Heritage Trails Nursing And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 2 of 6 residents (Resident #1 and #2) reviewed for a clean and homelike environment. The facility failed to ensure Resident #1's bedside commode was emptied appropriately on 05/08/25. The facility failed to ensure Resident #2's urinal was emptied appropriately on 05/08/25. This failure placed residents at risk of decreased feelings of self-worth and a diminished quality of life. Findings included: A record review of Resident #1's face sheet dated 05/08/25 reflected a [AGE] year-old female who was readmitted to the facility on [DATE]. Resident #1's diagnoses included unspecified dementia (a decline in mental abilities), acute on chronic systolic congestive heart failure (heart condition where the heart's left ventricle isn't pumping blood effectively), muscle weakness (loss of muscle strength), and essential primary hypertension (high blood pressure that doesn't have a known…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for 2 of 7 Resident (Resident #64 and Resident #24) reviewed for quality of care. 1. The facility failed to ensure Resident #64 had a clean air filter in his CPCP Machine and the facility towel dried Resident #64's CPAP mask versus allowing to air dry. 2. The facility failed to ensure Resident #24 had an air filter in his CPAP Machine and the facility failed to allow Resident #64's CPAP mask, along with the head strap, to air dry. The failures placed residents who use CPAP treatment at risk of respiratory infection. Findings included: 1. Record review of Resident #64's AR, dated 7/9/2024, reflected a [AGE] year-old-male who admitted to the facility on [DATE]. He was diagnosed with critical illness myopathy (which was a disease having involved muscles of the extremities,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview 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 transmission of communicable diseases and infections for 1 of 1 laundry. The facility failed to ensure laundry staff handled and transported linens in a manner to ensure cleanliness and protect from dust and soil to prevent cross-contamination and the spread of infections. This failure could place residents at risk for development of communicable diseases and infections that could diminish a residents' quality of life. Findings were: Observation on 07/09/24 at 02:05 pm revealed the LS walking down the hall delivering linens to residents on an uncovered linen cart. Clothing for multiple residents was hanging openly on the cart. There were other residents, staff, and visitors in the hall when she was delivering the linens. In an interview on 07/09/24 at 02:05 pm the LS stated that staff normally covered laundry from the laundry building to the residents…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide advance notice of change in services and charges not covered under Medicare for 1 of 3 residents (Residents #3) reviewed for Medicaid and Medicare Coverage Liability Notices. The facility failed to ensure Resident #3 was provided a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage Form CMS-10055 (SNF ABN) when she was discharged from Medicare Part A skilled nursing services. This failure placed residents, or their representatives, at risk of not being fully informed about services covered by Medicare Part A. Findings Included: Record review of Resident #3's AR, dated 7/11/2024, reflected a [AGE] year-old woman who admitted to the facility on [DATE]. She was diagnosed with congestive heart failure (which was a long-term condition that happened when the heart could not pump blood well enough to give your body a normal supply.) Record review of Resident #3's Quarterly MDS, dated [DATE], Section C., Cognitive Patterns indicated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the resident assessment accurately reflected the resident's status for 1 of 7 Residents (Resident #51) who were reviewed for accuracy of assessments. The facility incorrectly coded Resident #51 with weight loss on the quarterly MDS. This failure placed residents at risk of incorrect care and services necessary for their physical, mental, and psychosocial well-being. Findings included: Record review of Resident #51's AR, dated 7/9/2024, reflected an [AGE] year-old woman who admitted to the facility on [DATE]. She was diagnosed with encounter for removal of internal fixation device (which was admittance to remove a medical device post-surgical procedure.) Record review of Resident #51's Quarterly MDS, dated [DATE], reflected Section C., Cognitive Patterns: Resident #51 had a BIMS Score of 12. A BIMS Score of 12 indicated the resident had moderate cognitive impairment. Record review of Resident #51's order summary report reflected an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart and ensure infection control measures during implementation of care, handling, cleaning, storage and disposal of equipment, supplies, biohazardous waste and including infection control practices for mechanical ventilation/tracheostomy care including the use of humidifiers were followed by staff for 2 (Residents #1 and #2) of 5 residents reviewed for respiratory care, in that: 1. The facility failed to ensure Resident #1's nasal cannulas and tubing and Resident #1's and 2's CPAP masks and tubing were properly stored when not in use. These failures could place residents at risk of cross-contamination and illness. Findings included: Record review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to establish an infection prevention and control program that must include, at minimum, an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for 1 of 1 facility reviewed for an antibiotic stewardship program. The facility did not have pharmacist review for antibiotic stewardship. The facility did not have protocols incorporated in the overall infection prevention and control program and had no system of reports related to monitoring antibiotic usage and resistance data such as the rate of new antibiotic starts, types prescribed or days of antibiotic treatment per 1,000 resident days; antibiotic resistance based on laboratory data from, for example the last 18 months; or tracking measures of outcome surveillance related to antibiotic use. This failure could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections. Findings include: Record review of Facility Infection Control…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 8 of 12 residents (Residents #74, #48, #26, #47, #61, #71, #59 and #25) reviewed for care plans. The facility failed to address Residents #74, #48, #26, #47, #61, #71, #59 and #25's Code Status on their comprehensive person-centered care plan. This failure could place residents at risk of receiving cardiopulmonary resuscitation (CPR) against their wishes. Findings include: Record review of Residents #74, #48, #26, #47, #61, #71, #59 and #25 revealed no care plan for their code status. Record review of Resident #74's face sheet revealed the Code Status was Full Code. Record review of Resident #48's face sheet revealed the Code Status was DNR. Record review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assist residents in obtaining routine dental care for one (Resident #194) of 18 residents reviewed for dental services. The facility failed to assist in providing routine dental services for Resident #194 after learning of lost dentures. This failure could place residents at risk for oral complications, dental pain, and a diminished quality of life. Findings included: Record review of Resident #194's face sheet revealed a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #194 had diagnoses which included Metabolic encephalopathy (a problem in the brain, caused by a chemical imbalance in the blood), acute pulmonary edema (an abnormal buildup of fluid in the lungs), bipolar disorder, without psychotic features (Mood is elevated out of keeping with the patient's circumstances and may vary from carefree joviality to almost uncontrollable excitement), and cognitive communication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.