Average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Chisolm Trail Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to provide sufficient CNA staffing on multiple overnight shifts, leaving the secured memory care unit without a CNA and the building without any CNA coverage for part of the night while only two RNs were on duty. Two residents with severe cognitive impairment, extensive ADL dependence, incontinence, and pressure-ulcer risk had no documented overnight care during these shifts, despite care plans requiring close supervision, two-hour rounding, incontinence care, repositioning, and monitoring for behaviors and medication side effects. Staff interviews confirmed that one NA was the only aide in the building for much of the night, did not enter the secured unit, and could round on residents only once, while RNs did not perform CNA-level care or routine rounding. Multiple CNAs, an LVN, and an RN described frequent understaffing, lack of a dedicated CNA on the secured unit, and absence of a facility policy specifying minimum staffing levels or required actions when staff failed to report.
Incomplete and Missing Out of Hospital DNR Documentation: The facility failed to ensure advance directive records were complete and available for three residents. One resident’s OOH-DNR was not in the EHR at the time of review, while two other residents had OOH-DNR forms that lacked the required physician signature and other completion elements. Records showed all three residents had DNR status documented in their care plans or orders, and staff stated a valid OOH-DNR required physician signatures and upload to the EHR.
Food Storage and Refrigeration Deficiencies: Staff failed to keep food properly sealed, labeled, and dated in the kitchen freezer and nourishment room refrigerator. Frozen items were observed crushed, wet, exposed to air, and missing labels/dates, while the nourishment refrigerator held resident food and drinks at 47-49 degrees with several unlabeled and undated items. Staff gave inconsistent answers about proper temperature ranges and food storage requirements, and facility policy required opened food to be sealed, labeled, dated, and kept at safe temperatures.
Smoking Materials Left on Residents During Smoke Break: Three residents were observed with cigarettes and/or a lighter on their person during a smoke break, despite care plans, smoking assessments, and the facility smoking policy stating that smoking materials were to be kept at the nurses’ station and not stored in resident rooms or on residents. The residents had varying cognitive impairment and multiple medical diagnoses, and staff interviews confirmed that residents were not supposed to keep smoking materials on them, but the materials were still found with the residents.
Care plans for two residents remained marked full code even after their advance directives changed to DNR. One resident had COPD, DM2, and bipolar disorder with moderate cognitive impairment, and the other had pneumonia, dysphagia, dementia, COPD, respiratory failure, kidney failure, and severe cognitive impairment. Records showed DNR paperwork and orders were entered, but the care plans were not updated. Staff including the MDS LVN, SW, MR LVN, DON, and ADM stated the care plan should reflect the resident’s DNR choice, but responsibility for the update was unclear.
Missed Ordered Wound Care for a Resident With a Stage IV Heel Pressure Injury. A resident with dementia, DM2, and a stage IV right heel pressure injury did not receive ordered daily wound care on multiple occasions, and the TAR showed several missed treatments. Interviews with the WC LVN, DON, MDS LVN, and ADM confirmed that wound care was to be completed by the WC LVN or charge nurses and documented after completion, but the record reflected gaps in treatment and one instance where a dressing remained in place for days.
A resident with epilepsy and a PEG tube order for phenobarbital had an inaccurate narcotic count on the hall 5 med cart because the starting amount was doubled when the medication was received, and staff later subtracted doses from the wrong total. The facility also had expired meds in the med storage room and on a hall 1 med cart, while staff interviews showed there was no clear process or assigned schedule for checking and removing expired medications.
Unsecured Medication Cart Left Unattended: A hall 1 nurse's medication cart was observed left unattended and unlocked when an LVN walked away from it. The LVN stated she forgot to lock the cart, and multiple staff, including the DON and ADM, stated the facility expectation was to lock medication carts any time staff stepped away from them. The facility policy stated medication carts must be locked or attended to by authorized staff.
A resident with severe cognitive impairment and a history of skin integrity risk was found to have multiple small red scratches under both eyes that were not documented during a weekly skin assessment. The TN responsible for the assessment did not record the scratches, and the DON confirmed that such findings should be included according to facility policy.
The facility did not report several incidents of alleged abuse, neglect, or injury—including a resident being struck by a family member, a physical altercation between two residents, and a resident sustaining a hip fracture after a fall—to the State Agency within the required timeframes. Although staff performed internal assessments and notifications, mandated external reporting was delayed or omitted, contrary to facility policy.
Two residents with severe cognitive impairment were not adequately protected from physical abuse and neglect. In one case, a resident struck a visiting family member and was then hit in the face by the visitor, resulting in visible injury. In another case, a resident who wandered into another's room was physically struck by that resident after a verbal exchange. Staff did not prevent these incidents or consistently recognize and report them as abuse, despite the residents' known behavioral risks.
A facility failed to have physician orders for suctioning, monitoring secretions, or replacing suction equipment for a resident with a history of aspiration pneumonia and other health issues. The resident was observed in distress, struggling to breathe, and pointing to the suction machine. Staff interviews revealed the resident had increased secretions after a recent hospital visit, but necessary orders were not in place, posing a risk of aspiration.
A resident was readmitted to a facility without having her wound treatment orders reinstated, leading to the worsening of existing pressure injuries and the development of a new one. The resident, who was at risk due to her medical history, did not receive necessary wound care from the time of her readmission until the orders were reinstated. Staff interviews indicated a lack of awareness and communication regarding the resident's treatment needs.
A facility failed to ensure resident privacy by not knocking before entering rooms, affecting four residents. A CNA admitted to saying 'knock, knock' instead of physically knocking due to difficulty carrying meal trays. Staff interviews confirmed awareness of the policy requiring knocking to respect residents' privacy. Residents had mixed reactions, with one preferring staff to knock every time. The facility's policy mandates knocking to protect privacy, with exceptions only in life-threatening situations.
The facility failed to maintain infection control by not sanitizing a wrist blood pressure monitor between uses on four residents. LVNs C and D did not clean the monitor, risking disease transmission. Residents involved had conditions like hypertension and dementia, requiring careful monitoring. The facility's policy requires equipment disinfection before and after each use, which was not adhered to.
A resident with multiple medical conditions, including dementia and Alzheimer's, did not receive her lunch tray at the same time as her table mate and other residents, contrary to the facility's dining policy. Staff interviews revealed that the policy requires all residents at the same table to be served simultaneously, but this was not followed, leading to the resident feeling left out. The staff acknowledged the oversight but did not provide a specific reason for the delay.
A resident's call light was found on the floor and out of reach, despite staff training on call light placement. The resident, with a history of dementia and other conditions, was unable to call for help. Staff interviews confirmed the importance of call light accessibility, aligning with facility policy.
A resident with multiple health conditions, including diabetes, did not receive proper nail care, resulting in dirty and untrimmed nails. Despite the facility's protocol that CNAs and nurses are responsible for nail hygiene, the resident's request for nail care was unmet, and staff interviews confirmed a lapse in executing these duties. The deficiency highlights a failure in communication and adherence to care plans.
The facility failed to provide specialized rehabilitative services as ordered for two residents, leading to inadequate physical therapy and occupational therapy sessions. Staffing issues and lack of communication were cited as reasons for the deficiencies.
Overnight CNA Shortage Leaves Secured Unit and High-Acuity Residents Without Required Care
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient CNA staffing on the overnight shift, resulting in a lack of supervision and care for residents, including those on a secured memory care unit. On two specific overnight shifts (10 p.m. to 6 a.m.), the secured unit was left without a CNA, and from 4 a.m. to 6 a.m. there was no CNA in the building at all, despite a census of 67 residents, 11 of whom resided on the secured unit. Facility records, including the Facility Daily Assignment, Nurse Aide Daily Sign-In Sheet, and time sheets, showed that only one nurse aide (NA) worked from the afternoon through 4:04 a.m., and no CNA coverage was scheduled or present from 4 a.m. to 6 a.m. During this time, two RNs (RN G and RN H) were on duty but did not provide CNA-level care or routine rounding on all residents. Two residents with significant care needs were specifically affected by the lack of documented care on these overnight shifts. One resident was an elderly female with sequelae of cerebral infarction, dementia, chronic pain, chronic pulmonary edema, communication deficit, and a history of TIA and stroke. Her MDS showed a BIMS score of 02 (severe cognitive impairment), and she required substantial/maximal assistance with oral and toileting hygiene, was always incontinent of bowel and bladder, and was at risk for pressure ulcers. Her care plan required supervision for bed mobility, transfers, eating, and toileting, close supervision with regular compliance rounds due to elopement risk, and monitoring for shortness of breath and related symptoms. Point-of-care documentation for March showed no evidence of care provided on the overnight shifts in question, with all required documentation fields (ADLs, CNA care, incontinence, skin checks, behaviors, shortness of breath, and turning/repositioning) left blank. Another resident, also an elderly female, had diagnoses including UTI, GI hemorrhage, hyperkalemia, vascular dementia, CHF, chronic kidney disease, and chronic pain syndrome. Her MDS also reflected a BIMS score of 02 (severe cognitive impairment) and indicated she required substantial/maximal assistance with toileting hygiene and was totally dependent for personal hygiene, dressing, bathing, rolling, sit-to-stand, and transfers. She was occasionally incontinent and at risk for pressure ulcers, with care plan interventions including monitoring for adverse medication effects and behaviors each shift, assistance with turning/repositioning, and ensuring heels were floated. Her March point-of-care documentation likewise showed no documented evidence of care on the same overnight shifts, with blanks for ADL assistance, CNA care, behaviors, bowel incontinence, medication side effects, skin changes, fall risk, and snacks. Multiple staff interviews confirmed that staffing was often insufficient, particularly on overnight shifts, and that the secured memory care hallway, which housed residents with dementia and wandering behaviors, was sometimes left without a CNA. One CNA reported that on the night in question she was the only NA in the building, was approved to work only until 4 a.m. due to a 16-hour limit, and did not enter the secured unit due to lack of experience and discomfort; she stated she rounded on all other residents only once during the shift. She also reported that the two RNs on duty did not assist with resident care or check on the secured unit. Other CNAs and an LVN stated that staffing was frequently short, that there were often only two CNAs for the entire building when three to four were believed necessary, and that the secured unit was sometimes observed unattended early in the morning. The ADON acknowledged there was no facility policy specifying minimum staffing levels or required actions when staff failed to report, and confirmed that on the night in question only one NA was in the building from 10 p.m. to 4 a.m., with no CNA coverage from 4 a.m. to 6 a.m. The ADON stated that everyone in the building was expected to round on residents every two hours, but also stated she was not aware that the NA did not round on the secured unit and relied on RN reports that everything was under control. A family member of one resident reported that a room camera showed no staff checking on the resident from approximately 9:30 p.m. to 5:30 a.m. that night. A nurse familiar with the resident’s condition stated that this resident, who was bedfast, on hospice, and exhibited restless movements, required monitoring every two hours due to fall risk. Another RN reported that on the understaffed overnight shift, medications were administered late, residents were not rounded on every two hours, and no staff member was assigned to the secured memory care unit, with management aware of the staffing concerns.
Incomplete and Missing Out of Hospital DNR Documentation
Penalty
Summary
The facility failed to ensure that advance directive information was properly completed and available in the electronic health record for three residents reviewed. Resident #1 was admitted with multiple diagnoses including pneumonia, dysphagia, dementia, COPD, respiratory failure, kidney failure, and a history of falls. Her admission MDS showed a BIMS score of 07, indicating severe impairment. Her care plan listed her advance directive as full code, and the electronic health record did not contain an Out of Hospital DNR at the time of review, although the record later showed an Out of Hospital DNR had been signed and uploaded after the review time. A doctor’s order also reflected a DNR directive. Resident #4 was admitted and later readmitted with diagnoses including unspecified dementia, type 2 diabetes mellitus, hyperlipidemia, major depressive disorder, and COPD. Her quarterly MDS showed a BIMS score of 01, indicating severe cognitive impairment. Her order summary reflected DNR status, and her electronic record contained an Out of Hospital DNR form dated [DATE]. However, the physician statement section of the form had no physician signature, no date, no printed name, and no license number. The section requiring all persons who signed above to sign below also had no physician signature. Her care plan stated that she had chosen do not resuscitate and that her wishes would be honored. Resident #65 was admitted and readmitted with a primary diagnosis of cerebral infarction and was located in the secured unit. Her quarterly MDS showed a BIMS score of 09, indicating moderate cognitive impairment. Her face sheet and care plan both listed DNR as the advance directive and code status, with the goal that the patient’s wishes would be honored. Review of her clinical record showed an Out of Hospital DNR form dated [DATE], but the section requiring the physician’s signature was not signed. Staff interviews confirmed that a physician signature was required for the Out of Hospital DNR to be valid and that valid forms were to be uploaded to the electronic health record. Staff also stated that if a valid Out of Hospital DNR was not in the electronic health record, the resident might be treated as full code and CPR could be initiated.
Food Storage and Refrigeration Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen walk-in freezer and the nourishment room refrigerator. In the walk-in freezer, several boxes of frozen food were stacked on top of each other and were observed to be crushed, smashed, wet from condensation, and covered with ice. Several frozen food items were not properly sealed, were exposed to air, and were not dated. One box of frozen garlic bread was not properly sealed and exposed to air, and one bag of frozen cookie dough was not properly sealed, exposed to air, and not labeled or dated. The freezer cooling machine was also observed with condensation water dripping onto boxes of frozen food and the shelving unit. In the nourishment room, the refrigerator temperature log showed temperatures of 44 degrees on multiple days, then 48 degrees and 49 degrees on later observations. The thermostat inside the refrigerator was observed at approximately 47 degrees, 48 degrees, and 49 degrees. The refrigerator contained resident food and drinks, including opened bottles of soda, canned sodas, salad dressing, nourishable shakes, a plastic bag containing food, and pudding cups from the kitchen. Several items in the refrigerator were not labeled or dated. Staff interviews showed that the refrigerator was used for residents' drinks and food, that nursing staff monitored the temperature, and that staff were responsible for labeling and dating items placed in the refrigerator. Interviews with nursing, dietary, and administrative staff showed inconsistent understanding of the proper refrigerator temperature and the requirements for labeling, dating, sealing, and storing food. The DON stated he did not know the correct temperature range at first and later stated the range should be between 35 degrees and 46 degrees, while other staff gave different answers. The DM, CDM, CKs, and nursing staff stated that opened food should be sealed, labeled, and dated, and that food not properly sealed, labeled, or dated should be discarded. Facility policies reviewed stated that open packages of food are to be stored in sealed bags or covered containers and dated when opened, and that potentially hazardous food shall be maintained at 41 degrees F or less or 140 degrees or above.
Smoking Materials Left on Residents During Smoke Break
Penalty
Summary
The facility failed to ensure that its smoking policies were formulated, adopted, and enforced for three residents who smoked. During observation of a smoke break, Resident #20 was seen with a pack of cigarettes in her bra, Resident #5 was seen pulling a pack of cigarettes and a lighter out of his pocket, and Resident #78 was seen with a pack of cigarettes in her pocket. The facility records for these residents stated that smoking materials were to be kept at the nurses’ station, and the smoking policy stated that matches, lighters, or other ignition sources were not permitted to be kept or stored in the resident’s room. Resident #5 was a male with diagnoses including end stage renal disease, unsteadiness on feet, atrial fibrillation, COPD, dementia, low back pain, hyperlipidemia, legal blindness, hypertension, insomnia, and tobacco use. His MDS reflected a BIMS score of 12 and identified him as a current tobacco user. His care plan stated he was an everyday smoker and included interventions such as keeping the lighter at the nurses’ station with cigarettes in a smoking box, supervision based on smoking assessment, and smoking only in designated areas with a smoking apron. His smoking assessment stated he was safe to smoke unsupervised and that all smoking materials would be kept at the nurses’ station. Resident #20 was a female with diagnoses including cerebral infarction, dementia, seasonal allergies, NSTEMI, type 2 diabetes mellitus, hyperlipidemia, and cardiomyopathy. Her MDS showed a BIMS score of 09 and did not identify her as a current tobacco user, but her care plan stated she was an everyday smoker and included assistance to and from the designated smoking area, observation for unsafe smoking behaviors, no cigarettes or smoking material on her person, and use of a smoking apron. Her smoking assessment also stated she was safe to smoke unsupervised and that all smoking materials would be kept at the nurses’ station. Resident #78 was a female with diagnoses including multiple pelvic fractures, protein-calorie malnutrition, type 2 diabetes mellitus without complications, and a history of TIA. Her MDS showed a BIMS score of 09 and did not identify her as a current tobacco user, but her care plan stated she smoked and included designated smoking areas, no oxygen in the smoking area, no smoking materials or igniters stored in resident rooms, monthly safe smoking assessments, and that she was safe to smoke unsupervised. Her smoking assessment also stated that all smoking materials would be kept at the nurses’ station.
Care Plans Not Updated to Reflect DNR Status
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for 2 of 10 residents whose code status changed from full code to DNR. Resident #7 was admitted with diagnoses including COPD, type 2 diabetes mellitus, and bipolar disorder, and her advance directive listed DNR. Her change-of-condition MDS reflected a BIMS of 11, indicating moderate cognitive impairment. However, her care plan was documented as full code on two care plan entries even though an Out of Hospital DNR was signed and a DNR order was entered into the record. Resident #1 was admitted with multiple diagnoses including pneumonia, dysphagia, hypertension, dementia, history of falling, shoulder pain, asthma, wheelchair dependence, COPD, anemia, hyperlipidemia, respiratory failure, kidney failure, and UTI. Her quarterly MDS reflected a BIMS score of 07, indicating severe impairment. Her care plan also remained full code even though the record showed an Out of Hospital DNR was signed, uploaded to the medical record, and a doctor’s order for DNR was signed. During interviews, the MDS LVN, SW, MR LVN, DON, and ADM all stated that when a resident changes advance directives to DNR, the care plan should be updated to reflect that change. They also stated they were unsure who was responsible for making the update, with responses indicating the task may have been assigned to the MDS LVN, the SW, or shared among staff. The facility policy stated that the comprehensive care plan must reflect the resident’s rights, including the right to refuse treatment, and should be updated as resident preferences and goals change.
Missed Ordered Wound Care for a Resident With a Stage IV Heel Pressure Injury
Penalty
Summary
The facility failed to ensure ordered wound care was provided for a resident with a stage IV pressure injury to the right heel. The resident had diagnoses including unspecified dementia, type 2 diabetes mellitus, hyperlipidemia, major depressive disorder, and chronic obstructive pulmonary disease, and the quarterly MDS showed severe cognitive impairment with one or more pressure ulcers/injuries. The wound care physician ordered daily cleansing of the right heel wound with normal saline or wound cleanser, application of collagen, and coverage with calcium alginate and protective foam secured with kerlix and tape. Review of the treatment administration record showed no wound care treatment signed off on six dates in July and August 2025. The missed treatments were on 07/19/2025, 07/20/2025, 07/24/2025, 08/02/2025, 08/03/2025, and 08/04/2025. The most recent wound care physician note before the survey exit documented the wound as improved, with decreased necrotic tissue and decreased surface area. During interviews, the wound care LVN stated she was responsible for wound care when scheduled and that charge nurses were responsible when she was off duty. She stated the record showed no wound care was performed on several of the listed dates and said she had performed wound care on 08/04/2025 but forgot to sign it off. She also stated she removed a dressing on 08/04/2025 that had her initials and the date of 08/01/2025, indicating no wound care had been provided for the prior two days, and that she notified the DON but did not document it. The DON, MDS LVN, and ADM all stated wound care was to be performed as ordered and signed off after completion, and the DON stated the nurse responsible for wound care on 07/19/2025 and 07/20/2025 was no longer working at the facility.
Expired Medications and Incorrect Controlled Substance Count
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident by not ensuring accurate medication storage and controlled substance accounting. Resident #8 was admitted with epilepsy, cognitive communication deficit, and cerebral palsy, and had an order for Phenobarbital oral elixir 20 mg/5 mL, 15 mL via PEG tube twice daily for seizures. During observation of the hall 5 nurses’ medication cart, a bottle of phenobarbital labeled for Resident #8 was present, and the narcotic count sheet showed an amount remaining of 1397 mL. Record review showed the facility had received 2 bottles totaling 946 mL on 07/17/2025, but the staff member who received the medication doubled the starting amount to 1892 mL on the count sheet. During interview, the WC LVN stated she had just received the keys and did not count with the previous person because she was nervous about the medication administration observation. She stated it appeared the staff member who received the medication doubled the amount because there were two bottles, and staff had been subtracting doses from the incorrect total instead of counting what was actually present. The DON and WC LVN later completed a corrected medication count of 973 mL. The DON stated staff were expected to count the medication in front of them and not calculate the remaining amount based on previous totals. The facility also failed to remove expired medications from storage areas. Observation of the medication storage room revealed three bottles of Oyster Shell Calcium with Vitamin D 500 mg-5 mcg with an expiration date of 06/2025. Observation of the hall 1 nurses’ medication cart revealed one bottle of Bismuth Subsalicylate 525 mg/30 mL with an expiration date of 08/2024. Staff interviews showed there was no specific staff member or timeline assigned for checking the medication storage room for expired medications, and staff were unsure who was responsible for checking medication carts or how often those checks occurred. The DON stated there was not a process in place for ensuring the medication storage room was checked for expired medications, and he expected nurses and medication aides to check medication carts every shift for expired medications.
Unsecured Medication Cart Left Unattended
Penalty
Summary
The facility failed to ensure the hall 1 nurse's medication cart was stored and secured in accordance with its medication storage policy when it was left unattended and unlocked. On 08/07/2025 at 10:23 AM, an observation on hall 1 showed the nurses' medication cart for hall 1 left unattended and unlocked. During an interview at 10:25 AM, LVN G stated she was responsible for the cart and had forgotten to lock it when she walked down hall 1. She stated that leaving the cart unlocked could negatively impact a resident because anyone could get into the cart and take something they were not supposed to. Multiple staff members interviewed later that day stated the facility's expectation was to lock the medication cart any time staff walked away from it, and that the staff member with the keys was responsible for securing it. The WC LVN, MDS LVN, MR LVN, DON, and ADM each stated that medication carts should be locked when unattended and that staff were responsible for monitoring carts during rounds. Record review of the facility policy titled Medication Storage in the Facility stated that medications and biologicals are to be stored safely and securely, and that medication rooms, carts, and supplies are locked or attended to by persons with authorized access.
Failure to Accurately Document Skin Assessment Findings
Penalty
Summary
A deficiency occurred when a resident with a history of cognitive communication deficit, dementia, and risk for pressure ulcers did not receive an accurate skin assessment as required by professional standards and the facility's policy. On the date in question, the resident's weekly skin assessment was documented as having no new skin integrity issues by a TN. However, direct observation revealed multiple small red scratch-like marks under both of the resident's eyes, which were not documented in the assessment. The resident was unable to be interviewed due to severe cognitive impairment. When the LVN was shown the resident, she acknowledged the presence of scratch marks and stated that such findings should be documented in a skin assessment. The TN who completed the assessment admitted she did not document the scratches, explaining she typically only records issues that require treatment, such as skin tears or open areas. The DON confirmed that scratches should be documented as they represent a break in the skin and could worsen. The facility's policy requires a head-to-toe skin assessment, including documentation of any redness, bruising, rashes, blisters, skin tears, open areas, ulcers, and lesions.
Failure to Timely Report Alleged Abuse, Neglect, and Injuries to State Agency
Penalty
Summary
The facility failed to ensure timely reporting of alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, to the State Agency as required. In multiple instances, incidents involving residents were not reported within the mandated timeframes. For example, an incident involving a resident who was struck by a family member, resulting in facial bruising, was not reported to the State Agency within two hours as required for events involving bodily injury. The facility became aware of the incident in the evening, but the report was not submitted until the following day. In another case, two residents were involved in a physical altercation after one resident entered the other's room. Although staff intervened and assessed both residents for injuries, and an incident report was completed, the event was not reported to the State Agency. Interviews with staff revealed a lack of clarity regarding the need to report resident-to-resident altercations as potential abuse or neglect, and the incident was only documented internally. Additionally, a resident who sustained a fall and was later found to have a right hip fracture did not have the incident reported to the State Agency within the required timeframe after x-ray results confirmed the injury. The x-ray findings were available to the facility, but the report to the State Agency was delayed. Staff interviews indicated that while internal notifications and assessments were performed, external reporting requirements were not consistently met. Facility policies required immediate reporting of such incidents, but these were not followed in the cited cases.
Failure to Protect Residents from Physical Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from physical abuse and neglect in two separate incidents involving residents with severe cognitive impairment. In the first incident, a male resident with severe dementia, depression, and a history of wandering and physical aggression was involved in an altercation with a family member (FM) visiting another resident. The resident, who had a BIMS score indicating severe cognitive impairment and a care plan noting lack of awareness of personal boundaries, became agitated and physically struck the FM. The FM responded by hitting the resident in the face, resulting in visible bruising. Staff interviews and documentation confirmed that the resident was not adequately supervised at the time, and the altercation was not prevented. In the second incident, another resident with severe cognitive impairment and a history of wandering entered the room of a different resident. The resident whose room was entered responded by physically striking the wandering resident after a verbal exchange. Staff observed the incident and separated the residents, but the event was initially treated as a general incident rather than as potential abuse or neglect. The care plans for both residents did not adequately address the risk of resident-to-resident altercations, and staff interviews revealed inconsistent understanding of how to identify and report abuse in such situations. Both incidents demonstrate failures in supervision and in the implementation of care plans designed to address known behavioral risks. The facility did not ensure that residents with a history of wandering and aggression were adequately monitored or that interventions were in place to prevent altercations with other residents or visitors. Documentation and interviews indicate that staff were aware of the residents' behavioral histories but did not take sufficient action to prevent or immediately recognize abuse and neglect when it occurred.
Lack of Physician Orders for Suctioning in High-Risk Resident
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility did not have a physician's order for suctioning, monitoring for secretions, or instructions on when to replace the suction machine's cannister and tubing for a resident who was at risk of aspiration. The resident, a male with a history of aspiration pneumonia, cerebral infarction, anoxic brain injury, dysphagia, and hypoxemia, was observed struggling to breathe and pointing to his suctioning machine, indicating distress and the need for suctioning. Interviews with staff revealed that the resident had started having secretions after a recent hospital visit for aspiration pneumonia. The resident's care plan and physician orders did not include necessary instructions for suctioning, despite the resident's high risk of aspiration. The MDSC noted that an order for PRN suctioning should have been in place, especially for a resident who is NPO and unable to communicate their needs. The facility's failure to have appropriate orders and monitoring in place could lead to serious health risks for the resident.
Failure to Reinstate Wound Treatment Orders
Penalty
Summary
The facility failed to ensure that a resident received necessary treatment and services to promote wound healing and prevent new pressure ulcers from developing. This deficiency was identified for one resident who was readmitted from the hospital without having her wound treatment orders reinstated. As a result, her existing wounds worsened, and she acquired a new pressure injury during the period from her readmission until the treatment orders were reinstated. The resident, who was cognitively intact, had a history of pressure ulcers, diabetes, and other health conditions that increased her risk for skin integrity issues. Upon her readmission, the facility did not reinstate her wound treatment orders, which were crucial for managing her pressure injuries. The absence of these orders led to a deterioration in her condition, as evidenced by the worsening of her existing wounds and the development of a new pressure injury. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's treatment needs following her readmission. The wound care director was unaware that the resident went without treatment orders, and the director of nursing acknowledged that it was the responsibility of the admitting nurse to reinstate all orders. This oversight in care management placed the resident at risk for further complications, including infection and pain.
Failure to Ensure Resident Privacy by Not Knocking Before Entering Rooms
Penalty
Summary
The facility failed to ensure the personal privacy of four residents by not knocking on their doors before entering their rooms. This deficiency was observed during meal tray delivery, where a CNA entered the rooms of these residents without knocking. The CNA admitted to saying 'knock, knock' instead of physically knocking, citing difficulty in carrying meal trays as the reason for not knocking. This practice was contrary to the facility's policy, which mandates knocking and announcing oneself before entering a resident's room to protect their right to privacy. Interviews with staff, including the CNA, AM, DON, and ADM, revealed that all were aware of the policy requiring staff to knock before entering a resident's room. They acknowledged the importance of this practice in respecting residents' privacy and preventing feelings of invasion. Despite this awareness, the CNA did not adhere to the policy, and the AM was unaware of her failure to knock. The DON emphasized the importance of knocking for residents' rights and privacy, while the ADM reiterated that all staff and visitors should knock before entering. Interviews with the residents involved showed mixed reactions. One resident stated that staff usually knock, and it does not bother her when they do not. Another resident expressed a preference for staff to knock every time, although she was unsure of her feelings when they did not. The facility's policy on residents' rights, dated 2012, clearly states that staff must always knock and ask permission to enter a resident's room, with exceptions only in life-threatening situations or when the resident is unable to respond.
Infection Control Lapse in Equipment Sanitization
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in the use of a wrist blood pressure monitor for four residents. Licensed Vocational Nurses (LVNs) C and D did not clean and disinfect the wrist blood pressure monitor between uses on different residents. This oversight was observed during blood pressure monitoring of Residents #10, #39, #60, and #131. The failure to sanitize the equipment could potentially lead to the transmission of infections among residents. Resident #10, a female with multiple health conditions including hypertension and coronary artery disease, had her blood pressure taken by LVN C, who did not sanitize the monitor before using it on Resident #39. Resident #39, a male with hypertensive heart disease and other conditions, was subsequently monitored with the same unsanitized equipment. Both residents had care plans that required monitoring of vital signs due to their cardiovascular conditions. Similarly, LVN D failed to sanitize the wrist blood pressure monitor before and after using it on Resident #60, a female with dementia and hypertension, and Resident #131, a female with dementia and congestive heart failure. Both LVNs acknowledged the importance of sanitizing equipment to prevent disease transmission but admitted to lapses in practice. The facility's policy mandates that all equipment used for resident care be cleaned with an approved disinfectant before and after each use, a protocol that was not followed in these instances.
Failure to Serve Meal Trays Simultaneously
Penalty
Summary
The facility failed to treat a resident with respect and dignity during dining services, as observed on 07/09/2024. Resident #15, who has a range of medical conditions including dementia, Alzheimer's disease, and difficulty swallowing, did not receive her lunch tray at the same time as her table mate, Resident #35, and other residents in the dining room. This delay in serving her meal tray was noted during an observation at 12:00 pm, where Resident #35 received her meal at 12:08 pm, while Resident #15 did not receive hers until 12:23 pm. Interviews with staff, including CNAs and the Director of Nursing (DON), revealed that the facility's policy for dining tray pass requires all residents at the same table to receive their meal trays before staff move on to the next table. However, this policy was not followed, as staff passed trays to other residents in the dining room before realizing that Resident #15 had not received her meal. Staff interviews indicated that the kitchen being busy was sometimes a reason for delays, but no specific reason was given for the delay in Resident #15's case. The facility's Dining and Meal Service Policy, dated 08/01/2012, states that individuals at the same table should be served and assisted at the same time. Despite this policy, the staff, including the Administrator, acknowledged that Resident #15's meal tray was not served in accordance with the policy, which could lead to the resident feeling left out or forgotten. The staff did not provide a clear explanation for the oversight, indicating a need for better attention to ensure all residents are served simultaneously as per the facility's policy.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a necessary accommodation for resident needs and preferences. This deficiency was observed during a survey on 07/11/24, where Resident #47's call light was found on the floor and out of reach. The resident, a male with a history of dementia, dysphagia, cerebral infarction, and osteoarthritis, was unable to complete a cognitive assessment and was dependent on assistance for daily activities. Despite being non-verbal, the resident was observed to be clean and not in distress at the time of the survey. Interviews with multiple staff members, including a medical assistant, licensed vocational nurse, certified nursing assistant, the administrator, and the director of nursing, confirmed that they had been trained on the importance of call light placement. They acknowledged that call lights should always be within reach to prevent incidents or accidents and to ensure residents can call for help if needed. The facility's policy, as referenced from a clinical nursing skills book, also emphasized the importance of maintaining call lights within reach for resident safety.
Failure to Provide Adequate Nail Care for a Resident
Penalty
Summary
The facility failed to provide adequate nail care for a resident, identified as Resident #57, who was unable to perform activities of daily living independently. The resident, a male with a history of atrial fibrillation, dementia, dysphagia, and bipolar disorder, required assistance with personal hygiene, including nail care, as outlined in his comprehensive care plan. Despite this, observations revealed that the resident's fingernails were jagged, slightly long, and dirty, with a thick brown substance underneath each nail. Interviews with the resident and staff members highlighted a breakdown in communication and responsibility regarding nail care. The resident reported requesting nail care from a staff member a week prior, but was informed that a foot doctor was needed due to his diabetic condition. However, the resident had not seen a foot doctor since his admission. Staff interviews revealed that CNAs were responsible for checking and maintaining residents' nail hygiene, and if a resident was diabetic, the nurse should have been informed to handle the nail care. Despite this protocol, the resident's nails remained uncleaned and untrimmed. The facility's staff, including the MA, LVN, CNA, ADM, and DON, acknowledged their training in ADLs and nail care, and recognized the potential risks of infection and dignity issues associated with poor nail hygiene. However, the failure to ensure Resident #57's nails were properly maintained indicated a lapse in the execution of these responsibilities. The facility's policies for ADL and nail care were requested but not detailed in the report, leaving a gap in understanding the specific procedural failures that led to this deficiency.
Failure to Provide Specialized Rehabilitative Services
Penalty
Summary
The facility failed to provide specialized rehabilitative services as required for two residents. Resident #1, a [AGE] year-old female admitted for aftercare following joint replacement surgery, did not receive physical therapy (PT) and occupational therapy (OT) as ordered. Her physician orders specified PT services five times a week for five weeks and OT services five times a week for eight weeks. However, documentation showed she only received PT three times and OT twice since her admission. The Director of Rehabilitation (DOR) acknowledged the shortfall, citing staffing issues and personal illness as reasons for the missed sessions. The Assistant Director of Nursing (ADON) also confirmed the inconsistency in therapy services due to staffing problems with the contract agency providing therapy services. Resident #2, a [AGE] year-old female admitted with diagnoses including cerebral infarction and major depressive disorder, was not evaluated for PT, OT, or speech therapy (ST) upon admission as ordered in her clinical records. Her quarterly care plan indicated she had impaired neurological status related to a stroke, but she was not receiving any PT or OT. The DOR stated she was not notified about Resident #2 needing therapy until the resident verbally requested it. The ADON mentioned that they were waiting for insurance approval for Resident #2's therapy services. Both residents expressed dissatisfaction with the therapy services provided, with Resident #1 planning to discharge to home health services due to inadequate therapy at the facility. Interviews with facility staff revealed systemic issues in the therapy department, including inconsistent therapist availability and lack of communication regarding therapy needs. The ADON and DOR both acknowledged the negative impact of not providing therapy as ordered, which could lead to a decline in residents' physical abilities. The Administrator admitted that the current DOR had been irresponsible with her leadership and had not ensured adequate therapy coverage during her absence. The facility's policy on the frequency, duration, and intensity of therapy services was not adhered to, resulting in the deficiencies observed.
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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 Lockhart
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Parkview Nursing And Rehabilitation Center | 1.4 mi | ★★★★★ | 8 | 3 |
| Avir At Magnolia | 13 mi | ★★★★★ | 21 | 2 |
| Avir At Luling | 13.6 mi | ★★★★★ | 17 | 0 |
| Diversicare Of Luling | 14.9 mi | ★★★★★ | 0 | 0 |
| Legend Oaks Healthcare And Rehabilitation-kyle | 15.5 mi | ★★★★★ | 9 | 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 August 2026) and official state health department websites.