Estates Healthcare And Rehabilitation Center

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

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

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 REDACTED], reflected the resident was a [AGE] year-old male, who admitted to the facility

on [DATE REDACTED]. The resident's diagnoses included hemi[TRUNCATED]

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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

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Estates Healthcare and Rehabilitation Center

201 Sycamore School Rd Fort Worth, TX 76134

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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

situation on 09/04/25. The DON reported that all staff were expected to notify the Administrator immediately

after the allegation was reported. The DON reported that residents have the right to be free from abuse and that if abuse is not reported immediately, problem resolution may be delayed, and residents may be harmed further. The DON stated her expectations were for staff to keep all residents safe and free from abuse.

Interview on 09/10/25 at 11:56 AM with the Administrator revealed CNA A told Resident #1 Fuck you the previous night (09/04/25) around 6 pm. The Administrator said during her interview with Resident #1, he told her that CNA A cursing at him was unprovoked. The Administrator said Resident #1's roommate also confirmed that CNA A did say fuck you to Resident #1 on the night of 09/04/25. The Administrator stated that the Social Worker notified the Administrator on 09/05/25 of the abuse allegation after Resident #1 notified the Social Worker. The Administrator stated on 09/05/25 is when the facility had begun their investigation. The Administrator reported being unaware that LVN B was aware of the situation the previous night on 09/04/25. The Administrator revealed she expected her staff to treat residents with respect and to report any abuse immediately. The Administrator reported that verbal abuse can put residents at risk of psychological harm and not notifying the Administrator immediately can delay interventions and may cause

the abuse to continue happening. The Administrator revealed her number is posted throughout the building, and she wants to be notified at any time if abuse occurs or is suspected. 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.

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

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Estates Healthcare and Rehabilitation Center

201 Sycamore School Rd Fort Worth, TX 76134

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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

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.

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

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Estates Healthcare and Rehabilitation Center

201 Sycamore School Rd Fort Worth, TX 76134

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 - Few

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

immediate discharge . Record review of Resident #8 and Resident #9's care plans were updated. Record

review of Resident #8's clinical records revealed Resident #8 was assessed and transported to the emergency room for further evaluation with no findings or new orders. Record review of Resident #8's clinical records revealed Resident #8 was being monitored for behaviors throughout each shift upon his return from the hospital on [DATE REDACTED] 8:30 PM until 06/19/25 at 6:00 PM until with no further signs of aggression or agitation. Record review of Staff Surveys were conducted on 06/17/25 - 06/18/25 by 24 staff over what signs and symptoms to look for when resident had a change in condition, how to respond when witnessed a resident-to-resident altercation, who do you report abuse/neglect allegations to? All with the understanding to immediately separate residents during resident-to-resident altercation and report to the nurse and the abuse coordinator which was the Administrator. 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.

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If continuation sheet