Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Enterprise Estates Nuring Center during CMS and state inspections, most recent first.
The facility did not complete required annual performance reviews for a Certified Medication Aide and two Certified Nurse Aides who had been employed for over a year. Administrative staff confirmed that no evaluations were conducted for the current year, and the facility could not provide an Employee Performance Evaluation Policy when requested.
The facility did not consistently hold QA&A committee meetings with the required members present, as the Medical Director attended only some meetings and there was limited documentation of the process prior to the current administrator's tenure. The administrative staff also lacked training on the QA&A process, and the committee did not meet as frequently as required by facility policy.
Staff did not use required Enhanced Barrier Precautions, such as gowns and gloves, during urinary catheter care for two residents, and failed to follow infection control protocols. The facility also lacked documentation and tracking of infections for nearly a year, with administrative staff confirming that infection surveillance had not been performed and prior records were missing.
A resident with multiple health conditions and a history of pressure ulcers did not receive physician-ordered interventions, including the use of an air overlay mattress and proper wound assessments. Staff failed to apply the required pressure relief device, did not consistently document wound measurements, and did not use enhanced barrier precautions during wound care. The absence of these interventions was confirmed by nursing and administrative staff, and the facility could not provide a policy on pressure ulcer prevention and treatment.
Nursing staff did not obtain required daily INR lab tests for a resident receiving Coumadin and Lovenox, failed to notify the physician of missed or inadequate blood draws, and continued administering anticoagulants without the necessary monitoring. Documentation and staff interviews confirmed the lapses, and the facility could not provide a relevant nursing services policy.
A resident with a history of stroke, aphasia, hypertension, and atrial fibrillation was prescribed Coumadin and Lovenox and required daily INR monitoring. Over several days, staff failed to obtain or document required blood samples, did not notify the physician of missed or unsuccessful draws, and continued administering anticoagulants without the necessary lab results. When the lab was finally completed, the INR was critically high, indicating a failure to follow physician orders and facility policy for lab monitoring and communication.
A resident was administered Risperidone, an antipsychotic medication, without an approved diagnosis or documented physician rationale for its use. The resident had multiple mental health diagnoses and required significant assistance, but the facility did not meet policy requirements for psychotropic medication use, including proper documentation and physician certification.
A resident with multiple chronic conditions was transferred to the hospital on two occasions due to changes in condition, but the facility did not notify the State Long Term Care Ombudsman of these facility-initiated discharges. Staff confirmed that notification was not sent for hospital discharges, and the facility was unable to provide its Admission, Transfer, Discharge policy when requested.
The facility did not update care plans for two residents with indwelling urinary catheters to include Enhanced Barrier Precautions, and staff provided catheter care without proper protective equipment. Additionally, after a resident with dementia experienced a significant fall with injury, the care plan was not revised to include new interventions or document an investigation, despite facility policy requiring such updates after adverse events.
A resident with hemiparesis, hemiplegia, and mild cognitive impairment was found with a bed rail that had excessively large openings, and there was no documentation of a side rail assessment or safe use evaluation in the medical record. Facility staff confirmed that required assessments and safety checks, as outlined in facility policy, were not completed for this resident.
A consultant pharmacist did not notify the physician or DON about the need for further documentation regarding the continued use of Risperidone for a resident with an unapproved diagnosis. The resident, who had Lewy body dementia and other mental health conditions, was receiving Risperidone for an unapproved indication without a documented rationale, and the facility could not provide a policy on pharmacy reviews.
Failure to Complete Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to complete required annual performance reviews for three nurse aides who had been employed for over a year. A review of personnel records showed that a Certified Medication Aide and two Certified Nurse Aides, all of whom had been employed for more than a year, did not have documented annual performance evaluations for the current year. Administrative staff confirmed that while there was an annual review from the previous year, no evaluations had been conducted for the current year due to changes in administrative personnel. Additionally, when requested, the facility was unable to provide an Employee Performance Evaluation Policy. The facility's evaluation form, which covers areas such as knowledge, skillset, judgment, quality of work, productivity, dependability, communication, initiative, and resident/family focus, was not utilized for the required annual reviews.
Failure to Maintain Required QA&A Committee Meetings and Membership
Penalty
Summary
The facility failed to maintain a Quality Assessment and Assurance (QA&A) committee that met at least quarterly and included the required members in attendance. Review of the QA&A committee attendance rosters showed that the Medical Director was only present at two of the documented meetings, and there was limited information available regarding the QA&A process prior to the current administrator's employment. The current administrative staff member reported not having received training related to the QA&A process and confirmed that only one meeting involving the Medical Director had occurred since her employment began. The facility's own policy required the QA&A team to meet monthly and quarterly, with membership including the DON, a physician, and at least three facility staff members, but these requirements were not consistently met.
Failure to Implement Enhanced Barrier Precautions and Maintain Infection Control Program
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) during urinary catheter care for two residents with indwelling catheters. In one instance, staff provided catheter care and peri-hygiene to a resident with severe cognitive impairment, multiple comorbidities, and a suprapubic catheter, but did not use a barrier gown as required by EBP protocols. In another case, a staff member assisted a resident with an indwelling catheter and removed the urine collection bag without wearing gloves, also failing to follow EBP guidelines. Administrative staff confirmed that EBP should have been used during these care activities and that EBP should be included in the care plans. Additionally, the facility lacked a structured and documented infection prevention and control program. There was no documentation of infection tracking, including the type of infection, antibiotic usage, resolution, or additional cultures, for a period spanning nearly a year. Administrative staff acknowledged that infection tracking had not been performed for several months due to staffing changes and other priorities, and prior documentation could not be located. The facility's infection control policy outlined requirements for surveillance, reporting, and prevention, but these procedures were not being followed in practice. The deficiencies were observed through direct observation of care, interviews with staff, and review of medical records and facility policies. The lack of adherence to EBP during high-contact care and the absence of infection surveillance and documentation contributed to the facility's failure to maintain an effective infection prevention and control program as required by federal standards.
Failure to Implement Physician-Ordered Pressure Ulcer Interventions
Penalty
Summary
The facility failed to provide physician-ordered interventions for a resident with a history of diabetes mellitus, Parkinson's disease, localized edema, and a pressure-induced deep tissue injury on the left heel. The resident was identified as high risk for pressure ulcers and had specific physician orders for wound care, including the use of a collagen dressing, Hydrofera Blue foam dressing, and an air overlay mattress to relieve pressure. Despite these orders, staff did not apply the required air overlay device to the resident's bed, as confirmed by both nursing and administrative staff. Additionally, staff did not consistently document wound measurements or characteristics during weekly skin checks, and there was a lack of enhanced barrier precautions during wound care. The resident's care plan also included nutritional interventions to support wound healing, but the primary deficiency centered on the failure to implement the ordered pressure relief interventions. Observations revealed that the resident's left heel wound had reopened, with visible swelling and discoloration of the foot, and the wound was not measured as required. Interviews with staff confirmed that the air overlay mattress was not in place and that wound assessments were incomplete. The administrative nurse acknowledged the absence of the air overlay device and the lack of proper documentation and care plan updates. The facility was unable to provide a policy on pressure ulcer prevention and treatment when requested by surveyors.
Failure to Follow Physician Orders for Anticoagulant Monitoring
Penalty
Summary
Nursing staff failed to follow physician orders for a resident who returned from the hospital with diagnoses including cerebral infarction, aphasia, hypertension, and atrial fibrillation. The resident required daily INR monitoring due to ongoing administration of Coumadin and Lovenox. Over several days, staff did not obtain the required blood samples for PT/INR testing as ordered. Documentation showed missed or inadequate blood draws, and there was no evidence that the physician was notified of these failures or the inability to obtain lab results. Despite the lack of INR results, the resident continued to receive anticoagulant medications as prescribed. The resident's medical record indicated multiple missed opportunities for lab draws, including instances where the lab was closed or the resident declined to go to the lab, but staff did not attempt to draw blood at the facility or notify the physician. Eventually, when a PT/INR was obtained, the result was critically high. Interviews with nursing staff and administrative personnel confirmed that the daily INR labs had not been completed as ordered. The facility was unable to provide a policy related to nursing services when requested.
Failure to Obtain and Communicate Required Lab Results for Anticoagulant Monitoring
Penalty
Summary
The facility failed to obtain adequate blood samples for a resident who required daily INR monitoring following hospitalization, as ordered by the physician. The resident, who had a history of cerebral infarction, aphasia, hypertension, and atrial fibrillation, was prescribed Coumadin and Lovenox, both anticoagulant medications. Despite physician orders for daily INR testing, there were multiple days when blood samples were either not collected, not successfully obtained, or not processed due to lab closure or unsuccessful attempts. On several occasions, staff did not notify the physician about the missed or failed blood draws, and the resident continued to receive anticoagulant medications without the required laboratory monitoring. Documentation in the resident's medical record showed that on one day, no attempt was made to draw blood, and on another, two unsuccessful attempts were made without physician notification. On a subsequent day, the resident declined to go to the lab, and there was no evidence that staff attempted to draw blood at the facility or informed the physician. The following day, staff did not draw a sample because the lab was closed and again failed to notify the physician. Eventually, when the blood was drawn, the INR was found to be critically high. The facility's laboratory policy required timely and accurate lab testing, proper documentation, and communication, but these protocols were not followed in this case.
Failure to Ensure Approved Diagnosis for Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that a resident received an approved diagnosis for the use of Risperidone, an antipsychotic medication, as required by policy and regulation. The resident had documented diagnoses of Lewy body dementia, anxiety disorder, recurrent major depressive disorder, and impulse disorder. The resident's Minimum Data Set (MDS) indicated moderately impaired cognition, no behaviors or mood issues, and a need for maximum staff assistance with activities of daily living. Despite this, the resident was administered Risperidone for Lewy Body Dementia with behavioral disturbance, but there was no approved diagnosis or physician's rationale documented for the use of this medication for that specific condition. The care plan directed staff to administer medications as ordered, obtain labs, and provide gradual dose reductions as recommended by the pharmacist, with monthly reviews by the consultant pharmacist and physician. The consultant pharmacist requested the diagnosis for Risperidone, and the physician responded that it was for Lewy Body Dementia with behavioral disturbance. However, administrative staff later verified that this was an unapproved diagnosis and that the physician had not provided a rationale for the unapproved use. The facility's policy required a qualifying diagnosis and target behaviors for each psychotropic drug, as well as physician certification of necessity, which was not met in this case.
Failure to Notify Ombudsman of Facility-Initiated Hospital Discharge
Penalty
Summary
The facility failed to notify the State Long Term Care Ombudsman (LTCO) of a facility-initiated discharge of a resident to the hospital. The resident had multiple complex medical conditions, including atherosclerotic heart disease, cerebral infarction, diabetes mellitus, stage 3 renal failure, and hypocalcemia. The resident required extensive staff assistance with activities of daily living, was frequently incontinent, required continuous oxygen, and used a wheelchair. On two separate occasions, the resident experienced changes in condition that resulted in transfers to the hospital—first for hyperkalemia and later for congestive heart failure exacerbations. In both instances, the resident was admitted to the hospital and later returned to the facility. Review of the electronic medical record and staff interviews revealed that there was no documentation of notification to the LTCO regarding the resident's discharge to the hospital. The facility's social services staff confirmed that they do not notify the Ombudsman when a resident is discharged to the hospital, only when discharged home or to another facility. Additionally, the facility did not provide an Admission, Transfer, Discharge policy when requested.
Failure to Revise Care Plans for Catheter Care and Fall Prevention
Penalty
Summary
The facility failed to revise and update care plans for multiple residents in accordance with their changing clinical needs and current standards of care. For two residents with indwelling urinary catheters, the care plans did not include Enhanced Barrier Precautions (EBP) as required. Observations showed that staff provided catheter care without the use of barrier gowns, and administrative staff confirmed that EBP should have been implemented and documented in the care plans. The facility's own policy required that care plan revisions be made by a licensed nurse in collaboration with the interdisciplinary team and communicated to all staff, but this was not followed for these residents. Additionally, a resident with a history of falls and severe cognitive impairment experienced a significant fall resulting in lacerations to the head and ear. The care plan for this resident was not updated to reflect new interventions or changes in status following the fall, and there was no documentation of a post-fall investigation or implementation of resident-centered interventions to prevent recurrence. The facility's policy required care plan updates and specific instructions to staff after adverse events such as falls, but this was not done. The deficiencies were identified through observation, record review, and staff interviews. Staff and administrative personnel acknowledged that care plans should have been updated to reflect current needs and interventions, including EBP for catheter care and fall prevention strategies after an incident. The lack of timely and appropriate care plan revisions was contrary to both facility policy and regulatory requirements.
Failure to Assess and Ensure Safe Use of Bed Rail
Penalty
Summary
The facility failed to properly assess and ensure the safe use of a bed rail for a resident with hemiparesis, hemiplegia, transient ischemic attack, major depressive disorder, and chronic pain. The resident, who had mild cognitive impairment and required substantial assistance with mobility, was observed lying in bed with a side rail installed on the right side. The side rail had openings approximately 12.5 inches wide and 18 inches from the top of the rail to the mattress. The resident's medical record did not contain documentation of a side rail assessment or evidence of safe use for the side rail in place. Administrative staff confirmed that bed rails should be assessed quarterly or with significant changes in the resident's status, and acknowledged that the bed rail in use had openings that were too large. The facility's policy requires assessment of the resident for risk of entrapment, review of risks and benefits with the resident or representative, informed consent, and correct installation and maintenance of bed rails, including regular gap measurements following FDA guidelines. These required assessments and safety checks were not documented or performed for the resident in question.
Failure to Ensure Proper Notification and Documentation for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that the consultant pharmacist notified the physician or the director of nursing regarding the need for further documentation about the continued use of Risperidone for a resident with an unapproved diagnosis. The resident in question had diagnoses including Lewy body dementia, anxiety disorder, recurrent major depressive disorder, and impulse disorder. The resident's care plan required monthly medication reviews by the consultant pharmacist and physician, as well as documentation of gradual dose reduction attempts and the physician's response. The physician's order specified Risperidone for Lewy Body Dementia with behavioral disturbance, but this is an unapproved diagnosis for the medication, and no rationale for its use was documented by the physician. During the review, it was found that the consultant pharmacist had requested the diagnosis for the use of Risperidone, and the physician responded with the unapproved diagnosis. However, the consultant pharmacist did not follow up to notify the physician or the director of nursing about the need for further documentation to justify the continued use of Risperidone for this unapproved indication. Additionally, the facility was unable to provide a policy on pharmacy reviews when requested. These actions and omissions resulted in a failure to comply with requirements for monthly drug regimen reviews and proper documentation for the use of antipsychotic medications.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Enterprise
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Memorial Hospital Ltcu (village Manor) | 5.3 mi | ★★★★★ | 0 | 0 |
| Chapman Valley Manor | 7.5 mi | ★★★★★ | 0 | 0 |
| Tallgrass Healthcare Campus | 16.1 mi | ★★★★★ | 8 | 1 |
| Legacy At Herington | 17.7 mi | ★★★★★ | 0 | 0 |
| Wakefield Care And Rehab | 22.5 mi | ★★★★★ | 13 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.