Health inspection·May 8, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **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 secondary cause). A record review of Resident #1's Quarterly MDS assessment, dated 04/09/2025, reflected Resident #1 had a BIMS score of 15, which indicated cognitively intact. Resident #1's Quarterly MDS Section GG Functional Abilities and Goals reflected that Resident #1 required supervision or touch assistance in the areas of toileting hygiene, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. A record review of Resident #1's care plan, dated 05/08/2025, reflected Resident #1 was care planned for: Resident #1 has bladder incontinence r/t does not always feel urge to void with an intervention for Resident uses bariatric disposable briefs. During an observation and interview on 05/08/2025 at 9:15am, Resident #1's bedside commode had yellowish liquid in it that appeared to be urine. Resident #1 stated that urine had been there all morning. Resident #1 stated she last used the bedside commode around 6:45am. Resident #1 stated that it's normal for urine to be in her bedside commode due to staff not making rounds. Resident #1 stated the CNA A had been in her room a few times since she last used the bedside commode but did not empty it. Page 1 of 3 675748 675748 05/08/2025 Heritage Trails Nursing and Rehabilitation Center 301 Lincoln Park Dr Cleburne, TX 76033

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation and interview on 05/08/2025 at 11:30am, Resident #1's bedside commode had a brief and yellowish liquid in it that appeared to be urine. Resident #1 stated her bedside commode had not been emptied since I last observed it. A record review of Resident #2's face sheet dated 05/08/25 reflected a [AGE] year-old male who was readmitted to the facility on [DATE]. Resident #1's diagnoses included epilepsy unspecified not intractable without status epilepticus (a seizure disorder where the specific cause of the seizures isn't known), unspecified fracture of right lower leg sequela (a last problem that's a result of a broken right leg), fracture of left lower leg squeal (a long-term condition that develops after the initial break has healed but still affects the leg), and muscle weakness (loss of muscle strength). A record review of Resident #2's Quarterly MDS assessment, dated 02/09/2025, reflected Resident #1 had a BIMS score of 15, which indicated cognitively intact. Resident #2's Quarterly MDS Section GG Functional Abilities and Goals reflected that Resident #2 was dependent in the areas of toileting hygiene, lower body dressing, putting on/taking off footwear. Resident #2 required substantial/maximal assistance in the areas of shower/bathe self, upper body dressing, and personal hygiene. A record review of Resident #2's care plan, dated 05/08/2025, reflected Resident #2 was care planned for: Resident #2 has potential for complications r/t fracture of fracture of unspecified parts of lumbosacral spine and pelvis (lower part of spine that connect to the pelvis, sequela: unspecified fracture of right lower leg, lower leg, sequela; other fracture of left lower leg, sequela. During an observation and interview on 05/08/2025 at 10:50am, Resident #2's urinal had yellowish liquid in it that appeared to be urine. Resident #2 stated that he used his urinal around 9:00am and the CNA had not emptied it. Resident #2 stated that his urinal usually doesn't get emptied until shift change. Resident #2 stated that his CNA for the day was CNA B. During an observation on 05/08/2025 at 11:57am, Resident #2's urinal appeared to have yellowish liquid in it that appeared to be urine. During an observation on 05/08/2025 at 1:09pm, Resident #2's had 1 full urinal and a partially full urinal that appeared to have yellowish liquid in it that appeared to be urine. During an interview on 05/08/2025 at 1:45pm, CNA B stated that he was the CNA working with Resident #2 for the day. CNA B stated that rounds were made at least every two hours. CNA B stated that during rounds CNAs should be checking to see if bed commodes and urinal need emptying. CNA B stated that he had been working assisting other resident and didn't realize that Resident #2 urinals needed to be emptied. CNA B stated that if a resident's urinal or bedside commode was not emptied could cause flies and odors in the resident's room. During an interview on 05/08/2025 at 1:55pm, LVN A stated she emptied Resident #1's bedside commode around 11:45am. LVN A stated when she emptied Resident #1 beside commode there was urine and a brief in it. LVN A stated she was not sure how long the urine and brief had been there. LVN A stated that anyone that enters the resident room could have emptied the bedside commode. LVN A stated that CNAs should make rounds at least every two hours. LVN A stated during the CNAs round they should be checking to see if a resident needs assistance, ensure call lights are within reach, and emptying bedside commodes and urinal. LVN A stated a negative outcome of not emptying a bedside commode or urinal 675748 Page 2 of 3 675748 05/08/2025 Heritage Trails Nursing and Rehabilitation Center 301 Lincoln Park Dr Cleburne, TX 76033

F 0584 could be odor and flies. Level of Harm - Minimal harm or potential for actual harm During an interview on 05/08/2025 at 2:15pm, CNA A stated that she was the CNA working with Resident #1 for the day. CNA A stated that rounds were made at least every two hours. CNA A stated that during rounds CNAs should be checking to see if bed commodes and urinal need emptying. CNA A stated that Resident #1 urinates frequently so there are times that her bedside commode is not emptied. CNA A stated that if a bedside commode was not emptied timely that could cause odors and the resident may not be able to use the bedside commode if it was full. Residents Affected - Few During an interview on 05/08/2025 at 3:30pm, the DON stated any nursing staff such as CNAs, Medication Aides, or nurses could empty a bedside commode/urinal. The DON stated that CNAs made rounds every two hours or as needed. The DON expected for bedside commodes and urinal to be emptied in a timely manner. The DON stated if bedside commode or urinal was not emptied in a timely manner that could cause odors, and flies. During an interview on 05/08/2025 at 4:00pm, the ADM stated that nursing staff were responsible for ensuring that bedside commodes and urinals are emptied appropriately. The ADM stated that CNAs are to made rounds every two hours or as needed. The ADM stated that a negative outcome of a resident's bedside commode or urinal not being emptied in a timely manner would be odors. The ADM stated she expected for nursing staff to empty bedside commode and urinals in a timely manner to prevent odors. Review of the facility's Bedpan/Urinal, Offering/Removing policy, dated Qrt 3, 2018, reflected, Purpose: The purpose of the procedure is to provide the resident with bedpan and/or a urinal assistance. Preparation 1. Review the resident's care plan to assess for any special needs of the resident. 2. Assemble the equipment and supplies as needed. General Guidelines 1. Check to see if the resident is on intake and output before discarding the urine and feces. 2. Do not allow the resident to sit on a bedpan for extended periods. This is not only uncomfortable to the resident, it also causes skin breakdown. 3. If the resident prefers to keep a urinal at his bedside, check if frequently. Empty and clean it as necessary. 675748 Page 3 of 3