in a 17-day delay in chemotherapy medication. The facility lacked a system to track and follow up on medications brought in from outside pharmacies or families. Immediate Jeopardy was identified but later removed after corrective actions and staff education.

The facility failed to ensure that drugs and biologicals were properly labeled and stored, with several expired medications found in medication rooms and carts. Additionally, the kitchen failed to properly label, date, and store food and beverage items, including staff personal items mixed with residents' food, posing risks of medication errors and food-borne illness.