Ennis Care Center

In the surveyor’s words

From the most serious findings on record at Ennis Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689Feb 1, 2024

  44021 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. […]

• Immediate jeopardy, patternF755Aug 11, 2023

  Based on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring and administering of all drugs to meet the needs of the residents , for one (Resident #1) of 9 residents reviewed for medication use using medications that are brought in by outside pharmacies or families, in that: 1. The facility failed to ensure Resident #1 received his chemotherapy medication for 17 days (07/07/23 to 07/23/23) after medication was delivered to the facility (between 06/29/23 and 07/07/23) for 1 of 9 residents reviewed for medication administration. Resident #1 should have restarted medication on 07/07/23. […]

• Immediate jeopardy, patternF760Aug 11, 2023

  Based on interview and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 8 residents (Resident #1) reviewed for significant medication errors. The facility failed to ensure Resident #1 received his chemotherapy medication for 17 days (07/07/23 to 07/23/23) after medication was delivered to the facility (between 06/29/23 and 07/07/23) for 1 of 9 residents reviewed for medication administration. Resident #1 should have restarted medication on 07/07/23. Medication error was discovered when FAM called to see if medication needed to be replenished and medication was started again on 07/24/23, which Resident #1 to not receive medication as ordered for 17 days. An IJ was identified on 08/09/23 at 3:30 PM. […]

• Immediate jeopardy, patternF600Aug 8, 2022

  Based on observation, interview and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property and exploitation for one (1) of seven (7) residents (Resident #1) reviewed for sexual abuse. The facility failed to put interventions into place when they admitted a resident (Resident #2) on 02/23/22 that had previous inappropriate sexual behaviors. As a result, Resident #2, who resided on the secured unit, was seen on video footage sexually abused Resident #1, for approximately 43 minutes on 06/19/22. An Immediate Jeopardy (IJ) was identified on 06/21/2022 at 5:15 p.m. […]

• Immediate jeopardy, isolatedF689Nov 19, 2025

  Based on interview and record review the facility failed to ensure residents remained free from accidents, hazards and each resident received adequate supervision and assistance when being transferred for 1(resident #1) of 5 residents reviewed for accidents and hazards.The facility failed to ensure a safe transfer with a mechanical/Hoyer lift to assist in the transfer of Resident #1 on 11/7/2025 when CNA A did not follow the protocol of having two staff to operate the Hoyer lift resulting in Resident #1 falling and sustaining a fractured right humerus (upper arm) and a closed head injury.This failure could result in serious injuries to residents and potentially death.The noncompliance was identified as PNC. The facility was provided with the IJ template on 11/18/2025. […]