Inspection·May 25, 2023

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment for 4 of 18 (resident # 8, # 24, # 45, and #55,) residents reviewed for accuracy of assessment. Residents Affected - Some -The facility failed to ensure that for Residents # 8, # 24, # 45, and #55, the MDS assessment correctly noted the resident's lack of natural teeth, tooth fragments, and/or dentures. -The facility failed to accurately assess Resident #24 for his mental illness (qualifying diagnoses) on his annual MDS assessment. These failures could place residents at risk for not receiving care and services to meet their needs. Findings included: Resident # 8 Record review of Resident #8's face sheet, dated 05/25/2023, reflected a-[AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included, end stage renal diseases (kidney failure) heart failure, lack of coordination (inability to walk), Dementia (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life) major depressive disorder and type 2 diabetes (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel). Record review of Resident #8's Annual MDS assessment, dated 07/29/2022, revealed a BIMS score of 11 out of 15 reflected moderately impaired cognition. Further review of section L oral\ dental status -A -G was left blank. Letter Z none of the above were present was checked indicating that Resident # 8 had no dental concerns. Record review of Resident #8's care plan dated 05/16/2019 with a revision date of 04/06/23 read in part Resident #8 dentition (pertains to the development of teeth and their arrangement in the mouth) is very poor. Intervention: Encourage resident to do good oral care date initiated 05/16/19, provide diet as ordered. Observation and interview on 05/23/23 at 10:00am revealed Resident #8 was in his room. Observation (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 10 Event ID: 675053 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675053 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chisolm Trail Nursing and Rehabilitation Center 107 N Medina Lockhart, TX 78644 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)