Enterprise Health & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Enterprise Health & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jan 18, 2026

  Based on interviews, resident's medical records, review of Facility Reported Incidents (FRIs) received by the State Agency, the facility's investigative files, and facility policies titled Abuse, Neglect, and Exploitation, Social Media Use, Cell Phones, and Confidentiality Statement, the facility failed to protect the residents' right to be free from sexual abuse perpetrated by other residents, physical abuse perpetrated by other residents, and exploitation/mental abuse perpetrated staff. Specifically:1. On 02/11/2025 the facility failed to protect Resident Identifier (RI) #168's right to be free from sexual abuse. On 02/11/2025 around 7:30 PM, Certified Nursing Assistant (CNA) #13 was making rounds on the Memory Care Unit (MCU) and observed RI #168 sitting on RI #97's bed. […]

• Immediate jeopardy, isolatedF607Jan 18, 2026

  Based on interviews, resident's medical records, review of Facility Reported Incidents (FRIs) received by the State Agency, the facility's investigative files, and the facility policy titled Abuse, Neglect, and Exploitation, the facility failed to ensure its abuse policy was implemented to establish a safe environment and implement protocols for preventing, identifying, and investigating an allegation of sexual abuse on 02/11/2025. On 12/18/2024 Resident Identifier (RI) #97 began having documented episodes of sexually inappropriate behaviors towards staff. Progress notes in RI #97's medical record included seven entries of sexually inappropriate behaviors documented by six different staff members from 12/18/2024 until 02/11/2025. […]

• Immediate jeopardy, isolatedF867Jan 18, 2026

  Based on record review, interview, the facility's policy titled Abuse, Neglect, and Exploitation, and the facility plan titled Quality Assurance and Performance Improvement (QAPI) Plan the facility failed to implement an effective QAPI program related to a resident-to-resident sexual abuse incident.Specifically, the facility's Quality Assurance Committee failed to review the incident to verify that a thorough investigation was conducted, failed to the incident as abuse, and failed to analyze contributing risk factors including residents wandering without supervision on a unit with a resident who had a documented history of sexually inappropriate behavior toward staff. […]

• No harm, potential for more than minimal, widespreadF812Jan 18, 2026

  Based on observations, interviews and facility policies titled, Date Marking and Food Safety, Kitchen Hood Inspection and Cleaning, and Automated Ware Washing Policy, the facility failed to ensure food items in dry storage and the freezer were labeled with use by dates; the vents in the stove hood were free of dust and grease; and plates and bowls were dried properly before being used to serve food to residents. These deficient practices created the potential for cross-contamination and/or foodborne illnesses. These deficient practices had the potential to affect 162 of 162 residents who received meals from the kitchen. Findings Include: 1) A review of a policy titled, Date Marking for Food Safety, with a Reviewed/Revised: dated of 10/2025, revealed. […]

• No harm, potential for more than minimal, isolatedF609Jan 18, 2026

  Based on interview, review of the Online report submitted to State Agency and facility policy, titled Abuse, Neglect and Exploitation the facility failed to report an allegation of sexual abuse on 02/11/2025 to local law enforcement when Resident Identifier (RI) #97 was found with his/her hands in RI #168's brief.This affected two out of six residents sampled for abuse.Findings include:Review of the facility's policy titled, Abuse, Neglect and Exploitation, with a revised date of 01/01/2024 documented: Policy: It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse. […]