Estates Healthcare and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Estates Healthcare and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF600Sep 10, 2025

  Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 5 of 6 residents (Residents #1, #2, #3, #8, and #9) reviewed for abuse. 1. The facility failed to ensure adequate supervision was provided to prevent a physical altercation between Residents #8 and #9 on the facility's memory care unit on 06/17/25 and failed to ensure the nurse on the unit, RN K, had visual access to the residents to be able to intervene timely. Resident #9 punched Resident #8 approximately eight times in the face/head resulting in Resident #8 having an abrasion and swelling on the left side of his face. 2. The facility failed to ensure Resident #1 was free from verbal abuse when he was verbally abused by CNA #1 on 09/04/25. 3. […]

• Immediate jeopardy, patternF689Feb 14, 2025

  Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for two of six residents (Resident #67 and Resident #99) reviewed for accidents. 1. The facility failed to provide adequate supervision to prevent Resident #99, who had cognitive impairment and resided on the secure unit, from eloping from the facility on 02/03/25 when the resident pried open the window in his room and made it 0.9 miles away from the facility. An Immediate Jeopardy was identified on 02/12/25 at 3:50 PM. […]

• Immediate jeopardy, patternF600Dec 13, 2023

  Based on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse and neglect for 2 of 5 residents (Resident #1 and Resident # 2) reviewed for abuse and neglect. The facility failed to prevent Resident #3 from physically abusing Resident #2, when Resident #3 punched Resident #2 in the face on 08/24/23. The facility failed to ensure Resident #1 was free from abuse and neglect by not providing adequate supervision and services, when the facility allowed Resident #3, who had a history of physically assaulting residents and staff, to continue to reside in the facility. […]

• Immediate jeopardy, isolatedF600May 1, 2026

  Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 1 of 24 residents (Resident #17) reviewed for abuse. The facility failed to ensure CNA Z did not abuse Resident #17 on 04/30/2026 during incontinent care. An IJ (Immediate Jeopardy) 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. […]

• Immediate jeopardy, isolatedF689Sep 10, 2025

  Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistive devices to prevent accidents for 2 of 5 residents (Resident #8 and Resident #9) reviewed for supervision. The facility failed to ensure adequate supervision was provided to prevent a physical altercation between Residents #8 and #9 on the facility's memory care unit on 06/17/25 and failed to ensure the nurse on the unit, RN K, had visual access to the residents to be able to intervene timely. Resident #9 punched Resident #8 approximately eight times in the face/head resulting in Resident #8 having an abrasion and swelling on the left side of his face. […]