Inspection·August 31, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice to promote wound healing and to prevent new pressure ulcers from developing for one (Resident #1) of three residents reviewed for pressure injuries. Residents Affected - Some The facility failed to reinstate Resident #1's wound treatment orders after she was readmitted from the hospital on [DATE] until 07/16/24. Her wounds worsened and a new pressure injury was acquired during that timeframe. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 08/30/24 at 1:44 PM. While the IJ was removed on 08/31/24 at 12:55 PM, the facility remained at a level of actual no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of improper wound management, the development of new pressure injuries, deterioration in existing pressure injuries, infection, and pain. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including pressure ulcers, diabetes, history of sepsis (a serious condition in which the body responds improperly to an infection), adult failure to thrive, and muscle wasting and atrophy (wasting away). Review of Resident #1's readmission MDS assessment, dated 07/18/24, reflected a BIMS of 14, indicating she was cognitively intact. (Section M) Skin Conditions reflected she was at risk of developing pressure ulcers/injuries and had one stage II, one stage III, and one stage IV pressure injury. Review of Resident #1's quarterly care plan, dated 07/02/24, reflected she was at risk of developing pressure ulcers with interventions of conducting weekly skin inspections and providing treatments as ordered. Review of Resident #1's hospital discharge paperwork from her hospitalization from 07/07/24 - 07/11/24, reflected the following: PTWC consulted for management of CAPIs to L buttocks and sacrum. [Resident #1]'s CAPI to L buttocks measures 1x1.5 cm and appears to be a stage 2. Wound consists of 100% red viable tissue. CAPI to coccyx measures 1x0.5 cm and consists of 50% slough and 50% red viable tissue after selective (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 7 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 08/31/2024 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)