Inspection Reports for Heritage Trails Nursing & Rehabilitation

The visit was complaint-related due to allegations that bedside commodes and urinals were not emptied timely, causing odors and potential discomfort to residents. The complaint was substantiated based on observations and interviews with residents and staff.

The facility failed to ensure that Resident #1's bedside commode and Resident #2's urinal were emptied appropriately on 05/08/2025, placing residents at risk of decreased self-worth and diminished quality of life. Interviews and observations confirmed that staff did not empty these items timely, despite rounds being made every two hours as expected.

The facility failed to update Resident #1's code status from DNR to Full Code as requested, resulting in no CPR being provided when the resident was found unresponsive and subsequently expired. The facility identified an Immediate Jeopardy which was later removed, but the facility remained out of compliance at a level of no actual harm due to the need to evaluate corrective systems. The facility implemented corrective actions including audits, staff education, enhanced documentation protocols, and quality assurance monitoring.

The facility failed to provide advance notice of Medicare coverage changes to Resident #3, inaccurately coded weight loss for Resident #51 due to inconsistent weighing methods, and did not properly maintain CPAP machines for Residents #64 and #24, including failure to clean or replace air filters and improper drying of masks. Additionally, the facility failed to ensure laundry linens were transported covered to prevent contamination.

The facility failed to ensure proper storage of respiratory equipment such as nasal cannulas, tubing, and CPAP masks for two residents, which could place residents at risk of cross-contamination and illness. Staff interviews revealed inconsistent knowledge and practices regarding oxygen equipment storage, despite in-service training. The facility's policy requires oxygen tubing and cannulas to be stored in plastic bags when not in use, but observations showed this was not consistently followed.

The facility failed to establish a comprehensive antibiotic stewardship program including pharmacist review, protocols, and a system to monitor antibiotic use and resistance data. The infection preventionist and team monitored antibiotic use through electronic health records but lacked consolidated reports and a licensed pharmacist to oversee antibiotic stewardship.

The complaint investigation found that RES #1 and RES #2 engaged in a physical altercation causing physical harm. RES #1 was diagnosed with a urinary tract infection and treated with antibiotics. Both residents were separated and monitored. RES #2 admitted to initiating the altercation. Staff interviews confirmed proper response and training. The facility determined the incident was not due to staff failure.

The facility failed to protect two residents from a physical altercation that caused actual harm. Both residents received medical treatment and psychological evaluation. The facility separated the residents and provided ongoing monitoring and counseling services. Staff were trained on abuse prevention and proper response to altercations. The facility concluded the incident was not due to staff failure.

The facility failed to develop and implement comprehensive care plans that included residents' Code Status for 8 of 12 residents reviewed, risking CPR against residents' wishes. Additionally, the facility failed to assist one resident in obtaining routine dental care after learning of lost dentures, potentially impacting oral health and quality of life.