Chisolm Trail Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Chisolm Trail Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF686Aug 31, 2024

  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. The facility failed to reinstate Resident #1's wound treatment orders after she was readmitted from the hospital on 07/11/24 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. […]

• Actual harm, patternF697Aug 23, 2026

  Based on interview and record review the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preference for 1 of 17 residents (Resident #3) reviewed for pain management. The facility failed to consistently and accurately monitor Resident #3's pain levels beginning 05/25/2026 until she was hospitalized on [DATE]. On 08/04/2026 Resident #3's nursing note by LVN B reflected that she was in pain. Resident #3's increased pain was documented in nursing notes by RN A, RN B, and LVN C. Resident #3 was sent to the hospital on [DATE] when she was in excruciating pain and diagnosed with bilateral sacral fractures. […]

• Actual harm, patternF726Aug 23, 2026

  Based on interview and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services by failing to appropriately assess, manage, and respond to acute, extreme levels of pain for 1 of 8 residents (Resident #3). The facility failed to ensure nurses caring for Resident #3 accurately documented her long-term pain levels in PCC (electronic health record). After a fall on 07/13/2026 a nursing note by LVN B dated 08/04/2026 reflected Resident #3 began complaining of pain. Nurses' notes reflected that Resident #3's pain increased and her ADLs declined. Resident #3 was sent to the hospital on [DATE] and diagnosed with bilateral sacral fractures. […]

• No harm, potential for more than minimal, patternF689Jul 14, 2026

  Based on interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #3) reviewed for use of mechanical lifts. The facility failed to ensure mechanical lifts were always operated by two staff members during transfer of residents for Resident #3 on 04/17/2026 (by CNA A) and 06/14/2026 (by CNA B). This failure placed residents at risk of injury.Findings included: Review of the undated face sheet for Resident #3 reflected an [AGE] year-old female admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, patternF578Aug 7, 2025

  Based on interview and record review the facility failed to ensure residents had the right to request, refuse, and/or discontinue treatment, to participate in experimental research, and to formulate advance directives for 3 of 10 residents (Resident #1, #4 and #65) reviewed for advance directives. The facility failed to ensure that Resident #1's out of hospital DNR was uploaded to the electronic health record and the care plan was updated.The facility failed to ensure that Resident #4's out of hospital DNR was signed by the physician and uploaded to the electronic health record on [DATE].The facility failed to ensure that Resident #65's out of hospital DNR was signed by the physician and uploaded to the electronic health record on [DATE]. […]