CHISOLM TRAIL NURSING AND REHABILITATION CENTER

Nursing Home Inspector

107 N MEDINA
LOCKHART, TX 78644
Caldwell County
Phone: 512-398-5213
Provider Number: 675053
Last Inspection: 09/21/2017

About the Nursing Home

Number of Beds: 96
Number of Residents: 67
Beds Available: 29
Percent Occupancy: 70%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

64

Facility
35

County
22

TX
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

64

2017
46

2016
46

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

9/21/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep residents' personal and medical records private and confidential. Pattern : Minimal 4 9/22/2017
 
Failed To: Allow residents to easily view the results of the nursing home's most recent inspection. Widespread : Potential 4 9/22/2017
 
Failed To: Reasonably accommodate the needs and preferences of each resident. Pattern : Minimal 4 10/12/2017
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Pattern : Minimal 4 10/20/2017
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Pattern : Minimal 4 10/20/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 9/22/2017
 
Failed To: Ensure residents maintain acceptable nutritional status. Pattern : Minimal 4 9/22/2017
 
Failed To: Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Pattern : Minimal 4 9/22/2017
 
Failed To: Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed. Pattern : Minimal 4 9/22/2017
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Potential 4 9/22/2017
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Pattern : Minimal 4 10/20/2017
 
Failed To: At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. Pattern : Minimal 4 9/28/2017
 
Failed To: Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Widespread : Potential 4 9/22/2017
 
Failed To: Make sure that a working call system is available in each resident's room or bathroom and bathing area. Pattern : Minimal 4 10/11/2017
 
Failed To: Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. Pattern : Minimal 4 10/20/2017
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Pattern : Minimal 4 10/20/2017
 

9/29/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 10/1/2016
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 10/1/2016
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Pattern : Minimal 4 10/1/2016
 
Failed To: Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. Pattern : Minimal 4 10/1/2016
 
Failed To: Ensure residents maintain acceptable nutritional status. Pattern : Minimal 4 10/1/2016
 
Failed To: Ensure that residents are safe from serious medication errors. Pattern : Minimal 4 10/1/2016
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 10/1/2016
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Widespread : Minimal 5 10/1/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 10/1/2016
 
Failed To: Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Widespread : Potential 4 10/1/2016
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Widespread : Minimal 5 10/1/2016
 

10/9/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide residents with private access to a telephone. Pattern : Minimal 4 10/22/2015
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Pattern : Minimal 4 10/22/2015
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Pattern : Minimal 4 10/22/2015
 
Failed To: Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Pattern : Potential 3 10/22/2015
 
Failed To: Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Isolated : Minimal 3 10/22/2015
 
Failed To: Post nurse staffing information/data on a daily basis. Widespread : Potential 4 10/22/2015
 
Failed To: Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed. Pattern : Minimal 4 10/22/2015
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 10/22/2015
 
Failed To: Make sure that doctors visit residents regularly, as required. Pattern : Minimal 4 10/22/2015
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Pattern : Minimal 4 10/22/2015
 
Failed To: Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Widespread : Potential 4 10/22/2015
 
Failed To: Provide bedrooms that don't allow residents to see each other when privacy is needed. Isolated : Minimal 3 10/22/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

3/9/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Pattern : Minimal 4 4/5/2016
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Pattern : Minimal 4 4/5/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 4/5/2016
 
Failed To: Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Pattern : Minimal 4 4/5/2016
 

1/12/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 2/3/2016
 
Failed To: Provide or obtain dental services for each resident. Pattern : Minimal 4 2/3/2016
 

3/11/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 3/31/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg TX State Avg
Number of Residents 67 61.60 75.11
Registered Nurses 0.66 0.47 0.59
Licensed Practical / Vocational Nurses 0.83 0.64 0.94
Certified Nursing Assistants 1.58 1.44 2.20
Total Staff Hours 3.07 2.55 3.73

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% TX State Avg%
of high risk long-stay residents with pressure ulcers 3 6 6
of long-stay residents assessed and appropriately given the pneumococcal vaccine 73 94 91
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 38 86 92
of long-stay residents experiencing one or more falls with major injury 3 3 3
of long-stay residents who have depressive symptoms 1 3 3
of long-stay residents who lose too much weight 5 3 5
of long-stay residents who received an antianxiety or hypnotic medication 17 21 26
of long-stay residents who received an antipsychotic medication 11 15 17
of long-stay residents who self-report moderate to severe pain 6 4 5
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 28 19 20
of long-stay residents whose need for help with daily activities has increased 19 14 18
of long-stay residents with a catheter inserted and left in their bladder 3 1 2
of long-stay residents with a urinary tract infection 5 7 3
of low risk long-stay residents who lose control of their bowels or bladder 66 45 49
of short-stay residents assessed and appropriately given the pneumococcal vaccine 44 85 77
of short-stay residents who had an outpatient emergency department visit 12 14 13
of short-stay residents who made improvements in function 58 56 59
of short-stay residents who newly received an antipsychotic medication 0 4 2
of short-stay residents who self-report moderate to severe pain 15 12 12
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 24 74 74
of short-stay residents who were rehospitalized after a nursing home admission 30 25 23
of short-stay residents with pressure ulcers that are new or worsened 3 45 46