Estates Healthcare And Rehabilitation Center

Review of the in-services on 05/01/26 completed on 04/30/26 revealed all staff were re-educated on Trauma Informed Pain Management, Notification of Change, Customer Service and Bedside Care.

Interviews on 04/30/26 at 12:33 PM to 05/01/26 at 8:29AM with staff from various shifts were Administrator, DON, ADON J, MDS Coordinator L, MDS Coordinator M, Treatment Nuse, Activities Director, RN D, MA E, MA F, CNA G, CNA H, CNA I, CNA N, LVN O, LVN P, LVN Q, CNA R, CNA S, Housekeeping T, CNA U, MA V, LVN W, CNA X, CNA Y, MA AA, LVN BB, CNA CC, RN DD, CNA EE, PTA FF, MA GG, Dietary Manager, CNA HH, HR Coordinator, Medical Records, Floor Maintenance, CNA JJ, and CNA KK All staff were able to identify the following:- The different types of abuse and who to immediate report to.

They were to report to the Administrator and if she were not available, they were to report to the DON- Signs/symptoms of pain in residents and who report to.- Identify resident change in condition and who to immediately report to.- Customer service and proper bedside manner during care- Education on trauma informed care and ensure all residents who are trauma survivors receive competent trauma informed care and eliminate triggers that may cause re-traumatization of the residentAn IJ was identified on 04/30/26.

The IJ template was provided to the facility on [DATE] at 4:50 PM.

While the IJ was removed on 05/01/26, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained on the plan of removal.

675028 05/01/2026

Estates Healthcare and Rehabilitation Center 201 Sycamore School Rd Fort Worth, TX 76134

scabs.

She stated the red open spot on Resident #10's face were healing but Resident #10 would

plan and she was not aware it was not.

She stated it was the responsibility of the MDS Coordinators

stated the behavior should be care plan so that the staff would be aware, alert and know the resident's baseline.

Interview on 05/01/26 at 8:19 a.m., ADON K stated she was the ADON assigned to the memory care unit.

She stated Resident #10 had a behavior of picking on her skin and it was a behavior she had started at the facility.

She stated the red spots on her face were healing but the resident would take the scabs off. ADON K stated they had been treating the skin breakdown, educating the resident to not mess with it.

She stated the behavior should be care plan so that the staff were aware.

She stated it was her and the DONs responsibility to care plan the behavior.

She stated it was missed and she was not aware it was not care plan. ADON K stated the potential risk of not care plan Resident #10's behavior would be infection and staff not knowing that the resident had that behavior.

Record review of facility Comprehensive Care Planning policy, undated, reflected the following: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs.

675028 05/01/2026

Estates Healthcare and Rehabilitation Center 201 Sycamore School Rd Fort Worth, TX 76134

Review of the facility's undated policy titled Smoking Policy reflected the following: .1.

Matches, lighters, or other ignition sources for smoking are not permitted to be kept or stored in a resident's room 2.The resident must be within direct view of the smoking supervisor, in reasonably close proximity of the supervisor, and the supervisor must be able to quickly respond in the event of an emergency.

675028 05/01/2026

Estates Healthcare and Rehabilitation Center 201 Sycamore School Rd Fort Worth, TX 76134

Review of Resident #11's care plan revised on 02/11/25 reflected the resident required a tube feeding related to impaired swallowing.

Interventions included follow MD order for current feeding orders.

Review of Resident 11's Order Summary Report for May 2026 reflected the following: Enteral Feed Order every shift Flush tube with 60 ml water before and after medication and feedingsEvery 4 hours Flush enteral tube with 30ml water pre/post medication administration and 5-10 ml water between each medicationObservation on 04/30/26 at 9:03 AM, revealed RN D checked Resident #11's g-tube placement prior to the resident's feeding. RN D poured 30ml of water into the syringe attached to the g-tube and let it flow to gravity. RN D then poured the formula into the syringe.

After the formula had run through the syringe via gravity, he proceeded to flush with 30 ml of water after the feeding.

Interview and observation on 04/30/26 at 9:29 AM with RN D revealed he flushed Resident #11's g-tube with 30 ml of water before and after the feeding. RN D looked at the flush order and said he had read it wrong, and the order was 60 ml of water. RN D further stated it was important to flush with the right amount of water because that was the resident's hydration.

Interview on 05/01/26 at 6:17 PM with the DON revealed if Resident #11's g-tube water flush was 60ml per the physician order, then it should have been followed.

The DON said it was important, so the resident's g-tube lines stayed clear and free of clogs during the feedings.

Interview on 05/01/26 at 7:53 AM with ADON J revealed Resident #11 had two orders, one of the orders read to flush with 30ml before and after medications and the other order was to flush the g-tube with 60ml before and after medications and feedings. ADON J said they called the hospice company and clarified the order and the correct flush before and after feedings should be 60ml. ADON J further stated it was important for physician orders to be followed because flushing with too much water could overload the resident and flushing with too little could dehydrate the resident.

Review of the facility's policy titled Enteral Tube Medication Administration dated 2025 reflected the following: PolicyThe facility assures the safe and effective administration of enteral formulas and medications.

Selection of enteral formulas, routes, and methods of administration, and the decision to administer medications via enteral tubes are based on nursing assessment of the resident condition, in consultation with the physician.

675028 05/01/2026

Estates Healthcare and Rehabilitation Center 201 Sycamore School Rd Fort Worth, TX 76134

Based on observations, interviews and record reviews the facility failed to ensure all drugs and

to the keys for 1 of 5 carts reviewed for medication storage. LVN-A failed to secure her medication cart prior to walking away from it on 04/28/26.

This failure could place residents at risk of accessing medications not prescribed for them.

Observation on 04/28/26 at 5:30 a.m. a medication cart located outside the only nurses' station was unlocked.

All drawers were able to be opened, and multiple prescription and over the counter medications were in the drawers. In an interview on 04/28/26 at 5:33 a.m. LVN-A stated she had walked away for just a minute to talk with someone.

She stated she knew her cart should have been locked prior to walking away but did not think she was going to be gone very long and most of the residents were still in bed.

She stated the risk of leaving the cart unlocked was residents accessing medications not prescribed for them. In an interview on 04/30/26 at 9:39 a.m. the DON stated all medication carts were required to be locked if the nurse or medication aide was not directly in control of the cart. If they walked away from the cart, no matter how long they were going to be away, they must lock the cart.

She stated the risk of leaving the cart unlocked was a resident gaining access to medications that were not prescribed for them. In an interview on 04/30/26 at 9:54 a.m. RN-B stated that anytime she walked away from her cart, she was supposed to lock it.

She stated locking it prevented anyone not authorized from accessing the cart, or a resident from gaining access to medications they were not prescribed. In an interview on 04/30/26 at 9:58 a.m. LVN-C stated that anytime she was not directly at her cart, she had to lock it to prevent anyone else from gaining access to the medications inside.

She stated residents could access medications not prescribed for them. In an interview on 04/30/262/6 at 9:58 a.m. RN-D stated he always locked his medication cart any time he was away from it.

Failing to do so could allow residents to access medications that were not prescribed for them and possibly having a reaction to them. In an interview on 04/30/26 at 10:04 a.m. MA-E stated her cart had to be secured any time she walked away from it.

She stated leaving it unlocked could allow another resident to get access to medications that might not be theirs. In an interview on 04/30/26 at 10:08 a.m. MA-F stated her cart had to be locked any time she was not directly in front of it. It was kept secured to prevent anyone from accessing the medications inside and taking a medication not prescribed for them.

Review of the facility's policy Medication Storage in the Facility, dated 2025, reflected: Medications and biologicals are stored safely, securely, and properly.

The medication supply is accessible to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications

675028 05/01/2026

Estates Healthcare and Rehabilitation Center 201 Sycamore School Rd Fort Worth, TX 76134

Findings included:Observation on 04/28/26 at 8:38 a.m. Resident #4's bedside table contained her water cup, hairbrush, her book, and a graduated cylinder with traces of a yellow liquid at the bottom.In an interview on 4/28/26 at 8:38 a.m. Resident #4 stated the cylinder was used to measure the urine from her urinary catheter collection bag.

She stated it had been left on her bedside table a couple of other times in the past.

She stated she had asked the CNAs not to put it there, but they forget and do it anyway. Resident #4 stated she could not access her bathroom with her wheelchair so she could not put the cylinder in the bathroom herself. Resident #4 stated the cylinder had been there since the night shift emptied her collection bag around 6:00 a.m.

She stated she was concerned that the CNAs would do the same thing with a resident who might be confused, and that resident might drink from it. In an interview on 04/30/26 at 9:36 a.m. the DON stated the graduated cylinder should not have been left on the resident's bedside table.

The bedside table was considered clean, and the cylinder was definitely not clean.

She stated the risk of placing it there could be cross contamination with the resident's food and drink, and if the resident was confused, they may try to drink from it.

She did not know who had left it on the bedside table. In an interview on 04/30/26 at 9:50 a.m. CNA-G stated the graduated cylinder could not be left on the bedside table due to the risk of cross contamination with other items on the table like the drink cup or food. In an interview on 04/30/26 at 9:53 a.m. RN-B stated the graduated cylinder could not be left on a bedside table due to the risk of cross contamination.

Dirty items like the cylinder could not share the same space as clean items like a drink cup or food. In an interview on 04/30/26 at 9:56 a.m.

LVN-C stated dirty items could not be kept with clean items because of the risk of cross contamination. A resident's bedside table was generally considered a clean environment, and dirty items like urine measuring cups could not be left there. In an interview on 04/30/26 at 10:00 a.m.

CNA-H stated the cylinders used to empty urine bags should always be rinsed out and left in the bathroom, not put back on the bedside table.

She stated it was unsanitary and gross.

She stated the cylinder looked like something that could be drunk from, and a confused resident might try to drink from it. In an interview on 04/30/26 at 10:04 a.m. CNA-I stated dirty items like the cylinder should be kept off the bedside table where other clean items were. He stated there was a risk of cross contamination as well as it being unpleasant for the residents.

Review of the facility's undated policy Fundamentals of Infection Control Precautions, reflected: Consistent use by staff of proper hygienic practices and techniques is critical to preventing the spread of infections.