Cherokee Trails Nursing Home

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 1 of 1 facility (2 of 7 mechanical lift slings) and 1 of 4 residents (Resident #55) reviewed for hazards:1. The facility failed to ensure items labeled keep out of reach of children and a razor were not kept in a basin in Resident #55's room on the secured unit.2. The facility failed to remove faded, worn and damaged mechanical lift slings from service. This failure could result in a loss of quality of life due to injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles and included the appropriate accessory and cautionary instructions for 2 of 2 medication storage refrigerators reviewed for labeling and storage (medication storage refrigerator in the medication room on mid- hallway 100 and medication refrigerator for the front hallway 100). The facility failed to monitor and record temperatures of the refrigerator used for medication storage daily as required per facility policy for medication storage. This failure could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety for facility's only kitchen reviewed for food storage. 1. The facility did not ensure foods in the refrigerator, freezer and dry storage area were appropriately stored, labeled and dated when opened or removed from their original packaging or opened on 5/18/26. 2. The facility did not ensure food in the freezer was appropriately labeled and dated when removed from original packaging on 5/18/26. 3. The facility did not ensure food was not kept on the floor in kitchen and dry storage area on 5/18/26 and 5/19/26. 4. The facility did not ensure [NAME] C appropriately performed hand hygiene while preparing food for meal service on 5/19/26. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff, in 1 of two medications rooms (the front one hundred hallway medication room) reviewed for environmental concerns. The facility failed to ensure the medication room floor and under sink area, were free of roach droppings, and there was no open hole underneath the sink. These failures could place residents, staff and visitors at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, unsafe and creating a contamination risk (Additionally, cockroach droppings and skin proteins (tropomyosin) can trigger allergic reactions and worsen asthma or other respiratory conditions).

Inspectors wroteBased on interview and record review, the facility failed to ensure an encoded, accurate, and complete MDS admission assessment was transmitted to the CMS System within 14 days after completion for 1 of 6 residents (Resident #27) reviewed for admission MDS assessments. The facility failed to ensure Resident #27's Quarterly MDS assessments dated 1/5/2026 were transmitted within 14 days of completion. This failure could place residents at risk of not having records completed and submitted in a timely manner as required.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate MDS was completed for 1 of 4 residents reviewed for accuracy of assessments. (Resident #33). The facility failed to ensure the comprehensive MDS assessment dated [DATE] for Resident #33 wasn't miscoded for Parenteral/IV feeding (a method of delivering nutrients directly into the bloodstream for patients who cannot use their digestive system). This failure could place residents at risk of receiving inappropriate care and services.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #5) reviewed for infection control. The facility failed to ensure LVN F and CNA E wore the appropriate PPE when wound care was provided to Resident #5 who was on EBP on 5/20/2026. This failure could place residents at risk of exposure to infectious diseases due to improper infection control practices.

Inspectors wroteBased on interview and record review the facility failed to ensure each resident was treated with respect and dignity for 2 of 7 residents (Residents #1 and #2) reviewed for Resident Rights. The facility failed to ensure 09/10/2025, at 7:15 p.m., Resident #1 and Resident #2 were treated with dignity and respect when CNA A spoke rudely about taking them outside. This failure could place residents who smoke at risk of emotional distress and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and sanitary environment 3 of 12 residents (Residents #6, #9, and #19) reviewed for resident rights. The facility failed to provide Resident #6 a safe, clean, and sanitary environment on 3/17/2025 when the mattress on his bed was torn and his toilet seat was broken. The facility failed to provide Resident #9 a safe, clean, and sanitary environment on 3/17/25 when a foul sour odor was observed in her room. The facility failed to provide Resident #19 a safe, clean, and sanitary environment on 3/17/25 when his toilet had no toilet seat. These failures could place residents and visitors at risk for exposure to an unclean, unsanitary environment, risk of falls and other injuries due to an unsafe environment.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for 3 of 12 residents (Residents #18, #28, and #45) reviewed for accidents/hazards. The facility failed to remove worn and damaged mechanical lift slings from service from 03/17/2025 through 03/19/2025. This failure could place residents at risk of a loss of quality of life due to injuries.

Inspectors wroteBased on interview and record review, the facility failed to provide effective communications mandatory training for 4 of 14 employees (ADON, AD, CNA A and CNA F) reviewed for training, in that: The facility failed to ensure effective communication training was provided to the ADON, AD, CNA A and CNA F annually. This failure could place residents at risk of miscommunication and social isolation due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to provide the required compliance and ethics training for 3 of 14 employees (CNA A, CNA B and CNA F) reviewed for training in that: The facility failed to ensure annual compliance and ethics training was provided to CNA A, CNA B, and CNA F. This failure could affect residents and place them at risk of poor care or victimization due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to provide mandatory effective behavioral health training for 3 of 14 employees (CNA A, CNA B and CNA F) reviewed for training, in that: The facility failed to ensure annual effective behavioral health training was provided to CNA A, CNA B and CNA F. This failure could place residents with behaviors at risk of not receiving care to attain or maintain their highest practicable physical, mental, and psychosocial well-being due to lack of staff training.

Inspectors wroteBased on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #153) and 1 of 5 staff (MDS Coordinator) reviewed for infection control. The MDS Coordinator failed to wear appropriate PPE for enhanced barrier precautions when providing care to Resident #153 on 3/18/2025. This failure could place residents at risk of exposure to infectious diseases due to improper infection control practices.

Inspectors wroteBased on interview and record review, the facility failed to develop, implement, and maintain an effective training program for 3 of 14 employees (AD, DOR, and CNA B) reviewed for training. The facility failed to ensure the AD, DOR, and CNA B were trained on HIV annually. This failure could place residents at risk of not receiving care to attain or maintain their highest practicable physical, mental, and psychosocial well-being due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to develop, implement, and maintain an effective training program for 1 of 14 employees (DM) reviewed for training. The facility failed to ensure the DM was trained on dementia training annually. This failure could place residents at risk of not receiving care to attain or maintain their highest practicable physical, mental, and psychosocial well-being due to lack of staff training.

Inspectors wroteBased on observation and interview, the facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors with all required information for 2 of 2 days reviewed (3/17/2025 and 3/18/2025) for nurse staffing posting. The facility failed to post the daily staffing information in a prominent place on 3/17/2025 and 3/18/2025. This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents reviewed for accident (Resident #1). The facility failed to put interventions in place to prevent Resident #1 from sliding out of the wheelchair during transport on 2/19/24 and ensure that she was secured by the shoulder and lap belt harness, resulting in Resident #1 sliding out of her wheelchair during transport. The facility failed to ensure the transport staff were aware of how to properly position the shoulder and lap belt harness to ensure Resident #1 did not have forward bodily movement in the event of the driver had to quickly stop the van. An Immediate Jeopardy (IJ) situation was identified on 9/24/24 at 4:00p.m. The IJ template was provided to the facility on 9/24/24 at 4:00 p.m. [...]

Inspectors wroteBased on interviews and record review the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable State laws for 2 of 5 staff (CNA I and CNA J) reviewed for staff qualifications. The facility failed to ensure CNA I was appropriately certified to practice and provide CNA care in the State of Texas. The facility failed to ensure CNA J was appropriately certified to practice and provide CNA care in the State of Texas. This failure could place residents at risk of not receiving care and services from staff who were properly trained.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions in 1 of 1 kitchen reviewed for kitchen sanitation in that: The facility failed to label and date items in the dry storage and freezer. The facility failed to ensure the dish machine reached recommended minimal water temperature of 120 degrees Fahrenheit, (F) during the final rinse cycle. This failure could place the residents at risk of foodborne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to electronically submit to CMS (Centers for Medicare & Medicaid Services) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS for 1 of 4 quarters (Fiscal year 2023 for the fourth quarter July 1, 2023 to September 30, 2023) reviewed for administration. The facility failed to submit data for the fourth quarter of the fiscal year from July 1, 2023, to September 30, 2023, to CMS This failure could place residents at risk for personal needs not being identified and met.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility was free of pests for 1 of 12 (room [ROOM NUMBER]) rooms reviewed for pest control. The facility failed to ensure room [ROOM NUMBER] did not contain live roaches. This failure could place residents at risk of a diminished quality of life due to an unsafe environment.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 5 residents (Resident #5 and #14) and 3 of 6 staff (MA H, wound care doctor, and Treatment nurse) reviewed for infection control. MA H failed to properly clean reusable equipment in between each resident during medication administration on 02/06/2024. The wound care doctor failed to properly bag soiled wound bandages removed from Resident #5 on 02/05/2024. The Treatment nurse failed to perform proper hand hygiene while providing wound care to Resident #14 on 2/6/2024. These failures could place residents at risk of exposure to communicable diseases and infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow established policy regarding smoking areas, and smoking safety for 2 of 3 smoking areas reviewed. The facility failed to keep trash out of the red metal trash cans designated for cigarette butts in the smoking area and failed to implement their smoking safety policy. This failure could place residents who smoke at risk of physical harm and lead to an unsafe smoking environment. The Findings Included: During an observation on 2/5/2024 at 11:07 AM, 5 residents were outside of the dining room smoking with staff present and a red smoking can had cigarette butts and multiple empty cigarette boxes that was about ¾ full. There was a fire blanket and fire extinguisher present. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop, implement, and maintain an effective training program for 10 of 15 employees (ADON, Treatment Nurse, LVN J, SW, Dietary Manager, CNA A, CNA B, CNA K, MA L, and CNA M) new and existing staff reviewed for training. The facility failed to ensure ADON, SW, DM was trained on HIV, dementia, restraint reduction and completed 2-hour quarterly trainings annually. The facility failed to ensure the Treatment nurse was trained on HIV, restraint reduction and completed 2-hour quarterly trainings annually. The facility failed to ensure LVN J was trained on HIV, restraint reduction, fall prevention, and completed 2-hour quarterly trainings annually. The facility failed to ensure CNA A and CNA B was trained on HIV on hire. The facility failed to ensure CNA K was trained on HIV, and restraint reduction annually. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide effective communications mandatory training for 5 of 15 employees (ADON, Treatment Nurse, SW, CNA K and MA L) reviewed for training, in that: The facility failed to ensure effective communication training was provided to the ADON, Treatment Nurse, SW, CNA K and MA L annually. This failure could place residents at risk of miscommunication and social isolation due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to provide the required education on the rights of the resident and the responsibilities of a facility to properly care for its residents for 4 of 15 employees (ADON, LVN J, SW, and Dietary Manager) reviewed for training in that: The facility failed to ensure required training was provided on the rights of the resident and responsibilities of a facility to properly care for its residents was conducted annually to the ADON, LVN J, SW, and Dietary Manager. This failure could affect residents and place them at risk of being uninformed due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to provide the required annual or new hire Abuse training including all activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property, and resident abuse prevention for 4 of 15 employees (LVN J, LVN N, SW, and MA L) reviewed for training. The facility failed to ensure abuse training was provided to LVN J, LVN N, SW, and MA L. This failure could affect residents and place them at risk abuse due to lack of staff training.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program for 8 of 15 employees (DON, ADON, Treatment Nurse, LVN J, SW, Dietary Manager, CNA K, and MA L) reviewed for training, in that: The facility failed to ensure that quality assurance and performance improvement training was provided to the DON, ADON, Treatment Nurse, LVN J, SW, Dietary Manager, CNA K, and MA L This failure could place staff and residents at risk for not being aware of facility programs, implementation, and monitoring.

Inspectors wroteBased on interview and record review, the facility failed to provide the mandatory training on standards, policies, and procedures for an infection prevention and control program for 8 of 16 staff (DON, ADON, Treatment Nurse, LVN J, SW, Dietary Manager, CNA K, and MA L) reviewed for training, in that: The facility failed to ensure infection prevention and control training was provided to the DON, ADON, Treatment Nurse, LVN J, SW, Dietary Manager, CNA K, and MA L. This failure could place residents at risk of illness due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to provide the required compliance and ethics training for 8 of 15 employees (DON, ADON, Treatment Nurse, LVN J, SW, Dietary Manager, CNA K, and MA L) reviewed for training in that: The facility failed to ensure compliance and ethics training was provided to the DON, ADON, Treatment Nurse, LVN J, SW, Dietary Manager, CNA K, and MA L. This failure could affect residents and place them at risk of poor care or victimization due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to maintain record of the required annual in-service records and required in-service trainings for nurse aides were sufficient for the continuing competencies of nurse aides but must be no less than 12 hours per year and included abuse, neglect training for 2 of 5 staff, (CNA K and MA L) records reviewed for staff training. The facility failed to provide CNA K and MA L 12 hours of training per year. This failure could place residents at risk of being cared for by untrained staff.

Inspectors wroteBased on interview and record review, the facility failed to provide mandatory effective behavioral health training for 8 of 15 employees (DON, ADON, Treatment Nurse, LVN J, SW, Dietary Manager, CNA K, and MA L) reviewed for training, in that: The facility failed to ensure effective behavioral health training was provided to the DON, ADON, Treatment Nurse, LVN J, SW, Dietary Manager, CNA K and MA L. This failure could place residents with behaviors at risk of not receiving care to attain or maintain their highest practicable physical, mental, and psychosocial well-being due to lack of staff training.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide a safe, clean, comfortable, and homelike environment, which included clean bed and bath linens that are in good condition for 1 of 6 residents (Resident #33) reviewed for homelike environment. The facility failed to provide clean linens for Resident #33's shower. This failure could place residents at risk of poor hygiene and decreased sense of self-worth.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents who need respiratory care are provided such care, consistent with professional standards of practice for 2 of 9 residents (Residents #9 and #15) reviewed for oxygen usage. The facility failed to ensure Resident #9's oxygen tubing was changed weekly. The facility failed to ensure Resident #15's oxygen concentrator filter was clean and free of dust, oxygen tubing was changed weekly, and humidifier bottle was connected to the oxygen concentrator. These deficient practices could place residents at risk of breathing in dust and allergens, decreased effectiveness of oxygen concentrators and respiratory infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for 2 of 3 (Residents #50 and #28) residents reviewed for puree diets. The facility failed to prepare the pureed diet to the consistency required for Resident #50 and Resident #28. This failure could place residents who received pureed meat and vegetables at risk of not having nutritional needs met by consuming foods that could cause choking and decreased meal intakes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs and as prescribed by the physician for 1 of 6 residents (Resident #24) reviewed for therapeutic diets. The facility failed to serve 4oz of yogurt with lunch meal as prescribed by physician to Resident #24. This failure could place residents who received food from the kitchen at risk for decreased meal satisfaction, potential weight loss due to poor meal intake, not having their nutritional needs met, and a decline in health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items, per facility policy, for 1 of 4 resident's (Resident #2) personal refrigerators reviewed for food and nutrition services. The facility failed to ensure the refrigerator for Resident #2 did not contain a cup of peach yogurt dated 1/18/24. This failure could place residents at risk for food borne illnesses.