Nature Trail Health and Rehab

Inspectors wroteBased on interview, observation and record review the facility failed to provide three meals daily and the additional ordered protein for a resident with a diagnosis of severe protein calorie malnutrition and failed to provide ordered supplements and/or additional food items for 2 ( R52, and R57) of 9 residents reviewed for weight loss in a sample of 43. These failures resulted in R57 experiencing a severe weight loss of 25.6 pounds or a 14.83% weight loss in one month.

Inspectors wroteBased on interview, observation and record review the facility failed to provide a call light activation system in the community bathrooms and shower rooms. This failure has the the potential to affect all 60 residents residing in the facility.

Inspectors wroteBased on interview, observation and record review the facility failed to provide warm water in the resident's rooms for 4 (R7, R23, R26, R48) of 6 residents reviewed for warm water in a sample of 43.

Inspectors wroteBased on interview, observation and record review the facility failed to provide food the was at an appetizing temperature for 4 (R7, R39, R57, and R58) of 4 residents reviewed for cold food in a sample of 43.

Inspectors wroteBased on interview and record review the facility failed to ensure a care plan meeting was conducted for 1 of 3 (R5) residents reviewed for care plan meetings in the sample of 43. Findings Include:R5's admission Record with a print date of 12/3/25 documents R5 was admitted to the facility on [DATE] with diagnoses that include heart failure, dysphagia, diabetes, and bipolar disorder. R5's Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status score of 13 this indicates R5 is cognitively intact. R5's current medical record did not document a signature sheet or progress notes indicating a care plan meeting was conducted for R5. On 12/01/25 at 11:00 AM, R5 stated he had not been invited to a care plan meeting. On 12/2/25 at 2:59 PM, V3 (Social Services) stated she couldn't find a signature sheet for the care plan meeting. [...]

Inspectors wroteThe facility failed to ensure activities of daily living were provided for 2 of 3 (R24 and R52) residents reviewed for activities of daily living in the sample of 43 Findings Include: 1. R52's admission record dated 12/4/25 documents an admission date of 6/28/19. Same admission record documents diagnosis including but not limited to Alzheimer's disease, blindness one eye, and dementia. R52's minimum data set (MDS) dated [DATE] documents a brief interview for mental status score of 5 indicating R52 is not cognitively intact. The same MDS documents R56 is dependent upon staff for all activities of daily living (ADLs) including toileting, toileting hygiene, showering, and all personal hygiene. R52's most recent care plan documents R52 has an ADL self-care performance deficit related to her diagnoses of Alzheimer's disease, anxiety, major depressive disorder, and blindness. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure hand hygiene was performed per current standards of practice for 3 of 3 residents (R8, R12, R24) reviewed for infection control in the sample of 43. Findings Include: 1. R24's admission Record with a print date of 12/3/25 documents R24 was admitted to the facility on [DATE] and includes diagnoses of Guillain-Barre Syndrome, neuromuscular dysfunction of bladder, and urinary retention. R24's MDS (Minimum Data Set) dated 10/2/25 documents a BIMS (Brief Interview for Mental Status) score of 15, indicating R24 is cognitively intact. R24's current Care Plan documents a Focus area of (R24) has a need for indwelling catheter r/t (related to) neuromuscular dysfunction. This same Focus area includes interventions of, Provide catheter care every shift and as needed. Date Initiated: 10/19/25. [...]

Inspectors wroteBased on interview and record review the facility failed to provide an influenza vaccination for 1 (R57) of 5 residents reviewed for immunizations in a sample of 43.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper and safe administration of medications in accordance with facility policy for 2 (R1, R3) of 3 residents reviewed for pharmacy services in the sample of 13. Findings Include: 1. R1's Transfer/Discharge Report documented an admission date of 2/24/2025 and included diagnoses of bradycardia, heart failure, hypertension, type 2 diabetes mellitus with other circulatory complications, weakness and unsteadiness on feet. R1's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicates R1 is cognitively intact. R1's Care Plan had no documentation of self-administration of medications being a goal or focus area for R1. V2 (Adult Protective Specialist) stated, she had direct care with R1 for the past year. [...]

Inspectors wroteBased on interview and record review the facility failed to implement interventions to prevent falls for 1 of 6 (R122) residents reviewed for falls in a sample of 55. This failure resulted in R122 falling and sustaining a left intertrochanteric fracture and subsequent hospitalization. The Findings Include: R122's admission Record documents an admission date of 1/8/25 with diagnoses including unspecified dementia, weakness, and atrial fibrillation. R122's admission Record documents a date of discharge og 1/14/25 to a local acute care hospital. R122's Order Summary Report with a print date of 1/31/25 documents an order for a bed alarm and chair alarm every shift with an order date of 1/8/25. R122's Care Plan has a focus area of being at risk for falls and injuries related to weakness, CVA (cerebral vascular accident), and Atrial Fibrillation. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide services to increase and/or prevent further decrease of range of motion (ROM) for 5 (R23, R28, R3, R37, and R52) of 5 residents reviewed for decreased range of motion in the sample of 55. Findings Include: 1. R23's admission Record documented R23 as a [AGE] year-old with an admission date to the facility of 03/16/2024. Diagnoses listed are hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, other immunodeficiencies, type 2 diabetes mellitus, essential hypertension, lymphedema, generalized anxiety disorder, hyperlipidemia, and embolism and thrombosis of superficial veins of left lower extremity. R23's Order Summary Report with a print date of 01/31/2025 does not document an order for any range of motion or restorative nursing program. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the required 80 square feet of floor space per resident for 38 of 38 (R2, R16, R55, R8, R19, R5, R35, R20, R17, R50, R51, R26, R12, R43, R30, R31, R14, R1, R62, R56, R3, R48, R25, R41, R11, R24, R60, R40, R59, R61, R23, R46, R28, R18, R58, R47, R52, and R54) residents reviewed for room size in a sample of 55.

Inspectors wroteBased on interview and record review the facility failed to ensure a person-centered comprehensive care plan was developed with goals and interventions to address history of substance abuse for 1 (R1) of 3 residents reviewed for care planning in a sample of 3.

Inspectors wroteBased on interview and record review the facility failed to provide a SNF ABN Form (CMS-10055) for 1 of 3 residents (R26) reviewed for Beneficiary Protection Notification in the sample of 59.

Inspectors wroteBased on interview, observation, and record review the facility failed to develop and implement a person centered comprehensive care plan for tracheotomy care for 1 of 1 residents (R37) reviewed for care plans in a sample of 59.

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure nursing staff signed off medications they administered by using their own electronic signature and failed to provide tracheostomy care in accordance with professional standards of practice for 3 of 5 residents (R27, R41, and R37) reviewed for medication administration and tracheostomy care in a sample of 59.

Inspectors wroteBased on interview, observation, and record review, the facility failed to keep a resident requiring assistance with Activities of Daily Living hair clean and well groomed for 1 of 9 residents (R11) reviewed for Activities of Daily Living in a sample of 59.

Inspectors wroteBased on interview, observation, and record review the facility failed to provide tracheostomy care per facility policy/professional standards of practice and failed to implement a care plan with appropriate interventions to provide tracheostomy care for 1 of 1 resident (R37) reviewed for tracheostomy care in a sample of 59.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately document the administration of medication for 2 of 4 residents (R27 and R41) reviewed for medication administration in a sample of 59.

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure a medication error rate of less than 5%. There were 30 medication passing opportunities with 4 errors, resulting in a 13.33% error rate. The errors involved 1 of 4 residents (R27) reviewed during medication administration in the sample of 59.

Inspectors wroteBased on interview and record review the facility failed to follow their Pneumococcal Immunization Policy and failed to provide a Pneumococcal Immunization for 1 of 5 (R42) residents reviewed for Pneumococcal Immunizations in the sample of 59.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that 11 multiple bed resident rooms on the East hall and 14 multiple bed resident rooms on the South hall provided the required 80 square feet per resident bed for 41 of 41 (R28, R48, R15, R3, R5, R1, R42, R9, R45, R8, R53, R31, R34, R24, R38, R35, R162, R6, R37, R4, R163, R41, R30, R16, R40, R27, R17, R19, R29, R26, R47, R36, R18, R33, R20, R7, R25, R23, R211, R39, and R12) residents reviewed for room size in the sample of 59.

Inspectors wroteBased on interview, observation and record review the facility failed to utilize a gait belt to safely transfer a resident for 1 of 3 residents (R1) reviewed for transfers in the sample of 3. This failure resulted in R1 experiencing a large hematoma causing acute anemia that resulted in a blood transfusion and a six-night hospital stay. This past non-compliance occurred between 10/27/23 and 10/31/23.