Estates Healthcare And Rehabilitation Center
Estates Healthcare and Rehabilitation Center in Fort Worth, TX — inspection on September 10, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
jeopardy to resident health or safety
PM revealed the Administrator's phone number was posted in multiple locations, including at the nurses' station and in the hallway.
Record review of CNA A's personnel file reflected CNA A was suspended and terminated on 09/05/25.
Record review of facility's current, undated Abuse/Neglect Policy reflected the following: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart.
This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.
Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals.
The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility .
Verbal abuse: Any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents, or within their hearing distance, regardless of their age, ability to comprehend or disability .
Prior to the HHSC investigation, the facility took the following actions to correct the noncompliance:
Record review of Resident #1's Trauma Informed PRN Assessment had been completed on 09/05/25 with no concerns identified.
Record review of the facility's Skin Monitoring: Comprehensive CNA Shower
Record review had been completed on seven residents on 09/05/25.
Record review of safe surveys completed on 09/05/25 showed that nine residents had been interviewed by the facility with no issues noted.
Record review of In-Service Training record reflected 41 staff had been provided in-service training on abuse/neglect, resident rights, and behavior management on 09/05/25.
Interviews between 09/09/25 from 9:30 AM through 09/10/25 3:15 PM with the Social Worker, LVN B, LVN E, ADON C, ADON D, Housekeeper M, MA F, LVN G, Speech and Language Therapist, LVN H, CNA I, and CNA J revealed the facility staff were able to verify education was provided to them.
The staff stated they were educated on different types of abuse and neglect.
Staff stated they would intervene if they witnessed any type of abuse and immediately report to the Abuse Coordinator. 3.
Record review of Resident #2's Annual MDS, dated [DATE], reflected the resident was a [AGE] year-old male, who admitted to the facility on [DATE].
The resident's diagnoses included hemi[TRUNCATED]
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/10/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Estates Healthcare and Rehabilitation Center
201 Sycamore School Rd Fort Worth, TX 76134
SUMMARY STATEMENT OF DEFICIENCIES
Observation on 09/10/25 at 3:15 PM revealed the Administrator's phone number was posted in multiple locations, including at the nurses' station and in the hallway.
Record review of the facility's current, undated Abuse/Neglect policy reflected: .E.
Reporting.
When a suspected abused, neglected, exploited, mistreated or potential victim of misappropriation of property comes to the attention of an employee, that employee will make an immediate verbal report to the Abuse Preventionist or designee. If the discovery occurs outside of normal business hours, the Abuse Preventionist or designee will be called.
Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property of injury of unknown source to the facility administrator.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/10/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Estates Healthcare and Rehabilitation Center
201 Sycamore School Rd Fort Worth, TX 76134
SUMMARY STATEMENT OF DEFICIENCIES
been uploaded into the state's system, so they attempted that same day on 06/20/25.
The Administrator also stated that the Director of Rehabilitation's regional director assisted the Director of Rehabilitation by uploading the Simple forms and resolved the technical issue.
The Administrator revealed it was the Director of Rehabilitation's responsibility to upload the forms in a timely manner because it created a risk of delay in care to residents when forms were not uploaded time.
Record review of facility's PASRR Nursing Specialized Services Policy and Procedure, revised 03/06/19, reflected: Policy: It is the policy of Creative solutions in Healthcare facilities to ensure NFSS Forms are submitted timely and accurately.
Procedure: .8.
Therapy, CMWC DME or DME is notified ASAP after the IDT meeting. (You only have 3 days to enter PCSP Form after the PCSP meeting). 9.
The facility only has 20 business days from the Date of the PCSP meeting to submit a completed and accurate NFSS Form.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/10/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Estates Healthcare and Rehabilitation Center
201 Sycamore School Rd Fort Worth, TX 76134
SUMMARY STATEMENT OF DEFICIENCIES
Observation on 09/09/25 10:00 AM 09/10/25 4:00 PM throughout investigation revealed the door to the office on the memory care unit has been removed.
Both nurse and aide were making constant rounds to visibly check on each resident on the unit.
Staff were engaging with residents and not seen in the nurse's office.
Interviews on 09/09/25 from 11:22 AM through 09/10/25 3:30 PM with MDS Coordinator, CNA A, LVN B, ADON C, ADON D, LVN E, MA F, LVN G, LVN H, CNA I, CNA J, Social Services Director, Director of Rehabilitation, DON, and the Administrator, Activity Director, Housekeeping Supervisor, The facility staff were able to verify education was provided to them.
Facility staff were able to accurately summarize abuse and neglect, how to work with residents with behaviors, immediately separate residents in altercations and report.
Facility staff stated they monitor residents throughout the shifts, if behaviors were identified staff stated they were trained to redirect residents or placed them on 1:1 or q15 checks depending on the behavior.
Staff stated for residents who have had altercations or incidents they monitor closely, keep them separated to prevent any further incidents.
Staff stated they provide activities to keep them engaged and provide snacks throughout the day.
Staff stated upon shift change they will notify the incoming staff of any incidents or behaviors. On 09/10/25 at 3:30 PM, the Administrator and DON stated they were working with corporate to locate a policy on accident and hazards, supervision or quality of care; however, the policies were not provided prior to exit.
The noncompliance was identified as PNC.
The IJ began on 06/17/25 and ended on 06/19/25.
The facility had corrected the noncompliance before the abbreviated survey began.
Facility ID: