Health inspection·April 12, 2024

F 0825 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 04/08/24 it was documented that a therapist was unavailable and on 04/11/24 it reflected [Resident #1] declines participation with PT on this date reporting increased knee pain, stomach cramps, and legs hurting despite pain medication. Review of Resident #1's OT documentation, on 04/12/24, reflected she received OT services on 04/07/24 and 04/11/24. Review of Resident #2's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), muscle wasting and atrophy (wasting away), major depressive disorder, and other lack of coordination. Review of Resident #2's quarterly MDS, dated [DATE], reflected a BIMS of 6, indicating a severe cognitive impairment. Section O (Special Treatments, Procedures, and Programs) reflected she was not receiving any PT or OT. Review of Resident #2's quarterly care plan, revised 02/09/24, reflected she had impaired neurological status related to cardiovascular accident (stroke) and hemiplegia/hemiparesis (paralysis) on the right side with an intervention of observing her for changes in condition. Review of Resident #2's MD assessment/admission clinical records, dated 10/11/23, reflected the following: HPI: [Resident #2] is here to initiate nursing home admittance to (facility). Orders: PT and OT for ROM and balance Orders: ST for cognitive therapy Review of Resident #2's NP progress note, dated 11/07/23, reflected the following: . Recommend following up with therapy PT/OT eval . Review of Resident #2's OT documentation, dated 02/21/24, reflected she was evaluated for OT services with a goal of being able to pull her pants up. Review of Resident #2's PT documentation, dated 03/06/24, reflected she was evaluated for PT services with a goal of getting her right leg strong. During an observation and interview on 04/12/24 at 9:48 AM revealed Resident #1 and #2 sitting outside. Resident #1 stated she had received therapy maybe three times since she was admitted . She stated she had her hip replaced and it was important to her that she get strong enough to go back to living independently at her home. She stated the therapy she was receiving was inadequate and she was discharging from the facility the following Wednesday, 04/17/24, with home health services. She stated she had used the home health agency in the past and believed they provided more effective therapy than she was receiving at the facility. Resident #2 then stated when it came to therapy, she had not received shit since she was admitted . She was irritated and stated she could not understand why. She stated they (staff) had told her she was on some kind of damn list. During an interview on 04/12/24 at 10:04 AM, the ADON stating there had been issues with the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675053 If continuation sheet Page 2 of 3 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 04/12/2024 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)

F 0825 Level of Harm - Minimal harm or potential for actual harm therapy department. She stated they utilized a contract agency for therapy services and the DOR had been struggling to get staffing. She stated there were therapists at the facility five days a week but they were never the same days. She stated her expectations were that Resident #1 was getting therapy five times a week. She stated she was not sure if that had been happening. She stated Resident #2 recently got evaluated for PT and OT and they were waiting on her insurance to approve the services. Residents Affected - Few During an interview on 04/12/24 at 11:42 AM, the DOR stated she was notified in morning meetings when residents needed therapy evaluations. She stated she was never notified about Resident #2 needing therapy until she verbally requested it. She stated they were still waiting on her insurance for approval. She acknowledged Resident #1 had only received PT three times and OT twice since her admission. She was unable to give any explanation as to why that happened except, she stated she had been out sick earlier in the week (04/08/24 - 04/10/24) and since she was the main PTA, PT was not provided those days. She stated they have a COTA who provides OT Thursdays - Sundays, except they did not come the previous Thursday - Sunday (03/28/24 - 03/31/24) and was looking into why they did not come. She then stated the COTA was PRN and did not have a set schedule. She stated a negative outcome of residents not receiving therapy as ordered could be a decline in physical ability and they would not meet their goals. During an interview on 04/12/24 at 12:37 PM, the ADM stated her expectations were that therapy was provided as ordered. She stated she did not have a DON so it was the responsibility of the ADON and the MRD to review clinicals upon a resident's admission. She stated neither her current ADON or MRD were working at the facility when Resident #2 was admitted and she had not known she should have been receiving therapy. She stated her current DOR had already put in her two weeks and she (the DOR) had been irresponsible with her leadership. She stated the DOR had not been utilizing the tools she had. She stated she was out earlier in the week (DOR) and did not even notify her leadership to ensure another PT was sent to the facility. She stated they had already ensured therapists would be at the facility today and carrying on through next week. She stated if residents did not receive therapy per their orders, a negative outcome could be they may not meet their goals. Review of the facility's Frequency/Duration/Intensity of Therapy Services, dated 2024, reflected the following: It is the policy that therapists both employees and contractors determine frequency, duration, and intensity of therapy services to provide to each patient for optimal functional outcomes and expectation of improvement of quality of life. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675053 If continuation sheet Page 3 of 3