Enterprise Estates Nursing Center

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 27 residents. The sample included 12 residents, with five residents sampled for unnecessary medication. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 8 obtain an approved diagnosis for the use of Risperidone (an antipsychotic-class of medications used to treat major mental conditions which cause a break from reality) for dementia (progressive mental disorder characterized by failing memory, confusion) or the physician's rationale for why this specific drug was necessary to treat the condition.Findings included:- Resident R8's Electronic Medical

Record documented diagnoses of Lewy body dementia (type of progressive brain disorder that leads to a decline in thinking, reasoning, and independent function), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), recurrent major depressive disorder, and impulse disorder (sudden, forceful, irresistible urges to do something).Resident R8‘s Quarterly Minimum Data Set (MDS), dated [DATE REDACTED], documented a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. The MDS documented Resident R8 had no behaviors or mood issues. The MDS documented Resident R8 required maximum staff assistance for activities of daily living and mobility. The MDS documented Resident R8 received antipsychotic medication. Resident R8‘s Care Plan, dated 03/25/25, directed staff to give medications as ordered, obtain labs as ordered, and provide gradual dose reductions as recommended by

the pharmacist. The care plan stated the consultant pharmacist and the physician were to review medications monthly and make changes as needed. The care plan documented staff were to provide one-to-one reassurance and education regarding the disease process, medications, and procedures. The care plan documented staff were to list the last gradual dose reduction attempt of Risperidone and the physician's response. The Physician Order, dated 05/15/25, directed staff to administer Risperidone, 1 milligram (mg) daily at bedtime for Lewy Body Dementia with behavioral disturbance. The Consult Pharmacist Review, dated 05/09/25, requested the diagnosis for the use of Resident R8's medications, including Risperidone. The physician responded and indicated Risperidone was for Lewy Body Dementia with behavioral disturbance. On 09/23/25 at 08:12 AM, Certified Medication Aide (CMA) M administered medications to Resident R8 at the dining table. She crushed all medications and put them in vanilla pudding. Resident R8 took

the medications without problem.On 09/24/25 at 10:39 AM, Administrative Nurse D verified the diagnosis for the use of Risperidone was unapproved and the physician had not written a rationale for the unapproved use. The facility's undated Psychotropic Medication Use policy stated the physician's order for a psychotropic drug would include a qualifying diagnosis for that drug and the target behaviors for each specific drug. The attending physician must certify that a psychotropic medication was necessary to treat a specific condition or behavior.

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

Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Enterprise Estates Nursing Center

602 Crestview Drive Enterprise, KS 67441

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 0628 Level of Harm - Minimal harm or potential for actual harm

09/23/25 at 03:10 PM, Social Service X stated they do not send any notification of discharge to the Ombudsman regarding the residents' discharge to the hospital. Social Service X verified they would notify

the Ombudsman when a resident was discharged from the facility, home, or to another facility.The facility did not provide an Admission, Transfer, Discharge policy, as requested on 09/24/25.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Enterprise Estates Nursing Center

602 Crestview Drive Enterprise, KS 67441

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 0657

indicated.

Level of Harm - Minimal harm or potential for actual harm

On 09/23/25 at 11:45 AM, Administrative Nurse E stated she or Administrative Nurse D was not working at

the facility at the time of Resident R3's fall, so was unaware if an investigation was completed, but upon review, was unable to find an investigation with witness statements. Administrative Nurse E verified the staff should report an unwitnessed fall with injury to the administration, and an investigation would be completed along with witness statements and reported to the state if indicated. Administrative Nurse E stated the care plan should be updated with each fall, including interventions, and Resident R3's care plan was not updated.

Residents Affected - Few

The facility's Care Plan policy, undated, documented the care planning process includes assessment. Goal setting, intervention, referrals to other health care professionals, evaluations of resident responses to treatment, and revision of care and treatment in order to meet the resident's needs. The policy documented changes in the care plan would be required in the event the resident experienced an adverse event, including after every fall, to include specific instructions to staff based on the causal factors identified at the time of the occurrence and during the fall investigatory process to prevent or reduce the possibility for recurrence of a fall.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Enterprise Estates Nursing Center

602 Crestview Drive Enterprise, KS 67441

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)

Federal health inspectors cited ENTERPRISE ESTATES NURSING CENTER in ENTERPRISE, KS for a deficiency under regulatory tag F-F0686 during a standard health inspection conducted on 2025-11-17.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 11 deficiencies cited during this inspection of ENTERPRISE ESTATES NURSING CENTER.

Correction Status: Deficient, Provider has no plan of correction.

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

screened to determine if care needs may necessitate specialized beds or accessories, including but not limited to bed rails or other bed mobility devices. Assessment of need for special equipment or accessories to assess the resident to identify appropriate alternatives to installing bed rails or other bed mobility devices, and assess the resident for risk of entrapment from the bed rails prior to installation. Obtain and retain in the resident's clinical record, Informed consent for the use of bed rails and bed mobility enhancing devices. Gap measurements would be performed prior to installation and at least quarterly to ensure safety from potential entrapment following FDA guidelines for acceptable gaps: any open space between parameters of rail can present a risk of head entrapment, with the FDA-recommended space less than 4 and 3/4 inches.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Enterprise Estates Nursing Center

602 Crestview Drive Enterprise, KS 67441

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)

Federal health inspectors cited ENTERPRISE ESTATES NURSING CENTER in ENTERPRISE, KS for a deficiency under regulatory tag F-F0726 during a standard health inspection conducted on 2025-11-17.

Category: Nursing and Physician Services Deficiencies

The facility was found deficient in the following area: Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 11 deficiencies cited during this inspection of ENTERPRISE ESTATES NURSING CENTER.

Correction Status: Deficient, Provider has no plan of correction.

F 0730

Observe each nurse aide's job performance and give regular training.

Level of Harm - Minimal harm or potential for actual harm

The facility had a census of 27 residents. The sample included 12 residents. Based on observation and

record review, the facility failed to ensure the required annual performance reviews were completed for the three members reviewed. Findings included: - A review of the facility nurse and nurse aide performance evaluations revealed that Certified Medication Aide (CMA) R was hired on 03/21/24, Certified Nurse Aide (CNA) M was hired on 06/21/23, and CNA N was hired on 07/06/21. Randomly selected employees, who had been employed for over a year, lacked an annual review.On 09/23/25 at 11:06 AM, Administrative Staff B reported the facility had an annual review from 2023, but not for 2024. Administrative Staff B stated the facility had new administrative staff and had not performed an annual review.The facility's undated Employee Annual Performance Evaluation form included knowledge, skillset, judgement, quality of work, productivity and dependability, communication, initiative, and resident/family focus, which scored the employee for a percentage wage increase.Upon request, the facility failed to provide an Employee Performance Evaluation Policy.

Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Enterprise Estates Nursing Center

602 Crestview Drive Enterprise, KS 67441

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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 27 residents. The sample included 12 residents, with five residents reviewed for unnecessary drugs. Based on observation, interview, and record review, the facility failed to ensure the consult pharmacist notified the physician or the director of nursing of the need for further documentation regarding the continued use of Risperidone (antipsychotic medication- a class of medications used to treat major mental conditions that cause a break from reality) for Resident (R) 8 related to the unapproved diagnosis.Findings included:- Resident R8's Electronic Medical Record (EMR) documented diagnoses of Lewy body dementia (type of progressive brain disorder that leads to a decline in thinking, reasoning, and independent function), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), recurrent major depressive disorder, and impulse disorder (sudden, forceful, irresistible urges to do something).Resident R8‘s Quarterly Minimum Data Set (MDS) dated [DATE REDACTED] documented a Brief

Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. The MDS documented Resident R8 had no behaviors or mood issues. The MDS documented Resident R8 required maximum staff assistance for activities of daily living and mobility. The MDS documented Resident R8 received antipsychotic medication. Resident R8‘s Care Plan dated 03/25/25 directed staff to give medications as ordered, obtain labs as ordered, and provide gradual dose reductions as recommended by the pharmacist. The care plan stated

the consultant pharmacist and the physician were to review medications monthly and make changes as needed. The care plan documented staff were to provide one-to-one reassurance and education regarding

the disease process, medications, and procedures. The care plan documented staff were to list the last gradual dose reduction attempt of Risperidone and the physician's response.The Physician Order dated 05/15/25 directed staff to administer Risperidone, 1 milligram (mg) daily at bedtime for Lewy Body Dementia with behavioral disturbance. The Consult Pharmacist Review dated 05/09/25 requested the diagnosis for the use of Resident R8's medications including Risperidone. The physician responded and indicated Risperidone was for Lewy Body Dementia with behavioral disturbance.On 09/23/25 at 08:12 AM, Certified Medication Aide (CMA) M administered medications to Resident R8 at the dining table. She crushed all medications and put them in vanilla pudding. Resident R8 took the medications without problem.On 09/24/25 at 10:39 AM, Administrative Nurse D verified the diagnosis for the use of Risperidone was unapproved and the physician had not written a rationale for the unapproved use. She verified the consultant pharmacist had not attempted to notify the physician or the director of nursing of the need for further documentation regarding

the continued use of Risperidone for the unapproved diagnosis.The facility did not provide a policy on pharmacy reviews, as requested on 09/24/25.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Enterprise Estates Nursing Center

602 Crestview Drive Enterprise, KS 67441

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)

Federal health inspectors cited ENTERPRISE ESTATES NURSING CENTER in ENTERPRISE, KS for a deficiency under regulatory tag F-F0770 during a standard health inspection conducted on 2025-11-17.

Category: Administration Deficiencies

The facility was found deficient in the following area: Provide timely, quality laboratory services/tests to meet the needs of residents.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 11 deficiencies cited during this inspection of ENTERPRISE ESTATES NURSING CENTER.

Correction Status: Deficient, Provider has no plan of correction.

F 0868

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Level of Harm - Minimal harm or potential for actual harm

The facility had a census of 27 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to maintain a Quality Assurance Assessment and Assurance committee (QA&A) that met quarterly and had the required membership in attendance.Findings included:The facility provided QA&A committee attendance rosters for 01/23/25, 02/07/25, 07/02/25, and 09/11/25.

Upon review of the rosters, the Medical Director signed in attendance on 02/07/25 and 09/11/25. On 09/24/25 at 02:27 PM, Administrative Staff A reported she had begun employment with the facility in July 2025 and could find limited information from the previous administrator's QA&A process. Administrative Staff A stated she had not had training related to the QA&A process but had a meeting involving the Medical Director on 09/11/25.The facility's Quality Assurance policy, dated 07/20/16, documented that the Quality Assurance Team would meet on a monthly and quarterly basis to ensure quality care and compliance with regulations. The facility shall maintain a quality assessment and assurance consisting of

the director of nursing, a physician designated by the facility, and at least three members of the facility staff.

Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Enterprise Estates Nursing Center

602 Crestview Drive Enterprise, KS 67441

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 - Many

when she started a few months ago, she had many jobs to fill and did not track the infections.

Administrative Nurse E verified the designated facility prior to IP no longer working at the facility, and they were unable to find prior documentation of the infections for the last year.

On 09/24/25 at 11:10 AM, Administrative Nurse D verified the facility had not tracked infections from October 2024 to the present. Administrative Nurse D said the facility would start a system to identify infections on a map of the facility, but lacked complete documentation for the infection control programs inclusion in the policy and infection control guidelines.

The facility's Infection Control policy, undated, documented the facility would facilitate safe care of all residents and staff with known or suspected communicable diseases by establishing and maintaining an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The policy applies to all staff members from all departments of the facility, including direct and indirect care staff, contracted staff, consultants, volunteers, and others who provide care and services to residents on behalf of the facility, and students in a facility -supported training program, contracted and vendors of facility, residents residing in the facility, and visitor sin the facility. The Infection Prevention and Control Program would follow accepted Federal standards, including but not limited to the Centers for Disease Control (CDC), and is based on facility assessment and includes prevention, identification, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual agreement. The Infection Control Program includes surveillance, investigation, controlling and preventing infections in the facility including appropriate immunizations, appropriate reporting of infection incidents, standard and transmission -based precautions to prevent spread of infection, development of procedures such as isolation and quarantine to be applied to

an individual resident, circumstances to prohibit employees with communicable diseases or other infectious state from direct contact with residents or food, hand hygiene for staff involved in direct care contact, and maintaining a record of incidents and corrective actions related to infections. The infection control prevention and control program and antibiotic stewardship program is a function of the multidisciplinary, interdisciplinary team, including but not limited to the Medical Director, Director of Nursing, Infection Control Preventionist or designee, Administrator, and Consulting Pharmacist.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet