Cycle 1
Health 2025-03-19 · Fire 2025-03-19
9 health deficiencies
Top issue: Administration (4 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Rusk, TX
Cherokee Trails Nursing Home
2-star overall rating with 1-star inspections with $85,329 in total fines with 9 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
330 E Bagley Rd, Rusk, TX
(903) 683-5438
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
140
Certified beds
Average residents
50
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Advanced Healthcare Solutions
Operator or chain grouping
Approved since
2000-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
30 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.38
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.79
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.68
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.86
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.18
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.56
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.47
CMS adjusted RN staffing hours
Adjusted total hours
3.53
CMS adjusted total nurse staffing hours
Case-mix index
1.11
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
76%
Annual nurse turnover · state 52% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 8 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 12 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 10.98% |
8.2%
2.8 pts better
|
Numerator 9 · Denominator 82 |
| Staff flu vaccination coverage | 29.76% |
42%
12.2 pts worse
|
Numerator 25 · Denominator 84 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.1
0.2 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.6 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.7 |
2.1
1.6 pts worse
|
1.8
1.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.7 · Observed 3.6 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 47.5% |
97.1%
49.6 pts worse
|
93.4%
45.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.8% · Q2 41.7% · Q3 45.1% · Q4 62.0% · 4Q avg 47.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.5% |
3.3%
0.8 pts better
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.1% · Q3 3.9% · Q4 2.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.6% |
2.7%
2.1 pts better
|
11.4%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.2% · 4Q avg 0.6% |
| Percentage of long-stay residents who lose too much weight | 2.9% |
3.3%
0.4 pts better
|
5.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.8% · Q3 0.0% · Q4 4.7% · 4Q avg 2.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.7% |
18.9%
7.8 pts worse
|
19.6%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.4% · Q2 27.3% · Q3 28.3% · Q4 26.7% · 4Q avg 26.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.5% |
10.8%
1.3 pts better
|
16.7%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 3.8% · Q3 11.1% · Q4 16.0% · 4Q avg 9.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 14.3% |
15.4%
1.1 pts better
|
16.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 8.4% · Q3 12.0% · Q4 19.9% · 4Q avg 14.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.1% |
16.1%
7 pts better
|
14.9%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 7.0% · Q3 6.7% · Q4 9.1% · 4Q avg 9.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.6% |
15.0%
0.4 pts better
|
19.8%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.6% · Q2 20.9% · Q3 14.0% · Q4 12.1% · 4Q avg 14.6% |
| Percentage of long-stay residents with pressure ulcers | 2.7% |
4.2%
1.5 pts better
|
5.1%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 2.2% · Q3 2.0% · Q4 2.4% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 29.1% |
89.7%
60.6 pts worse
|
81.7%
52.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 29.1% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-07 · Fire 2024-02-07
21 health deficiencies
Top issue: Administration (7 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-12-07 · Fire 2022-12-07
9 health deficiencies
Top issue: Environmental (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-19
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-04-28
E · Potential for more than minimal harm
2025-03-19
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-04-28
E · Potential for more than minimal harm
2025-03-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-04-28
E · Potential for more than minimal harm
2025-03-19
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2025-04-28
E · Potential for more than minimal harm
2025-03-19
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-04-28
E · Potential for more than minimal harm
2025-03-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-28
E · Potential for more than minimal harm
2025-03-19
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-04-28
C · Minimal harm
2025-03-19
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Not marked corrected
D · Potential for more than minimal harm
2024-02-07
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-07
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-07
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-07
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-07
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-07
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2024-03-20
C · Minimal harm
2024-02-07
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Not marked corrected
E · Potential for more than minimal harm
2023-07-27
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-07-28
E · Potential for more than minimal harm
2022-12-07
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-01-07
E · Potential for more than minimal harm
2022-12-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-01-07
C · Minimal harm
2022-12-07
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Not marked corrected
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-19
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-04-28
E · Potential for more than minimal harm
2025-03-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-28
E · Potential for more than minimal harm
2025-03-19
F941 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected 2025-04-28
E · Potential for more than minimal harm
2025-03-19
F946 · Administration Deficiencies
Health
Provide training in compliance and ethics.
Corrected 2025-04-28
E · Potential for more than minimal harm
2025-03-19
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2025-04-28
D · Potential for more than minimal harm
2025-03-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-28
D · Potential for more than minimal harm
2025-03-19
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2025-04-28
D · Potential for more than minimal harm
2025-03-19
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2025-04-28
C · Minimal harm
2025-03-19
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-04-28
J · Immediate jeopardy
2024-09-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-09-26
E · Potential for more than minimal harm
2024-09-25
F839 · Administration Deficiencies
Health
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected 2024-09-26
F · Potential for more than minimal harm
2024-02-07
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-03-07
F · Potential for more than minimal harm
2024-02-07
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-03-07
F · Potential for more than minimal harm
2024-02-07
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-03-07
E · Potential for more than minimal harm
2024-02-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-07
E · Potential for more than minimal harm
2024-02-07
F926 · Environmental Deficiencies
Health
Have policies on smoking.
Corrected 2024-03-07
E · Potential for more than minimal harm
2024-02-07
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2024-03-07
E · Potential for more than minimal harm
2024-02-07
F941 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected 2024-03-07
E · Potential for more than minimal harm
2024-02-07
F942 · Resident Rights Deficiencies
Health
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Corrected 2024-03-07
E · Potential for more than minimal harm
2024-02-07
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2024-03-07
E · Potential for more than minimal harm
2024-02-07
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2024-03-07
E · Potential for more than minimal harm
2024-02-07
F945 · Infection Control Deficiencies
Health
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Corrected 2024-03-07
E · Potential for more than minimal harm
2024-02-07
F946 · Administration Deficiencies
Health
Provide training in compliance and ethics.
Corrected 2024-03-07
E · Potential for more than minimal harm
2024-02-07
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-03-07
E · Potential for more than minimal harm
2024-02-07
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2024-03-07
D · Potential for more than minimal harm
2024-02-07
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-03-07
D · Potential for more than minimal harm
2024-02-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-07
D · Potential for more than minimal harm
2024-02-07
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-03-07
D · Potential for more than minimal harm
2024-02-07
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2024-03-07
D · Potential for more than minimal harm
2024-02-07
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2024-03-07
K · Immediate jeopardy
2023-07-27
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-07-28
K · Immediate jeopardy
2023-07-27
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-07-28
J · Immediate jeopardy
2023-07-27
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-07-28
J · Immediate jeopardy
2023-07-27
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-07-28
J · Immediate jeopardy
2023-07-27
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-28
E · Potential for more than minimal harm
2022-12-07
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-12-07
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-12-07
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-12-07
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2022-12-08
Penalties and ownership
What sits behind the stars
$30,933
2024-09-25
Fine
Fine · fine $30,933
Fine
$54,396
2023-07-27
Fine
Fine · fine $54,396
Fine
Ownership
Baylor County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Cherokee Trails Hc LLC
Operational/Managerial Control · Organization
Hardin, Leslie
Corporate Officer · Individual
Lyons, Paula
W-2 Managing Employee · Individual
Silberstein, Ari
Operational/Managerial Control · Individual
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