Heritage Trails Nursing and Rehabilitation Center

Inspectors wroteBased 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.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide basic life support, including CPR, to a resident requiring emergency care prior to the arrival of emergency medical personnel in accordance with professional standards for one (Resident #1) of four residents reviewed for CPR. The facility failed to update Resident #1's records to reflect he requested a change in his code status on [DATE] from DNR (do not resuscitate) to Full Code. As a result, basic life support measures, including CPR (Cardiopulmonary Resuscitation) were not provided to Resident #1 when Resident #1 was found unresponsive and expired on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ Template was provided to the facility on [DATE] at 4:25 pm. [...]

Inspectors wroteBased on Interviews and record reviews, the facility failed to ensure that medical records were accurately documented for one (Resident #1) of four residents reviewed for accurate clinical records, in that: The facility failed to update Resident #1's records to reflect he requested a change in his code status on [DATE] from DNR (do not resuscitate) to Full Code. As a result, basic life support measures, including CPR (Cardiopulmonary Resuscitation) were not provided to Resident #1 when Resident #1 was found unresponsive and expired on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ Template was provided to the facility on [DATE] at 4:25 pm. While the IJ was removed on [DATE] at 5:03 pm, the facility remained out of compliance at a level of no actual harm at a scope of isolated because the facility's need to evaluate the effectiveness of the corrective systems. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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]. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect a resident's right to be free from abuse for 2 (RES # 1 and RES #2) of 15 residents who were reviewed for abuse. The facility failed to protect RES# 1 and RES # 2 from engaging in a resident-on-resident physical altercation on 10-3-2023 at 8:30 PM in the front lobby of the facility, which resulted in physical harm to both residents. This failure could place all residents at the facility at risk for physical harm.

Inspectors wroteBased 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.

Inspectors wroteBased 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.