Inspection visit

Health inspectionFebruary 1, 2024

Ennis Care CenterCMS #4554866 citations on this visit

6 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 6 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. The laundry facility contained numerous laundry chemicals that could cause serious injury if placed on exposed skin, eyes or ingested. 1. The facility failed to ensure Resident #23, and Resident #34 were adequately supervised to prevent them from leaving the secured unit unsupervised. Residents #23 and #34 had moderate/severe cognitive impairment, wandering behavior, and lacked safety awareness. On 01/29/24 at or around 3:30 PM, Residents #23 and #34 gained access to a courtyard that was currently under construction, leaving the secure unit unsupervised. 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. The laundry facility contained numerous laundry chemicals that could cause serious injury if placed on exposed skin, eyes or ingested. 2. The facility failed to ensure Resident #179 was adequately supervised to prevent him from leaving the secured unit unsupervised. Resident #179 had severe cognitive impairment, wandering behavior, and lacked safety awareness. On 01/14/24 at or around 3:30 PM and on 01/15/24 at or around 10:25 PM, Resident #179 gained access to a courtyard under construction, leaving the secure unit unsupervised. 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. The laundry facility contained numerous laundry chemicals that could cause serious injury if placed on exposed skin, eyes or ingested. 3. The facility failed to ensure that doors on the secure unit with magnetic locking mechanisms were functioning properly allowing secure unit residents unsupervised access to a courtyard that was under construction for several weeks. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 22 Event ID: 455486 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ennis Care Center 1200 S Hall St Ennis, TX 75119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety An IJ was identified on 01/30/24. The IJ template was provided to the facility on [DATE] at 2:07 PM. While the IJ was removed on 02/01/24 at 4:00 PM, the facility remained out of compliance at a scope of a pattern with no actual harm with a potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems, and lack of safety precautions for an adjoining courtyard under a current state of construction. Residents Affected - Some 4.The facility failed to properly maintain wheelchairs for Residents #41, #61, #65, and #66. These failures could place residents at risk for injury and/or death from eloping, falls, exposure to sharp debris, and possible exposure to harmful chemicals. Findings included: 1. Record review of Resident #23's quarterly MDS assessment, dated 11/13/23, revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Alzheimer's Disease, Dementia, Insomnia, Muscle Weakness, Unsteadiness on Feet, Difficulty Walking, and Other Lack of Coordination. The cognitive section C1000 of the MDS indicated Resident #23 had moderate cognitive impairment. She had symptoms which included continuous disorganized thinking, incoherent rambling, unclear flow of ideas, and unpredictable switching from subject to subject, no psychosis, and wandering behavior. She had an unsteady gait and required a walker for mobility. Record review of Resident #23's care plan dated 01/25/24, reflected a problem identified as risk for elopement .requires secured unit related to: Wandering Risk, Alzheimer's Disease initiated on 10/10/23 which reflected, [Resident #23] will remain safe during placement at Living Center on secured unit through review date target date 04/29/24. Interventions on the care plan, dated 10/10/23 reflected Assess for risk of elopement per living center policy and Redirect [Resident #23] from doors. Record review of Resident #23's Wandering Assessment, dated 10/10/23, completed by an unknown nurse, reflected Resident #23 was admitted for High Risk for Wandering, was disorientated, does not understand surroundings, independent with aid (cane/walker), Alzheimer's disease, known wanderer/history of wandering, Wander/elopement alarm not indicated. Record review of Resident #23's Quarterly Wandering assessment dated [DATE], completed by Licensed Wound Nurse, reflected Resident #23 was disorientated, Forgetful/short attention span, does not understand surroundings, independent with aid (cane/walker), Alzheimer's disease, Early dementia, known wanderer/history of wandering, Wander/elopement alarm is indicated. Record review of Resident #34's quarterly MDS assessment, dated 01/10/24, revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Alzheimer's Disease, Dementia, Neurocognitive Disorder with Lewy Bodies (protein growths in brain), Muscle Wasting, Hallucinations, Unsteadiness on Feet, and Other Lack of Coordination. The cognitive section of the MDS indicated Resident #34 had severe cognitive impairment. She had symptoms which included continuous disorganized thinking, incoherent rambling, unclear flow of ideas, and unpredictable switching from subject to subject, psychosis, and wandering behavior. Record review of Resident #34's care plan dated 01/22/24, reflected a problem identified as risk for elopement .related to: attempts to leave living center .wandering initiated on 06/22/23 which reflected, [Resident #34] will remain safe during placement at Living Center on secured unit through review date target date 12/20/23. Interventions on the care plan, dated 10/10/23 reflected Assess for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455486 If continuation sheet Page 2 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ennis Care Center 1200 S Hall St Ennis, TX 75119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 risk of elopement per living center policy and Redirect [Resident #34] from doors. Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #34's Wandering Assessment, dated 11/03/23, completed by ADON bb, reflected Resident #34 was admitted for High Risk for Wandering, could walk independently, was disorientated, does not understand surroundings, independent with aid (cane/walker), Alzheimer's disease, known wanderer/history of wandering. Residents Affected - Some Record review of Resident #34's Quarterly Wandering assessment dated [DATE], completed by LVN cc, reflected Resident #34 was disorientated, Forgetful/short attention span, combative, expresses fear and anxiety, does not understand surroundings, ambulates with one assist/Independent (no assist), Alzheimer's disease, dementia with psychosis, known wanderer/history of wandering, Wander/elopement alarm is indicated. In an interview on 01/29/24 at 10:00 a.m. with the Administrator revealed the facility had plumbing problems that had been addressed sometime the end of December, the Administrator stated that the construction had begun then and the trenches had been dug. The Administrator stated that would have been 4-6 weeks prior to today (01/29/24), but with he ice and the rain they had been unable to continue to correct the plumbing problems. He stated that the facility maintenance staff had covered the ditches with the plywood to make the area safer. In an interview on 01/29/24 at 4:51 PM, LVN L revealed that earlier that day Residents #23 and #34 had left the secure unit through a door that leads to the courtyard under construction. She stated that she must have had not been on that end of the hallway when Residents #23 and #34 went through the door. She stated that CNA PP had spotted the two residents in the courtyard and brought Residents #23 and #34 back to the secure unit. In an interview on 01/30/24 at 7:40 AM, CNA PP revealed she used to work on the secure unit and knows all the residents on the secure unit. She stated that sometimes the door on the secure unit (leading to the courtyard under construction) sticks and does not latch. She stated that she had just entered the courtyard from another building and saw Resident #34 holding the door open for Resident #23 so that Resident #23 could bring her walker through the door. She stated that the staff sometimes puts med carts or chairs in front of the door leading to the courtyard to deter residents on the secure unit getting outside of the unit. In an interview on 01/30/24 at 9:08 AM, with the Administrator revealed that he was aware that a couple of residents had managed to get out of the secure unit unobserved. He stated that it was his fault because he had not made sure that the door was secure as he entered the secure unit (from the courtyard entrance). He stated that he had notified all staff to be more mindful of the door not latching. He stated that the two residents (Resident #23 and #34) were found by another CNA right away. In an interview on 01/30/24 at 9:10 AM, the Maintenance Supervisor revealed that he had just found out about the door, he stated that it is not the door frame, but the door that is not hung right. In an observation on 01/29/24 at 10:45 a.m. the laundry room door was open and there was no one in the laundry. In and observation on 01/29/24 at 11:45 a.m. the laundry room door was open there was no one in the laundry. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455486 If continuation sheet Page 3 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ennis Care Center 1200 S Hall St Ennis, TX 75119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 In an observation on 01/30/ 24 at 1:00 p.m. the laundry door was open and there was no one in the laundry. Level of Harm - Immediate jeopardy to resident health or safety On 01/30/24 at 1:30 p.m. pictures were obtained of the courtyard of the ditches approximately 40 ft long and 3-4 feet deep, mounds of dirt broken pipes, debris that contained sharp edges of broken plastic pipe, broken fencing, barrels marked as hazard materials, and no protective fencing or signs indicating the hazards. Residents Affected - Some In an observation and interview on 01/30/24 at 3:17 PM, it was observed that the laundry facility was located within the courtyard that was under construction courtyard that was currently under construction. 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 door to the laundry facility was propped open with no automated door closing device was observed to be attached to the door. Directly inside the door to the left were numerous containers of laundry chemicals including All-purpose cleaner and degreaser, Neutralizing Sour, Chemical Alkaline Booster, Laundry Detergent and Laundry De-Stainer. All containers were observed to have warnings that denoted serious harm or injury if digested or continuous contact with exposed skin/eyes. Housekeeper EE stated that the housekeeping staff liked to keep the door open to the laundry facility because it gets very warm inside. 2. Record review of Resident #179's quarterly MDS assessment, dated 01/17/24, revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Alzheimer's Disease, Vascular Dementia, and sleep disorder. The cognitive section C1000 of the MDS indicated Resident #179 had severe cognitive impairment. He had symptoms which included continuous inattentiveness, continuous trouble falling asleep, continuous wandering and rejection of care behaviors. Record review of Resident #179's care plan dated 01/15/24, reflected a problem identified as [Resident #179] has realized that holding the memory unit locked door for 15 seconds will release the emergency egress function of door and door will open [Resident #179] has ambulated from memory unit into courtyard X 2 but has been redirected back to memory locked unit initiated on 01/16/24. Interventions on care plan, dated 01/16/24 reflected [Resident 179] to remain 1:1 until discharge. Care Plan dated 1/15/24, reflected a problem identified as risk for elopement and required a more secured unit to ambulate safely and freely related to: Attempts to leave living center, initiated on 01/16/24. Interventions on care plan dated 01/16/24 reflected, [Resident #179] Assess for risk of elopement per living center policy and Assess for secure unit. Record review of Resident #179's Elopement Risk Assessment, dated 01/12/24, completed by an unknown nurse, reflected Resident #179 was admitted with High Risk for Elopement, could walk independently, exhibited wandering behavior, was cognitively impaired and had poor decision-making skills, had verbalized a desire to go home and had eloped/wandered from his home without supervision prior to his admission to the facility. No quarterly Elopement assessment was available as the resident was at the facility for respite care x 5 days. Record review of Progress notes from 1/14/24 at 3:30 PM and written by LVN L revealed that Charge nurse was notified resident [Resident#179] was outside of exit door. Charge nurse noted resident on the sidewalk and immediately redirected resident back to unit. Resident was calm with some confusion noted. No injuries noted. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455486 If continuation sheet Page 4 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ennis Care Center 1200 S Hall St Ennis, TX 75119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Record review of Progress notes from 1/15/24 at 10:25 PM written by LVN K revealed that .this nurse hears the door rattle from res(ident)[Resident #179] pushing it once, then followed by quiet this nurse walks out of nurses station to see res [Resident #179] running on sidewalk toward 200 hall side building, this nurse try's to follow but has to put code in door as it is locked, this nurse runs outside and catches res as res is knocking on window of other building, this nurse turns res and takes res back inside locked unit where this nurse has to put code in again to get in, res is taken to nurses station and socks are changed and DON (Director of Nursing) is notified, this nurse blocks door while waiting on staff to come and look at door as res is put on 1 on 1 monitoring as well as Q(every)15 min checks. In an interview on 01/29/24 at 3:00 PM, with LVN L revealed that Resident #179 was a very busy resident, he would only sleep for 20 minutes at a time, and he constantly wandered and checked all the exit doors all day and all night. In an interview on 01/29/24 at 4:16 PM, CNA D revealed that the door next to the nurse's station (that leads to the courtyard under construction) sometimes does not latch and that it sometimes sticks open, so the staff must make sure that they check it every time they use the door . She stated that she had reported it to a nurse a couple of months back ago. An observation on 01/29/24 at 4:20 PM, revealed that the exit door from the secure unit to the courtyard under construction was intentionally left unlatched for 1 minute, no alarm sounded to indicate the door was open. In an interview on 1/30/24 at 4:50 AM, RN V revealed that she had heard of a few instances lately of residents getting out of the secure unit and that the door leading from the secure unit to the courtyard does not close very well. She stated that it would be very helpful to have some type of alarm that goes off on the doors on the secure unit. She stated that when the facility has fire drills that the staff in the secure unit would sometimes put barriers up in front of the doors on the secure unit because the fire alarm automatically unlatches the doors. In an interview on 01/30/24 at 5:00 AM, CNA M revealed that if a resident were to get out of the secure unit unsupervised, she would immediately bring the resident back to the secure unit and inform the Charge nurse or the Administrator. In an interview on 01/30/24 at 5:11 AM, LVN GGG revealed that the door next to the nurse's station on the secure unit (leading to the courtyard) sometimes sticks open and does not latch, she stated that she had reported it a while ago but could not remember when. In an interview on 01/30/24 at 7:40 AM, CNA PP revealed that the staff working on the secure unit would sometimes put med carts or chairs in front of the exit (leading to the courtyard) next to the nurse's station on the secure unit to deter residents from getting outside of eh unit. In an interview on 01/30/24 at 7:47 AM, LVN K revealed that she had been the nurse on the night that Resident #179 got out of the secure unit. She stated that there are no alarms on the door (leading to the courtyard) but that may be a good idea. She stated that the door (leading to the courtyard) would stick open and not latch from time to time. She stated that the door did latch after Resident #179 got out of the secure unit and that delayed her getting out to him, she stated that he had made it all the way to the 200 building. She stated that she brought the resident back to the secure unit and informed the DON that the door was not working well and that she did put some chairs in front (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455486 If continuation sheet Page 5 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ennis Care Center 1200 S Hall St Ennis, TX 75119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 of the door until other staff arrived to fix the door. Level of Harm - Immediate jeopardy to resident health or safety In an interview on 01/30/24 at 8:58 AM, the Administrator revealed he was aware of the door (on the secure unit leading to the courtyard) not closing properly and that the facility had put a new automatic door closer on the door to fix the problem. He stated the staff and visitors had been advised to make sure to check the door after they enter/exit to make sure that the door had latched properly. Residents Affected - Some In an observation and interview on 01/30/24 at 4:08 PM, Maintenance Assistant DD toured the under construction courtyard with the Investigator. He stated the trenches in the courtyard had been started by the Administrators son the same week as Christmas around the 19th or the 20th of December, he was not exactly sure. He stated the trenches had to be dug around 3-4 feet deep to get all of the pipe out of them and put in new pipe. He stated the trenches had been dug up and then there was a freeze aound Christmas so the ground had frozen and then it rained a lot after that, that was why the trenches were still there. He identified the trenches as being 3-4 feet deep with mud at the bottom. He identified the pIles of dirt anD debris next to the trenches as being 2-3 feet tall and containing large rocks, shards of broken pipe and other debris. In an interview and observation on 01/30/24 at 6:20 PM, the Maintenance Supervisor stated that he placed a new automatic door closer on the secure unit door (leading to the courtyard) a few weeks ago. He stated he thought that Resident #179 must have got out because he had pushed on the release on the door for more than 15 seconds to disengage the lock. Maintenance Supervisor then pushed on the exit bar to the door on the secure unit leading to the courtyard for a full minute, the magnetic door latch was observed to not disengage. He then stated that the door seemed not to be seated right in the door frame and that maybe that stopped the door from latching properly sometimes. In an observation on 01/31/24 at 8:30 a.m. revealed alarms had been placed on all the exit doors of the secured unit. In an interview on 01/31/24 at 9:10 a.m. with the Administrator revealed he had the Maintenance Supervisor purchase the alarms the evening before and place them on all the exit doors, so that an alarm would sound if the doors were opened. In an interview on 01/31/24 at 12:54 PM, the Administrator revealed that he and the DON had been trained by the Regional RN for elopement, wandering and safety concerns at the facility, and that all staff had been trained. He stated that he had designated the Housekeeping Supervisor and the Maintenance Supervisor to monitor the courtyard area. In an interview on 02/01/24 at 12:55 PM, the DON revealed that the staff were educated by in-services, hands on training and on-line training and that all training was currently up to date. She stated that she thought the IJ was caused by the courtyard being dug up for several weeks and not having the trenches blocked off and marked. Secure Unit residents may have injured themselves if they got out of the secure unit unsupervised. She stated that the facility now had alarms on the doors of the secure unit and the courtyard trenches were being filled in and the debris removed. She also stated that a self-closer mechanism was going to be installed on the laundry facility door to deter residents from having access to the chemicals stored there. In an interview on 02/01/24 at 3:00 PM, the Administrator and Maintenance Supervisor revealed that they made sure that the facility would do in-servicing and education and when and how to report and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455486 If continuation sheet Page 6 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ennis Care Center 1200 S Hall St Ennis, TX 75119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some identify that there may be discrepancies. The Admininstrator stated that he supervised through daily clinical meetings with the nursing department, have daily stand-up meetings with all the department heads including Maintenance and do daily advocacy rounds. I think the IJ occurred through an increase of hazards in the courtyard due to repairs. There was a missed opportunity for staff and visitors to make sure that the entrance to the secure was closed. To prevent another recurrence, the facility verified that the locks worked, the facility added alarms to the doors, staff were re-educated, to make sure that the door was checked and that the door was closed. They also stated that the facility was making sure that there were no debris or trenches in the courtyard that could (present) a hazard to residents. 4. Review of Resident #41's quarterly MDS assessment, dated 11/25/23, reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of schizoaffective disorder bipolar type (Mental illness), general weakness (weakness lower limbs), and abnormalities of gait and mobility (abilities to mobilizes safely ). Further review of the MDS reflected the resident was cognitively severely impaired and unable to make decisions for themselves. Review of the Resident #41's plan of care dated 11/25/23 with updates reflected goals and approaches to include wheelchair mobility for locomotion. Observation on 01/29/24 at 9:30 a.m., revealed Resident #41 was sitting in her wheelchair, in the secured unit activity room and had no skin problems. The wheelchair's right armrest was cracked with foam exposed. Review of Resident #61's quarterly MDS assessment, dated 01/06/24, reflected he was an [AGE] year-old male admitted to the facility on [DATE], with diagnoses of Schizoaffective disorder (mental illness), muscle wasting (muscle deterioration), abnormalities of gait and mobility (unable to mobilize safely), and unsteadiness on feet (instability to walk ). Further review of the MDS reflected the resident was cognitively severely impaired and unable to make decisions for themselves. Review of the Resident #61's plan of care dated 01/06/24 with updates reflected goals and approaches to include wheelchair mobility. in the secure unit activity room Observation on 01/29/24 at 9:31 a.m., revealed Resident #61 was sitting in his wheelchair in the secured unit activity room and the wheelchair's left and right armrests were cracked with exposed foam. There were no skin tears on arms. Review of Resident #65's annual MDS assessment, dated 01/28/24, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses of Dementia (brain dysfunction) pulmonary embolism (clot in the lung), abnormalities of gait and mobility (unable to mobilize safety), difficulty in walking, and muscle weakness . Further review of the MDS reflected the resident was cognitively severely impaired and unable to make decisions for themselves. Review of the Resident #65's updated plan of care dated 01/28/24 with updates reflected goals and approaches to include wheelchair mobility. Observation on 01/09/24 at 9:32 a.m., revealed Resident #65 was in her wheelchair in the secured unit activity room, and the wheelchair's right armrests were cracked with the foam exposed. There were no skin tears on arms. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455486 If continuation sheet Page 7 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ennis Care Center 1200 S Hall St Ennis, TX 75119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Review of Resident #66's annual MDS assessment, dated 01/23/24, reflected he was an [AGE] year-old male admitted to the facility on [DATE], with diagnoses of Dementia (brain disorder confusion & forgetfulness), unsteadiness on feet, and lack of coordination and weakness. Further review of the MDS reflected the resident was cognitively severely impaired and unable to make decisions for themselves. Review of the Resident #66's updated plan of care dated 01/23/24 with updates reflected goals and approaches to include wheelchair mobility. Observation on 01/09/24 at 9:35 a.m., revealed Resident #66 was in his wheelchair, wheeling in the hallway and with no skin problems. The wheelchair's right armrest was cracked with dried food in the cracks. Review of Resident #47's quarterly MDS assessment, dated 11/12/23, reflected he was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses of epilepsy (seizures), abnormality of gait and mobility, and instability of left knee. Further review of the MDS reflected the resident was cognitively severely impaired and unable to make decisions for themselves. Review of the Resident #47's updated plan of care dated 10/08/23 with updates reflected goals and approaches to include wheelchair mobility and skin not being in contact with hard surfaces since she has thin skin and a history of skin tears on her hands. Observation on 01/29/24 at 1:45 p.m., revealed Resident #47 was in her wheelchair and had no skin problems. The wheelchair's left and right armrests were cracked with the foam exposed. Resident #47 was unable to be interviewed. In an interview on 01/29/24 at 11:00 a.m., CNA D stated when a resident's wheelchair needed repair the staff were to tell the maintenance supervisor. CNA D stated she had not reported any wheelchairs that needed repair to the maintenance supervisor. In an interview on 01/29/24 at 11:05 a.m., LVN A stated when a resident's wheelchair needed repair the staff were to report it to the maintenance supervisor, LVN A stated she thought there was maintenance log at the nurses station in the other building but there was not one at this nurse's station. In an interview on 01/30/24 at 5:00 a.m., the with Maintenance Supervisor revealed the staff tells him if equipment needs to be fixed or if a room needs repair. He stated they are supposed to use the electronic reporting system, but they do not use it. He stated to his knowledge the staff had not been trained to use the electronic reporting system, he just fixes things when he knows about it. In an in interview on 01/30/24 at 9:15 a.m., the with Administrator and Maintenance Supervisor revealed neither of them were aware of any wheelchairs that required repair on the unit. The Administrator state the staff is supposed to use the electronic reporting system. The Administrator stated he did not know when or if the staff had been in-serviced on how to use the system, the staff just usually tells them, if the wheelchairs needed to be fixed. The Maintenance Supervisor agreed with the Administrator. A review of the electronic maintenance system with the Maintenance Supervisor on 01/30/24 reflected there were no entries that indicated residents' wheelchairs needed the armrest repaired for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455486 If continuation sheet Page 8 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ennis Care Center 1200 S Hall St Ennis, TX 75119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 October-January 2024. Level of Harm - Immediate jeopardy to resident health or safety In an interview on 02/01/24 at 1:32 PM, the Medical Director revealed that she had been informed of the IJ on 01/30/24. Residents Affected - Some Record review of the facility's Policy Statement Grounds dated 05/2018 version 1.1 (H5MAPL0360) reflected 1. Maintenance shall be responsible for keeping grounds free of litter .3. Areas around buildings (i.e., sidewalks, patio, gardens, etc.) shall be maintained in a safe and orderly manner at all times. Record Review of the facility's Policy Wandering and Elopements, dated 03/2019 version 1.2 (H5MAPL0944) reflected The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while harm while maintaining the least restrictive environment for residents .1. If identified as at risk for wandering, elopement or other safety issues .to maintain the resident's safety .483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and 483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents . A review of the facility's policy and procedure Maintenance dated July 2018 reflected It is the policy of this community to maintain all equipment provided by the facility, in good working order to ensure the safety and wellbeing of all residents and staff Equipment provided by the community will be: 1. Maintained in working order. A review for the facility's policy and procedure Assist devices and Equipment dated January 2020 reflected: Our facility maintains and supervises the use of assistive devices and equipment for residents device conation. 1. certain devices and equipment that assist with resident mobility, safety, and independence are provided for residents. These may include but limited to: .c. mobility devices wheelchairs, walkers, and canes) . 6.c. Device condition-devices and equipment are maintained on schedule and according to manufacture's instructions. Defective or worn devices are discarded or repaired . This was determined to be an Immediate Jeopardy on 01/30/24 at 2:07 PM. The Administrator was notified. The Administrator was provided with the IJ template on 01/30/24 at 2:07 PM The following plan of removal submitted by the facility was accepted on 02/01/24 at 9:52 AM and indicated the following: Plan of Removal: Immediate Corrections Implemented for Removal of Immediate Jeopardy. On January 30, 2024 at approximately 3:30 pm the following immediately corrective actions were taken: Resident #179 discharged to home (1/17) Director of Nursing and ADONs and MDSC, completed updated wander risk assessment on resident #23 and Resident #34 on (1/30). IDT reviewed interventions initiated and care plan updated r/t elopement risk (1/30). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455486 If continuation sheet Page 9 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ennis Care Center 1200 S Hall St Ennis, TX 75119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Maintenance Director installed (1/30) temporary magnet-activated alarms/chimes on all exit doors on Secure Unit until permanent alarm system can be installed by professional contractor (Contractor site survey completed 1/30 to provide quote by end of week). Maintenance Director physically inspected all Secure Unit doors/locks and tested each to make sure they're working correctly (closing properly without impediment, locking and unlocking with keypad only) completed 1/30. Administrator verified that already existing padlocks on courtyard gates, and mag-locks on halls adjoining Secure Unit, were securely locked and functioning properly to prevent elopement from facility via this route (1/31). Life Safety team alerted Admin that trench required orange construction fencing per OSHA regulations. Fence materials were immediately purchased and installed around trench area (1/31). IDENTIFICATION OF OTHER AFFECTED: All residents on Secure Unit have the potential to be affected. Director of Nursing /designee (ADON's and MDSC) completed Wander Assessment for all 20 residents on Secure Unit in Point Click Care on 1/30/2024, and all Secure Unit residents will be reassessed Quarterly by ADON (Ongoing for duration of Secure Unit stay) Director of nursing/designee validated all residents at high risk of elopement (17 of 20 residents on Secure Unit), (score of 11 or[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455486 If continuation sheet Page 10 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ennis Care Center 1200 S Hall St Ennis, TX 75119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based 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. Residents Affected - Some 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. Findings included: Review of RN staffing hours for October, 1st 2023 to December, 31st 2023 reflected zero hours worked by an RN 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) In an interview on 01/29/24 at 9:10 AM the Administrator stated there was some time that the DON was not available for work due to medical problems. He stated that he was aware that there may have been some missed RN hours and that the facility did have access to a nurse available during those times via a video interface, but that there may have been no RN during the missed hours reported to CMS. He stated that he did not think there were any missed nursing assessments, interventions, care, or treatments during that time, but not having an RN in the facility for those times maybe the possibility existed that some could have been missed. In an interview on 01/29/24 at 9:18 AM the DON stated she had been out on medical leave for a few weeks and that while there may have been a few days that there was not an RN in the building, they did have a RN available via video teleconference for those times that there was not an RN physically the building. She stated that she was sure there no missed nursing assessments, interventions, care, or treatments but without an RN in the building there was a possibility that a resident could have missed nursing assessments, interventions, care, or treatments. She stated that she was aware that there was supposed to be a RN in the building at least 8 consecutive hours a day, 7 days a week. Record review of facility policy dated August 2018 reflected the following, Policy Statement: The nursing services department shall be under the direct supervision of a registered or licensed practical/vocational nurse at all times. Policy Interpretation and Implementation: 1. A registered or licensed practical/vocational nurse (RN/LPN/LVN) is on duty 24 hours per day, seven days per week, to supervise the nursing services activities in accordance with physician orders and facility policy. 2. A registered nurse (RN) is employed as the Director of Nursing Services. The DNS is on duty (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455486 If continuation sheet Page 11 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ennis Care Center 1200 S Hall St Ennis, TX 75119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some during the day shift Monday through Friday. During the absence of the DNS, a nurse supervisor/charge nurse is responsible for the supervision of all nursing department activities, including the supervision of direct care staff. 3. The nurse supervisor/charge nurses are registered nurses (RN) or licensed practical vocational nurses (LPN/LVN), and are duly licensed by the state. 4. The Director of Nursing Services and/or the nurse supervisor/charge nurse, as a minimum, is responsible for: a. making daily resident visits to observe and evaluate the residence, physical and emotional status; b. reviewing medication, cards for completeness of information, accuracy in the transcription of physician orders, and adherence to stop order policies; c. reviewing individual, resident care, plans for appropriate goals, problems, approaches, and revisions, based on nursing needs; d. Assuring that the residence plan of care is being followed; e. arranging schedule to allow time for supervision and evaluation of performance of nursing personnel, and paid feeding assistants; f. informing attending physicians and resident families of changes in the residence, medical condition; g. charting and documenting medical records as necessary; h. keeping Nursing Service Personnel, informed of status of residence, and other related matters through written reports and verbal communication; i. Assigning work schedules and staffing to meet the needs of residence; providing direct resident care as necessary or appropriate; j. and other tasks and functions, that may become necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455486 If continuation sheet Page 12 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ennis Care Center 1200 S Hall St Ennis, TX 75119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based 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. Findings included: Observation of the kitchen on 01/29/24 at 09:19 AM revealed the following: -Ice Machine plastic vent, located on the front of the machine, the vent slats had dust on them. Ice Machine: filter behind the front vent had a lot of dust. In an interview on 01/29/24 at12:12 PM with the Dietary Supervisor, answered and said, cross contamination was the harm to resident regarding dust on the vent of the ice machine and any other items, could lead to sickness and death of the residents. Observation of the Dry Storage on 1/29/24 at 9:20 AM revealed the following: -Back wall on left side: 2nd row from top - 6 bags of Tostitos received date was 01/09/24, best used by; consumed by; of expiration date was October 2023 In an interview on 01/29/24 at12:12 PM the Dietary Supervisor stated she would have to check the policy to see how long they kept canned goods with no expiration date. Observations of refrigerator in storage area back wall on right side on 01/30/243 at 10:49 AM revealed the following: -Right side: 2nd row from top - three boiled eggs in clear sandwich bag dated 1/30/24, no item of description, no consume by or discard by date. In an interview on 10/30/24 at 10:52 AM with [NAME] J, when asked about no dates written on the outside of the bag, she stated it could be kept for four days. She stated dating the new products received with both received date and discard date once opened would let staff know how long you can keep (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455486 If continuation sheet Page 13 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ennis Care Center 1200 S Hall St Ennis, TX 75119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 the products. Level of Harm - Minimal harm or potential for actual harm Observation of the Kitchen on 01/30/24 at 11:30 AM revealed the following: Residents Affected - Some -Box fan sitting on top of freezer blowing in the direction of the food preparation area. The fan was clean and free of dust, but at the food preparation level. In an interview on 10/30/24 at 12:45 PM with Nutritionist, when asked what the expectations were for discard dates, she said food items not in their original packaging needed to be dated to ensure freshness. Asked nutritionist, about the fan being placed at food level and she responded that there is the possibility for dust particles that can cross contaminate the food and could potentially place residents at risk of food-borne illness. Stated she would inform the Dietary Manager and cooks. Record review of the Sanitization policy reflected ice machines and ice storage containers are drained, cleaned and sanitized per manufacturer's instructions. Record review of the food receiving and storage policy it reflected When food is delivered to the facility it is inspected for safe transport and quality before being accepted. Dry foods are labeled and dated (use by date). All foods stored in the refrigerator are covered, labeled and dated (used by date). Review of the U.S. FDA Food Code 2022 reflected: Chapter 3 . section 3-201.11 Compliance and Food Law: . C. Packaged Food shall be labeled as specified in Law, including 21 CFR 101 Food Labeling [* .(b) A food which is subject to the requirements of section 403(k) of the act shall bear labeling, even though such food is not in package form. Section 3-501.17 . Commercial processed food: Open and hold cold . B. 1. The day the original container is opened in the food establishment shall be counted as Day 1. 2. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. C. 2. Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section. 3. Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section. Definitions 3. Food Receiving and Storage - When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all PHF/TCS foods stored in the refrigerator or freezer as indicated. www.fda.gov eCFR- Code of Federal Regulations are indicating within the text by an *- www.ecfr.gov FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455486 If continuation sheet Page 14 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ennis Care Center 1200 S Hall St Ennis, TX 75119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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: Residents Affected - Some 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. Findings included: Review of Resident #3's EHR on 02/01/24 revealed the resident was a [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (cognitive loss disease), Diabetes (high blood sugar), and dementia (loss of memory and confusion). Review of Resident #3's quarterly MDS assessment, dated 12/12/23, reflected a BIMs score of 0, indicating the resident was severely impaired cognitively, unable to make decisions. Her functional status indicate he needed one staff to complete her activities of daily living, to include incontinent of bowel and bladder. Review of Resident #64's EHR on 02/01/24 revealed the resident was a [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses including Dementia, (loss of memory and confusion), chronic obtrusive pulmonary disease (shortness of breath), pressure areas right and left buttocks( breakdown of tissues on buttocks, bedsore), and protein-calorie malnutrition (does not eat well). Review of Resident #64's quarterly MDS, dated [DATE] revealed a BIMs score of 3, indicating she was severely impaired, unable to make decisions. Her functional status indicate he needed one staff to complete her activities of daily living, to include incontinent of bowel and bladder. Further review revealed that the resident had stage two chronic pressure areas on the right and left buttocks. Review of Resident #64's physician orders dated 01/03/24 reflected, alginate calcium apply once daily, with gauze island with border as secondary dressing. Review of Resident #5's EHR her on 02/01/24 revealed the resident was a [AGE] year-old female that was admitted to the facility on [DATE], with diagnosis including dementia, epilepsy, (seizures) and obsessive-compulsive disorder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455486 If continuation sheet Page 15 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ennis Care Center 1200 S Hall St Ennis, TX 75119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #5's quarterly MDS, dated [DATE] revealed a BIMs score of 15, indicating she was alert and oriented and able to make decision. Her functional status indicated she needed assist of one staff with her ADLs. Observation on 01/29/24 at 10:45 a.m., revealed CNA B donned clean gloves CNA B positioned Resident #3 on her back. CNA B unfastened the resident's brief tabs and wiped the pubic area with a disposable wipe, discarded the wipe, then she wiped her the folds of the groin inguinal (abdomen) area using wipes. CNA B proceeded to reposition Resident #3 on her left side and cleans her buttocks area, which was soiled with urine, then removed the brief and placed in a trash bag. CNA B placed a clean brief on Resident #3 and fastened it. CNA B continued with care for Resident #3 without discarding her soiled gloves, she pulled the resident's pants up and her shirt down and pulled the cover up over the resident. CNA B then removed her dirty gloves disposing of them in the trash bag, leaving the room after washing her hands. Interview on 01/29/24 at 10:50 a.m., CNA B stated she always changed her gloves between dirty and clean, but she was nervous and just did not do it after performing incontinent care on Resident #3. CNA B stated by not changing her gloves and sanitizing her hands you could spread germs to other residents. Observation on 01/29/24 at 10:53 a.m., the wound treatment nurse performed a wound care for Resident #64's right buttocks wound. The treatment nurse changed her gloves multiple times, but failed to sanitize/wash her hands or use the hand gel she had brought into the room between glove changes. Interview on 01/29/24 at 11:45 a.m., the wound care nurse said, she knew better than to not wash her hands or use wound hand gel between glove changes, but for some reason she did not remember. The wound care nurse said if her hands were not cleaned correctly, she could cross contaminant and spread infections to other residents. Observation on 01/29/24 at 11:40 a.m., LVN H was feeding Resident #55 got up to assist another resident, Resident #35 to the table. While wheeling resident #35 to table LVN H repositioned resident #35 in chair. LVN H went back to feeding resident #55 without sanitizing. Observation on 01/29/24 at 11:50 a.m., LVN I was assisting Resident #21 with eating lunch, she got up and went into office space, LPN I returned to the table sat down and started feeding Resident #21 again without sanitizing. Observation on 01/29/24 at 12:10 p.m., revealed MA C placing her medication cart out of the way, not sanitizing her hands, then taking a lunch tray and serving the tray to Resident #5, touched and moved the overbed table in the resident's room, touched the hand and shoulder of Resident #5., MA C walked out of the room, she was observed to not wash her hands or use hand sanitizer available in the hallway. MA C got another tray serving the tray to Resident #4, took the control and repositioned the resident's bed, touched the overbed table, moved it closer to the resident, placed the adult clothing protector on Resident #5. MA C prepared the tray, opened all the containers and placed a fork in the hand of the resident. MA C left the resident's room without washing her hands or using hand sanitizer until the charge nurse grabbed the bottle and stated, here use this. Interview on 01/23/24 at 12:40 p.m., LVN C on policy expectations on sanitation during feedings, LVN C revealed that she has been in-serviced on hand hygiene while assisting with feedings, aware if they you get up from the table, they must re-sanitize before feeding again. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455486 If continuation sheet Page 16 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ennis Care Center 1200 S Hall St Ennis, TX 75119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An interview on 01/23/24 at 1:00 p.m., with MA C revealed she had not completed hand hygiene after having direct contact with residents. MA C stated she was supposed to use the hand sanitizer in between serving each tray from the hall cart. MA C said she had been educated on appropriate hand hygiene. MA C said she had not sanitized her hands because she just jumped in to help the nurse served the hall carts. Interview on 01/30/24 at 4:45 p.m., the DON, she stated that her expectation was that staff would sanitize their hands prior to putting on and taking off gloves. She stated the staff should be changing their gloves from dirt to clean and sanitizing in between. If the staff changes gloves multiple times, they must sanitize their hands with soap and water or hand gel between each time. The DON stated that the staff had been trained on infection control, including appropriately sanitizing your hands while serving trays at meals. The DON sated she thought she would have to do some further training. Review of facility's Policies and Procedure titled: Infection Prevention and control Program, dated November 2023, reflected the following: The infection control prevention and control program is a facility -wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program . The program will be carried out by the facility infection control preventionist Policies/Procedures 1. The objectives of our infection control policies and practices are to: a. prevent, detect, investigate, and control infections in the community . b. maintain a safe, sanitary , and comfortable environment for personnel, residents, visitors, and the general public .e. provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment Review of facility's Policy and Procedure titled: Personal Protective Equipment-Gloves, dated July 2009 , reflected the following . wash your hands after removing gloves . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455486 If continuation sheet Page 17 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ennis Care Center 1200 S Hall St Ennis, TX 75119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings included: An observation on 01/29/24 at 11:07 a.m. of the activity room on the memory care unit revealed the sink water faucet was crusted green. An observation on 01/29/24 at 11:08 a.m. revealed in room [ROOM NUMBER] the floor was sticky and the floor in the bathroom was ere sticky and smelled of urine, there was a hole behind the toilet the size of a golf ball. The blinds in the room had five to six slats missing. The wooden wall protector, next to Bed B had been removed with exposed screw heads sticking out of the wall. An observation on 01/29/24 at 11:08 a.m., revealed in room [ROOM NUMBER] the handwashing sink, in the resident's room, the brackets were loose to the wall, allowed the sink to rock on the wall, Thethe floor under the sink was black with built up wax and loose dirt. The baseboard was missing from the wall under the sink. There was a hole in the baseboard in the corner next to the closet, the size of a golf ball that was as deep as a writing pen. The shared bathroom with room [ROOM NUMBER]'s bathroom revealed the toilet bowl was stained dark red and yellow dripping down inside the toilet bowel. The toilet base was black with built up dirt and grime, with the grouting missing from around the entire base of the toilet. The back of the toilet tank had a large plastic, ill-fitting cover. An observation on 01/29/24 at 11:10 a.m., revealed rooms [ROOM NUMBERS]'s shared bathroom revealed the floor was sticky and smelled of urine. In room [ROOM NUMBER] the baseboard was missing from the wall under the handwashing sink. The floor under the sink was black with built up wax and loose food particles. An observation on 01/29/24 at 11:17 a.m., revealed in rooms [ROOM NUMBERS]''s shared bathroom revealed the bathroom floor was sticky, with built up black wax and loose food and hair behind the toilet. The toilet bowel was stained black on the inside of the entire bowel. An observation on 01/29/24 at 11:30 a.m., reveealed in rooms [ROOM NUMBERS]'s shared bathroom revealed, the top to the toilet's ill-fitting cover was hanging off the side of the toilet. The baseboards beside the toilet were falling off, exposing an open wall. In room [ROOM NUMBER] the window screen was bent and was not attached to one side of the window, there were blankets piled up in the window seal, to keep the wind from coming through. The handwashing sink, in room [ROOM NUMBER] the brackets were loose and the sink was rocking on the wall. An observation on 01/29/24 at 11:40 a.m., revealed in rooms [ROOM NUMBERS]'s shared bathroom (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455486 If continuation sheet Page 18 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ennis Care Center 1200 S Hall St Ennis, TX 75119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some revealed the floor is sticky and there was an unbagged urinal on the back of the toilet with a dried black substance in the bottom. The baseboard was missing from the right wall next to the toilet. room [ROOM NUMBER]'s bathroom entrance revealed the bathroom tiles were all cracked at the entrance to the bathroom with dirt and food stuck to the exposed glue. An observation on 01/29/24 at 11:45 a.m., revealed rooms [ROOM NUMBERS]'s shared bathroom revealed there was two floor tiles partially cracked left side of toilet base. The ill-fitting cover on the back of the toilet is too big and falling off to one side exposing the water and mechanics of the toilet. In room [ROOM NUMBER] the wooden protective railing was missing on the entire wall, next to bed B, there were holes in the plaster of the wall with screw heads sticking out. The window next to bed B has black tape surrounding the windowpane top and bottom. There are blankets in the window seal, wind is felt coming through the window seal. In an interview on 01/29/24 at 11:50 a.m., Housekeeper E revealed she had been assigned to the memory care unit for today and she started at the front and worked her way down to the nurse's station, sweeping and mopping each room and bathroom. Housekeeper E said she thought the housekeeping supervisor knew about the condition of the bathrooms and some of the rooms . In an interview on 01/29/24 at 11:00 a.m., CNA D stated when a resident's room's needed repair the staff were to tell the maintenance supervisor. CNA D stated she had not reported any room's that needed repair to the maintenance supervisor . In an interview on 01/29/24 at 11:05 a.m., LVN A stated when a resident's room or bathroom needed repair or cleaning the staff were to report it to the maintenance supervisor and housekeeper, LVN A stated she thought there was maintenance log at the nurses station in the other building but there was not one at this nurse's station. In an interview on 01/30/24 at 5:00 a.m., the Maintenance Supervisor revealed the staff tells him if equipment needs to be fixed or if a room needs repair. He stated they are supposed to use the electronic reporting system, but they do not use it. He stated to his knowledge the staff had not been trained to use the electronic reporting system, he just fixes things when he knows about it. In an in interview on 01/30/24 at 9:15 a.m., the Administrator and Maintenance Supervisor revealed neither of them were aware of any rooms that required repair on the unit. The investigator started giving examples of the rooms and bathrooms requiring repair, the maintenance supervisor stated those too large plastic toilet covers are supposed to be there, I was told that the ceramic tops should all be replaced by the plastic tops because the ceramic tops can be used a weapon. The Administrator state the staff is supposed to use the electronic reporting system. The Administrator stated he did not know when or if the staff had been in-serviced on how to use the system, the staff just usually tells them, if the wheelchairs needed to be fixed. The Maintenance Supervisor agreed with the Administrator. In an interview on 01/31/24 at 10:19 a.m., the Housekeeping Supervisor revealed if she had been made aware of the condition of the memory care unit's bathrooms and rooms, that required cleaning. The Housekeeping Supervisor stated she had lost one housekeeper and she was working herself, but that was no excuse for the nasty areas, she found over on the unit. The Housekeeping supervisor stated the staff and her housekeeper that is working over there should have informed her, because she was unaware. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455486 If continuation sheet Page 19 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ennis Care Center 1200 S Hall St Ennis, TX 75119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the Policy and Procedure Maintenance Services dated revised December 2009 reflected Maintenance service shall be provided to all areas of the building . and equipment .1. The maintenance Department is responsible for maintaining the buildings in a safe and operating manner at all times .2. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines .maintaining the building in good repair and free from hazards .establishing priorities in providing repair services .providing routinely scheduled maintenance service to all areas .3 the Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the building . are maintained in a safe and operable manner .maintenance .shall follow established safety regulations to ensure the safety and well-being of all concerned . Event ID: Facility ID: 455486 If continuation sheet Page 20 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ennis Care Center 1200 S Hall St Ennis, TX 75119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based 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. Residents Affected - Some 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. CNA D stated the gnats and flies can be bad at times, it just depends on the season, she stated she would tell the maintenance man about them. Observation on 01/29/24 at 11:15 a.m. two gnats in the private activity room next to the television room on the secured unit. Observation on 1/29/24 at 11:20 a.m., revealed four gnats crawling on the wall next to the door in the sensory room on the secured unit. Observation on 01/29/24 at 11:22 a.m. three gnats crawling on the medication cart next to the nurse's station on the secured unit. Observation on 01/29/24 at 11:30 a.m. revealed two gnats crawling on the top of an overbed table in the dining area on the secured unit. Observation and interview on 01/29/24 at 12:20 p.m., in the main dining room, in the main building revealed a gnat on the glass the resident had been drinking out of and a gnat on the table crawling around the place of her table mate. Residents appeared to be alert, did not seem to notice the gnats. One resident did not want to speak with the surveyor, and the other resident only stated, yeah they are here during mealtimes, most of the time. The resident did not want to comment on any other question asked. Observation on 01/30/24 at 4:30 a.m., revealed a large water bug crawling down Hall 200 by the nurses station. Observation on 01/30/23 at 4:45 a.m. revealed a large water bug at the end of Hall 100. Interview on 01/30/24 at 5:05 a.m. CNA D revealed she had seen the water bugs before but had not told anyone. She said she would tell her nurse, but she had not told her. Observation on 01/30/24 at 5:30 a.m. revealed a large water bug by the nurse's station next to the door of therapy as a resident in a wheelchair wheeled to the kitchen and smashed the water bug. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455486 If continuation sheet Page 21 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ennis Care Center 1200 S Hall St Ennis, TX 75119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Observation at 01/30/24 at 5:45 a.m. the smashed water bug was still there. Level of Harm - Minimal harm or potential for actual harm In a confidential group interview on 01/30/24 at 10:30 a.m., 8 residents revealed there was a gnat problem. The residents stated the facility staff and Administrator had been told, but the gnats continued to be a problem. The residents stated they had seen the pest control provider at the facility but whatever the pest control provider was using to treat the gnats was not making a difference. One resident stated that he kept a fly swatter to swat the gnats away. Residents Affected - Some Interview and observation on 02/01/24 at 2:35 p.m. with LVN F revealed she thought there was pest log at the nurse's station, but she had never written anything in it. LVN F looked but could not find a pest control book, she opened another door, for storage and found the book in there. LVN A stated she would just tell the maintenance man if she saw pest. An interview on 02/01/24 at 12:00 p.m. with the Administrator revealed the facility had routine pest control visits during each month, if there was problem with gnats and flies, he was not aware. He stated the staff was supposed to use the logbook at the nurses station to document pest sightings, because then the pest control company would know what they had seen, between each visit. He stated he would probably be changing that to documenting in the electronic reporting system so her could monitor. Record review of the Facility's Pest Sighting Log revealed: dated 01/21 through the last entry 10/22 mentioned no water bugs or gnats. There were no current pest control logs filled out for 2023 or 2024. Record review of the pest control provider service information dated 11/01/23 through 01/22/24 revealed the following regarding the technician comments, There were entries for doors not closing correctly to the outside and standing water, promoting cockroaches. On 12/08/23 and 01/10/24 was the last visit from the pest control provider, checked specifically for gnats for fruit flies/gnats dusted drains and sprayed same shared responsibilities to the facility gaps in the doors when closed and standing water . Record review of the facility's policy dated May 2008, and titled Pest control reflected Our facility shall maintain an effective pest control program . 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455486 If continuation sheet Page 22 of 22

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Citations

6 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0689SeriousS&S Kimmediate jeopardy
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
0727GeneralS&S Epotential for harm
F727 - Except when waived under paragraph (f) or (g) of this section, the
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
0812GeneralS&S Epotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0880GeneralS&S Epotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0921GeneralS&S Epotential for harm
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
0925GeneralS&S Epotential for harm
F925 - Maintain an effective pest control program so that the facility is free of
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

FAQ · About this visit

Common questions about this visit

What happened during the February 1, 2024 survey of Ennis Care Center?

This was a inspection survey of Ennis Care Center on February 1, 2024. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at Ennis Care Center on February 1, 2024?

Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

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Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·February 1, 2024