Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Cherokee Trails Nursing Home during CMS and state inspections, most recent first.
A resident with dementia and severe cognitive impairment had a bath basin in her secured-unit room containing a safety razor and multiple items labeled keep out of reach of children. Staff said the items were left by hospice and acknowledged they could be dangerous for cognitively impaired residents who wandered. The facility also kept two faded mechanical lift slings in service, including one with an illegible care label, even though staff stated damaged slings could break during transfers and cause a fall with injury.
Medication refrigerators on two hallway 100 medication rooms contained insulin pens and vials requiring 36 to 46 degree refrigeration, but no temperature logs were present during observation. Record review showed multiple missing daily temperature entries on both refrigerator logs across April and May, despite the facility policy requiring daily recording by the charge nurse or designee. The DON and Administrator stated staff were responsible for medication storage and temperature logging.
Improper Food Storage and Hand Hygiene in Kitchen: Surveyors observed multiple food storage issues in the kitchen, including opened foods in dry storage and the freezer without labels, open dates, or use-by dates, food kept on the floor, and a refrigerated beverage left open to air. An employee was also observed handling food, changing gloves, and rinsing hands without soap, then drying hands on pants before putting on clean gloves. The DM and Administrator acknowledged the food safety and infection control concerns tied to these practices.
Unsanitary Medication Room Conditions: In 1 of 2 medication rooms reviewed, roach droppings were observed scattered on the floor and inside and around the sink cabinet, and an open hole with exposed pipes was seen under the sink. An MA, the Housekeeping/Laundry Supervisor, the DON, and the Administrator all acknowledged the condition after it was observed, and the area was described as unsanitary and unacceptable.
Late and Inaccurate MDS Transmission: The facility failed to transmit a resident’s quarterly MDS accurately and within the required timeframe. The resident had DM2, dementia, bipolar disorder, and anemia, and was dependent on staff for ADLs. The MDS was completed late, one version was inactivated, another was rejected for a record mismatch, and staff reported confusion about the batch submission and validation process.
Inaccurate MDS Coding for Parenteral/IV Feeding: A resident’s comprehensive MDS incorrectly indicated parenteral/IV feeding in Section K even though the EMR showed no record of IV or parenteral nutrition. The MDS nurse said the resident was supposed to receive IV antibiotics but instead received IM antibiotics, and the assessment was miscoded. The RCM said she only did spot checks, and the Administrator said the facility followed the RAI manual for MDS coding.
Failure to use required PPE during wound care: an agency LVN and a CNA provided wound care to a resident with a foot wound without wearing gowns, despite EBP signage and PPE being available. Both staff later stated they forgot the gowns and acknowledged the resident was on EBP. Facility leadership confirmed that residents with wounds require gowns and gloves during high-contact care, and the facility policy called for gown and glove use for wound care.
Two residents who smoked, one with hepatic encephalopathy and acute respiratory failure and another with cellulitis, severe sepsis, and chronic ulcers, reported that a CNA made rude, profane comments during staff-assisted smoking breaks, making one feel talked down to and upset. Other smoking residents reported hearing staff say it was a hassle to take them outside, though without recalling specifics or reporting distress. The CNA denied using inappropriate language, while the DON affirmed expectations for professional, non-profane communication and acknowledged that such behavior could cause emotional distress. The ADM investigated the allegations, and facility records documented that the CNA was discharged for speaking to residents in a manner that could be perceived as inappropriate and for inappropriate behavior, contrary to the facility’s resident rights policy requiring courtesy, consideration, and respect.
Three residents were found to be living in unsafe and unsanitary conditions, including a torn mattress, broken or missing toilet seats, and a persistent foul odor caused by hidden moldy food. Staff interviews revealed that maintenance issues were not addressed promptly due to staff turnover, and some residents' behaviors made it difficult for housekeeping to maintain cleanliness. Maintenance logs showed no recent requests, despite facility policy requiring daily cleaning and prompt repairs.
Several residents who required mechanical lifts for transfers were observed using slings that were faded, had unraveling straps, or were missing labels. Staff interviews revealed that slings were used despite visible wear, and some staff were unaware that bleaching slings could compromise their safety. Manufacturer guidelines and facility policy requiring removal of damaged slings were not consistently followed.
The facility did not ensure that four direct care staff members, including an ADON, an AD, and two CNAs, received annual mandatory training on effective communication as required by facility policy. Personnel files showed gaps in annual training, and interviews revealed confusion over responsibility for tracking and ensuring completion of these trainings, especially following a switch to a new online training system.
Three CNAs did not receive required annual compliance and ethics training, as shown by personnel file reviews and staff interviews. The facility's HR and interim Administrator were unclear about responsibility for annual training, and a recent change in the online training system contributed to the oversight.
Three CNAs did not receive required annual behavioral health training due to lapses in tracking and responsibility, as revealed by record review and staff interviews. The facility's policy and assessment mandate annual training, but a recent change in the online training system and unclear assignment of duties led to missed trainings.
A resident with a wound requiring enhanced barrier precautions received wound care assistance from an MDS Coordinator who failed to wear a gown, as required by facility policy, and only wore gloves despite signage and PPE supplies being present. The MDS Coordinator had received recent training on EBP but did not follow protocol during the care activity.
The facility did not provide required annual HIV training to three staff members, including an AD, DOR, and CNA, due to unclear responsibility for tracking annual trainings and issues with a recent transition to a new online training system. Personnel files and staff interviews confirmed the deficiency, which was contrary to the facility's own training policy and assessment.
A staff member did not receive required annual dementia training due to lapses in the facility's training program and unclear responsibility for tracking annual education. The deficiency was identified through record review and staff interviews, which revealed that the training was not completed as required by facility policy.
The facility did not post daily nurse staffing information in a location that was clearly visible and accessible to residents and visitors, as required. Instead, postings were placed on a wall near the SW office, which was not easily seen by those entering the facility. Staff responsible for the postings and the interim Administrator were unaware of the visibility requirement and there was no policy in place to guide proper posting.
A resident with severe cognitive impairment and multiple health issues slid out of her wheelchair during transport due to improper securement by the facility's van driver. The incident occurred when the driver had to brake suddenly, and the resident was not adequately secured with the shoulder and lap belt harness. Interviews and observations indicated that the van drivers were not properly trained on securement procedures, and the maintenance director responsible for training had not received adequate training himself.
The facility failed to ensure two CNAs were certified in Texas, as required by state law. CNA I and CNA J worked multiple shifts with expired certifications, despite the facility's knowledge of the issue. The Administrator attempted to assist CNA I with renewal, but issues persisted. This deficiency could risk residents receiving care from unqualified staff.
Unsafe items left in secured resident room; damaged lift slings remained in use
Penalty
Summary
The facility failed to keep Resident #55’s room on the secured unit free of accident hazards when a bath basin was observed containing a safety razor, vitamin A & D ointment labeled “keep out of reach of children,” an aerosol can of dry shampoo labeled “keep out of reach of children,” and a bottle of mouth rinse labeled “keep out of reach of children.” Resident #55’s record showed she was a female admitted with diagnoses including myocardial infarction and dementia, and her quarterly MDS indicated severe cognitive impairment and dependence or maximum assistance with most ADLs. Her care plan identified cognitive impairment. During interview, an LVN stated the hospice aide must have left the items in the resident’s room and acknowledged the items could be dangerous for cognitively impaired residents who wandered. The Administrator later stated the facility did not have a policy for safe environment and said that if razors and items labeled “keep out of reach of children” were left in resident rooms in the secured unit, it could be a potential safety concern for residents. The facility also failed to remove faded, worn, and damaged mechanical lift slings from service. In the laundry room, two of seven slings hanging to dry had faded straps, and one sling had a faded, illegible care label attached by only a few threads. The Laundry Supervisor said she considered the slings still usable and stated she had received sling-care in-service a long time ago. The Administrator, ADON, and Housekeeping-Laundry Supervisor all observed the slings and stated that damaged slings could break and cause a fall with injury.
Medication Refrigerators Lacked Required Temperature Logs
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional principles and the facility’s medication storage policy for 2 medication storage refrigerators on hallway 100. During observation, the medication storage refrigerator in the medication room on the front hallway contained 3 insulin pens and 3 insulin vials requiring refrigeration at 36 to 46 degrees, and there was no temperature log in the medication room. The medication storage refrigerator in the medication room on the mid-hallway also contained 3 insulin pens requiring refrigeration at 36 to 46 degrees, and there was no temperature log present there either. MA D stated that a log should be maintained and that staff should check and adjust the temperature every day. Record review showed repeated missing temperature entries on the refrigerator logs for both medication refrigerators. The front hallway refrigerator log had no temperatures recorded on multiple days in April and May 2026, and the mid-hallway refrigerator log also had multiple days with no temperature recorded in April and May 2026. The facility’s Medication Storage Policy dated 1/20/2021 stated that medications must be stored according to manufacturer recommendations and that refrigerator temperatures are to be maintained at 36 to 46 degrees, with charts kept on each refrigerator and levels recorded daily by the charge nurse or designee. The DON stated she had just started at the facility and had begun in-services with staff on obtaining and logging refrigerator temperatures, and the Administrator stated the ADON and DON were responsible for training nursing staff on medication storage and logging storage temperatures.
Improper Food Storage and Hand Hygiene in Kitchen
Penalty
Summary
The facility failed to store food in accordance with professional standards in its only kitchen reviewed for food storage. During an observation on 5/18/26, surveyors found a zip-top bag of vanilla wafer cookies in dry storage with no label, open date, or use-by date; a large opened bag of flour sitting on the floor; a bag of thick-sliced ham in the freezer tied in a knot with no label, open date, or use-by date; a bag of raisin bread in the freezer tied in a knot with no label, open date, or use-by date; and a carton of thickened sweet tea in the refrigerator with no opened date or use-by date and no lid, leaving it open to air. A box of sweet potatoes was also observed on the kitchen floor against the back wall with a large unopened bag of sugar sitting on top of it. On 5/19/26, the same box of sweet potatoes was still on the kitchen floor against the back wall with the bag of sugar on top of it. During the same day’s observation, [NAME] C was seen pureeing foods and checking temperatures. After temping food, she removed gloves, rinsed her hands at the dishwashing sink without using soap, put on clean gloves, and continued placing food on the steam table. She was again observed removing gloves and putting on clean gloves without washing her hands, and later rinsed her hands at the handwashing sink without soap and wiped them on her pants to dry them before putting on clean gloves. During interview, [NAME] A stated the meat in the freezer was pork chops she had just put in that morning and the bread was left over from breakfast that morning, and she had forgotten to date and label them when placing them in the freezer. [NAME] C stated she changed gloves often because she was unsure when she touched the trash can if her hands were dirty, and she did not use soap because there was no soap. She also stated wiping her hands on her pants was not good because there could be germs on her pants and that washing hands was important in the kitchen to prevent cross-contamination. The Dietary Manager and Administrator both stated that improper food storage, labeling, sanitation, and hand hygiene could create food safety and infection control concerns for residents who consumed food from the kitchen.
Unsanitary Medication Room Conditions
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment in 1 of 2 medication rooms reviewed, specifically the front 100 hallway medication room. During observation and interview on 05/20/2026 at 9:00 AM, roach droppings were seen scattered on the floor for about three feet from the entrance next to the sink, and an open hole measuring 24 inches across and 12 inches long was observed in the back portion of the cabinet under the sink with exposed pipes. Roach droppings were also observed covering the bottom and sides of the cabinet and spilling onto the floor. No active roaches were seen at that time. Staff interviews confirmed awareness of the condition after it was observed. An MA stated the droppings were disgusting and said she had not looked under the sink. The Housekeeping/Laundry Supervisor said the area was not cleaned routinely and described the condition as unacceptable and unsanitary. The DON stated she had not been aware of the condition and said the droppings were unsanitary. The Administrator reviewed photographs of the area and stated she was not aware of the hole or droppings under the sink. Later the same day, the hole under the sink had been repaired and patched, and the droppings had been cleaned from the floor and under the sink.
Late and Inaccurate MDS Transmission
Penalty
Summary
The facility failed to ensure an encoded, accurate, and complete MDS quarterly assessment for a resident with type 2 diabetes, dementia, bipolar disorder, and anemia was transmitted to the CMS system within the required timeframe. The resident’s quarterly MDS dated 1/5/2026 was completed on 1/19/2026, then later appeared again as completed and accepted on 2/20/2026 after the earlier version had been inactivated. The record also showed a CMS submission validation warning that the assessment was completed more than 14 days after the assessment reference date. The resident’s MDS record included a BIMS score of 99 because the interview could not be completed, and the resident was dependent on staff for ADLs. A care plan dated 7/14/2025 documented ADL self-care performance deficits and that the resident was at risk of not having needs met in a timely manner, with interventions noting dependence on staff for most care and two staff needed for transfers. The submission reports showed one record was rejected because the modification/inactivation record did not match a previously accepted record in iQIES, and another report warned of a resident information mismatch. During interviews, the MDS Coordinator stated the problem was not identified until February 2026 and that the assessment was later copied from the original and resubmitted. The Regional Reimbursement Coordinator said the batch had a validation ID but the assessment was not found in SIMPLE, and that the correction could not be submitted because the record had to be inactivated. The Administrator stated she was not aware the assessment had been submitted late and said the facility did not have a policy for MDS assessments.
Inaccurate MDS Coding for Parenteral/IV Feeding
Penalty
Summary
The facility failed to ensure an accurate MDS was completed for 1 of 4 residents reviewed for assessment accuracy, Resident #33. The comprehensive MDS assessment dated [DATE] incorrectly coded Section K to indicate that the resident had received parenteral/IV feeding during the last 7 days, even though the electronic medical record showed no record of parenteral or IV feedings. The resident was a [AGE]-year-old male admitted with a diagnosis of type 2 diabetes with uncontrolled blood sugar. During interviews, the MDS nurse stated the resident had not received parenteral or IV feedings and explained that the intended treatment was IV antibiotics, but the resident instead received IM antibiotics. She said the assessment was miscoded and that she would complete a modification. The Regional Reimbursement Coordinator stated she did not review every MDS because of the number of buildings she covered and instead performed spot checks. The Administrator stated the facility followed the RAI manual for MDS coding and acknowledged that incorrect coding could present an inaccurate view of the resident and affect resident care.
Failure to Use Required PPE During Wound Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for one resident reviewed for infection control. Resident #5 was admitted with diagnoses including hemiplegia following cerebral infarction, hypertension, major depression, and bipolar disorder. A quarterly MDS assessment dated 5/6/2026 indicated the resident had no impairment in thinking, had a BIMS score of 13, was not at risk for pressure ulcers/injuries, and did not have any unhealed pressure ulcers. Record review showed a care plan dated 5/14/2026 for a wound to the resident’s right foot, with interventions to clean the bottom of the right foot every shift for 14 days. Active physician orders dated 5/20/2026 directed wound care to cleanse the bottom of the right foot with wound cleanser, pat dry, apply calcium alginate, and cover with a dry dressing every day shift for 14 days. There was no physician order for EBP, although the resident was observed with EBP signage on the door and PPE available in the hallway. During the wound care observation, an agency LVN and a CNA entered the room, washed their hands, and applied gloves, but neither donned a gown. The LVN cleaned the overbed table, placed wax paper on it, and performed the wound care while repeatedly removing and replacing gloves and sanitizing hands. The CNA assisted by holding the resident’s leg. In interviews afterward, both staff stated they forgot to wear gowns and acknowledged the resident was on EBP and that gowns should have been worn. The ADON, DON, and Administrator stated that residents with wounds were on EBP and that staff should wear gowns and gloves during care. The facility policy stated that EBP includes gown and glove use during wound care for skin openings requiring a dressing.
Failure to Treat Smoking Residents With Dignity and Respect
Penalty
Summary
The deficiency involves failure to ensure residents were treated with dignity and respect during staff-assisted smoking breaks. A female resident with hepatic encephalopathy, acute respiratory failure, morbid obesity, and intact cognition (BIMS 14) required varying levels of assistance with ADLs and had a care plan identifying her as a smoker who needed assistance to and from the smoking area. A male resident with cellulitis of the left lower limb, severe sepsis with septic shock, non-pressure chronic ulcers, and moderately impaired cognition (BIMS 12) was independent in ADLs and had a care plan indicating he smoked and required supervised smoking due to noncompliance with facility policy. During a smoking break, both residents reported that a CNA made rude comments about taking them outside to smoke, including telling the male resident that he was always hassling her about smoking and telling the female resident that she did her the same “damn” way, which the female resident stated made her feel talked down to and upset. Additional interviews with three other residents who smoked indicated they had heard staff say it was a hassle taking them outside to smoke, though they could not recall specific dates, times, or staff names and reported no distress from those incidents. The CNA involved denied using inappropriate language or telling residents their care was a hassle. The DON stated that staff were expected to maintain professional behavior, including not cursing or using inappropriate language, and acknowledged that a CNA talking down to or using inappropriate language around a resident could put the resident at risk for emotional distress. The administrator reported responsibility for investigating allegations of abuse and neglect and described investigating the allegation that the CNA used inappropriate language and talked down to the two residents. Facility documentation showed that the CNA was discharged for speaking to residents in a manner that could be perceived as inappropriate language or talking down to residents, and for inappropriate behavior, in the context of a facility policy stating residents have the right to be treated with courtesy, consideration, and respect.
Failure to Maintain Safe and Sanitary Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, and sanitary environment for three residents as observed during the survey. One resident, who had severe cognitive impairment and was at risk for falls and infections, was found to have a torn mattress exposing foam and a broken toilet seat in his room. The resident was unaware of the broken items and reported no complications, but a CNA confirmed that such conditions could cause injury or infection. The CNA also stated that maintenance issues were not being addressed in a timely manner due to changes in maintenance staff. Another resident, who was cognitively intact and had diagnoses including emphysema and diabetes, was found in a room with a persistent foul sour odor. The odor was traced to a moldy avocado hidden among personal items. Staff interviews revealed that the resident often resisted room cleaning and hid items, making it difficult for housekeeping to maintain cleanliness. The housekeeping supervisor confirmed that daily cleaning was the standard, but some residents' behaviors impeded this process, and the presence of old food could have led to illness. A third resident, with severe cognitive impairment and incontinence, was observed to have a toilet with no seat, despite requiring assistance with toileting. The new maintenance director had not yet reviewed maintenance logs, and the administrator acknowledged that previous maintenance requests were not being completed. Review of the maintenance logbook showed no requests for the current or previous year, and facility policy required daily cleaning to maintain a sanitary environment. The facility's resident rights document also affirmed the right to a safe, clean, and comfortable environment.
Failure to Remove Damaged Mechanical Lift Slings from Service
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards by not removing worn and damaged mechanical lift slings from service for three residents who required mechanical lifts for transfers. Observations revealed that several residents were transferred or left sitting in wheelchairs with mechanical lift slings that were faded, had unraveling straps, or were missing labels. Staff interviews confirmed that slings were being used despite visible signs of wear, including faded colors and fraying, and that the color of the straps was not being used as an indicator of safety. Some staff were unaware that bleaching the slings could damage them and compromise their safety. Record reviews indicated that the affected residents had significant physical and cognitive impairments, requiring full assistance for transfers and daily living activities. Care plans for these residents specified the use of mechanical lifts for all transfers. Despite this, observations showed that slings in poor condition were still in use, and staff did not consistently follow manufacturer guidelines for inspecting and removing slings that showed signs of deterioration, such as fading or damage from improper laundering. Interviews with staff, including CNAs, laundry aides, and supervisors, revealed a lack of awareness regarding the manufacturer's instructions, which explicitly stated that slings should not be bleached and that faded or damaged slings should be immediately removed from service. The facility's own policy emphasized the right of residents to a safe environment, but this was not upheld due to the continued use of unsafe lift slings. The failure to remove these slings from service was directly observed and confirmed through staff interviews and record reviews.
Failure to Provide Annual Effective Communication Training to Direct Care Staff
Penalty
Summary
The facility failed to provide annual mandatory training on effective communication to four out of fourteen employees reviewed, including the Assistant Director of Nursing (ADON), Activities Director (AD), and two Certified Nursing Assistants (CNA A and CNA F). Personnel file reviews showed that while these staff members had completed effective communication training at some point, they did not receive the required annual training as stipulated by facility policy. The last recorded training dates for these employees did not align with the annual requirement, with some having only completed the training shortly after hire and not subsequently. Interviews with the Human Resources (HR) staff and the interim Administrator revealed a lack of clarity regarding responsibility for ensuring annual training compliance. HR indicated she was responsible for orientation training but was unsure about ongoing annual training responsibilities. The interim Administrator stated that HR was responsible for required trainings but was unaware that some staff had missed their annual training. The facility had recently transitioned to a new online training program, which contributed to the oversight in tracking and completing all required trainings. Facility policy and assessment documents confirmed that annual training on effective communication was required for all direct care staff.
Failure to Provide Annual Compliance and Ethics Training to Staff
Penalty
Summary
The facility failed to provide the required annual compliance and ethics training to three certified nursing assistants (CNAs) as evidenced by personnel file reviews. CNA A, hired on 9/3/2020, had not completed annual compliance and ethics training, with the last training recorded on 2/23/2024. CNA B, hired on 5/23/2023, had not completed annual training since 5/23/2023. CNA F, hired on 2/8/2024, had last completed the training on 2/9/2024, with no evidence of annual training thereafter. These findings were based on a review of training records and personnel files. Interviews with the HR staff and interim Administrator revealed a lack of clarity regarding responsibility for ensuring annual training was completed. The HR representative stated she was responsible for new hire training but was unsure who oversaw annual training. The interim Administrator indicated that the facility had recently changed to a new online training program and did not realize that some required trainings were missing from staff profiles. The facility's own assessment and policy documents confirmed that annual compliance and ethics training is required for all staff, but this was not consistently implemented.
Failure to Provide Annual Behavioral Health Training to Staff
Penalty
Summary
The facility failed to provide mandatory annual behavioral health training to three certified nursing assistants (CNAs) as required by facility policy and federal regulations. Record review showed that CNA A, CNA B, and CNA F did not complete annual behavioral health training within the required timeframe. Specifically, CNA A had not completed annual training since her last session in February 2024, CNA B had not completed training since May 2023, and CNA F had not completed training since February 2024. The facility's own assessment and policy require annual training for all staff, including behavioral health and trauma-informed care, but this was not consistently implemented. Interviews with the HR representative and interim Administrator revealed a lack of clarity regarding responsibility for ensuring annual training compliance. The HR representative was responsible for orientation training but was unsure who oversaw annual training, and the interim Administrator was not aware that some employees had missed their annual training. The facility had recently changed to a new online training program, which contributed to the oversight, as not all required trainings were included in staff profiles. This lapse resulted in staff not receiving the necessary behavioral health training as mandated by the facility's policy and assessment.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for one resident and one staff member. Specifically, a resident with a history of osteomyelitis, pressure ulcer, and surgical amputations was on enhanced barrier precautions (EBP) due to a wound. During wound care, the MDS Coordinator assisted by only wearing gloves and not a gown, despite signage and PPE supplies being present at the resident's door. The MDS Coordinator also sat on the floor while assisting with care. The resident's care plan indicated a risk for infection and required wound care per physician orders, and the facility's EBP policy required both gown and gloves for high-contact care activities involving wounds. Interviews with the MDS Coordinator revealed she was aware of the EBP requirements but failed to follow them during the incident, stating she did not notice the signage or PPE container. The ADON and DON confirmed that staff are trained on infection control and EBP, and that the MDS Coordinator had received recent training, as indicated by inservice records. The interim Administrator also confirmed the expectation for staff to wear both gown and gloves when providing care to residents on EBP, including those with wounds.
Failure to Ensure Annual HIV Training for Staff
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for new and existing staff, as evidenced by the lack of annual HIV training for three employees: the Activities Director (AD), Director of Rehabilitation (DOR), and a Certified Nursing Assistant (CNA B). Personnel records showed that the AD and DOR had not received annual HIV training, with their last training completed on the same date, and CNA B had not received annual HIV training since their hire date. Interviews with the Human Resources (HR) staff revealed uncertainty regarding responsibility for ensuring annual trainings, and the interim Administrator was unaware that some employees had missed required trainings. The facility had recently transitioned to a new online training program, which contributed to the oversight in completing all required trainings. Facility documentation, including the facility assessment and training policy, indicated that the training program was supposed to include orientation and ongoing training for all staff, with specific mention of HIV training as a required component. The policy required that training be completed prior to staff independently providing services and annually thereafter. The failure to ensure annual HIV training for the identified staff members was confirmed through record review and staff interviews.
Failure to Provide Required Annual Dementia Training to Staff
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for one of fourteen employees reviewed for training. Specifically, the Dietary Manager (DM) did not receive annual dementia training as required. The DM was hired on 2/15/2024 and completed dementia training on 2/16/2024, but there was no evidence of annual retraining. Interviews with the Human Resources (HR) staff revealed uncertainty about who was responsible for ensuring annual trainings, and the interim Administrator was not aware that some employees had missed required annual trainings. The facility had recently changed to a different online training program, which contributed to the oversight in completing all required trainings. Record reviews showed that the facility's assessment and policy required ongoing and annual training for all staff, including dementia management. The policy specified that training requirements should be met prior to staff independently providing services and annually thereafter. Despite these requirements, the DM did not receive the mandated annual dementia training, resulting in noncompliance with facility policy and regulatory expectations.
Failure to Prominently Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was posted in a prominent and readily accessible location for residents and visitors on two consecutive days. Observations revealed that the staffing postings were placed on a wall by the social worker (SW) office, which was not clearly visible from the front entrance, making it difficult for individuals entering the facility to see the information. Interviews with the HR staff member responsible for posting the information and the interim Administrator confirmed that they were unaware of the requirement for the posting to be visible to all upon entry and that there was no facility policy addressing the proper placement of the daily staff posting.
Inadequate Supervision and Securement During Resident Transport
Penalty
Summary
The facility failed to ensure adequate supervision and the use of assistance devices to prevent accidents for a resident during transport. The resident, who had severe cognitive impairment and was a fall risk, slid out of her wheelchair when the van driver had to brake suddenly. The incident occurred because the transport staff did not properly secure the resident with the shoulder and lap belt harness, leading to the resident sliding out of her wheelchair. The resident involved was an elderly female with multiple diagnoses, including cerebrovascular disease, hypertension, and chronic kidney disease. She required supervision or assistance for transfers and was considered a fall risk. During the transport incident, the resident was not properly secured in the van, which resulted in her sliding out of the wheelchair when the driver had to make an abrupt stop. The resident refused further medical assessment after the incident, although she later showed signs of bruising and reported pain. Interviews and observations revealed that the van drivers were not adequately trained on how to secure residents properly in the van. The maintenance director, who was responsible for training the van drivers, had not been trained himself. The facility's failure to ensure proper training and securement procedures placed residents at risk of injury during transport.
Failure to Ensure CNA Certification Compliance
Penalty
Summary
The facility failed to ensure that two Certified Nursing Assistants (CNAs), identified as CNA I and CNA J, were appropriately certified to practice in the State of Texas. This deficiency was identified through interviews and record reviews, which revealed that both CNAs had expired certifications. CNA I's certification had expired, and despite attempts to renew it, he faced issues with the credentialing system due to incorrect information. The facility's Administrator was aware of the issue and attempted to assist CNA I in resolving it, but the problem persisted. CNA I continued to work eight shifts as a CNA during the period when his certification was expired. Similarly, CNA J's certification was also expired, and the facility's records indicated that CNA J worked thirteen shifts as a CNA during this time. The facility's job description for CNAs requires them to be certified in good standing with the state, which was not the case for CNA I and CNA J. The failure to ensure that these staff members were properly certified could place residents at risk of receiving care from unqualified personnel.
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Illustrative
What surveyors actually found near you
We read the 56 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Rusk
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Arbors Healthcare And Rehabilitation Center | 2.5 mi | ★★★★★ | 18 | 0 |
| Legacy At Jacksonville | 11.9 mi | ★★★★★ | 8 | 0 |
| Avir At Jacksonville | 12.6 mi | ★★★★★ | 1 | 0 |
| Twin Oaks Health And Rehabilitation Center | 14.2 mi | ★★★★★ | 12 | 0 |
| Wells Ltc Nursing & Rehabilitation | 24.8 mi | ★★★★★ | 17 | 4 |
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