Nature Trail Health and Rehab

In the surveyor’s words

From the most serious findings on record at Nature Trail Health and Rehab, in the surveyor’s own words.

• Actual harm, isolatedF692Dec 8, 2025

  Based 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. Findings include:1. […]

• Actual harm, isolatedF689Feb 4, 2025

  Based 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 admitted [DATE] 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. […]

• Actual harm, isolatedF689Nov 10, 2023

  Based 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. Findings include: R1's Face Sheet documents Diagnosis to include: Hemiplegia and Hemiparesis following Cerebral Infarction affecting right dominant side, Aphasia following Cerebral Infarction, Chronic Obstructive Pulmonary Disease, Polyneuropathy, Anxiety Disorder, Contracture Right hand, Acute Pulmonary Edema and Contusion of Right Shoulder. […]

• Actual harm, isolatedF684Jan 27, 2021

  Based on record review, observation, and interview, the facility failed to follow a providers orders to begin ear irrigation and to bring the resident as scheduled for follow up treatment for one (R2) of three residents reviewed for following providers orders in the sample of four. This failure resulted in R2's impacted cerumen causing eardrum perforation and infection, and a delay in R2 being evaluated for hearing aids. Findings include: R2's Office Visit Provider Progress Notes documented: 12/18/20: Bilateral ear canals impacted with cerumen. Unable to see Tympanic Membrane(s) .Start [MEDICATION NAME] 2 drops to each ear twice daily for 7 days. […]

• No harm, potential for more than minimal, widespreadF919Dec 8, 2025

  Based 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.Findings include:On 12/02/25 at 2:20 PM in the shower room on the 200 hall across from room [ROOM NUMBER], the call light string by the toilet was behind the toilet and reaches approximately 3 inches above the bottom of the toilet tank. In this same bathroom, there is no call light available from the shower stall area.On 12/02/25 at 2:23 PM in the shower room on the 200 hall across and between rooms [ROOM NUMBERS], did not have a call light accessible near the toilet or the shower stall area.On 12/02/25 at 2:29 PM in the shower room on the 300 hall… […]