Inspection Reports for
NHC Place at the Trace
8353 Highway 100, Nashville, TN, 37221
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
3.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
14% better than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Census: 82
Deficiencies: 6
Date: Feb 12, 2025
Visit Reason
Routine inspection to assess compliance with regulatory standards including resident dignity, safety, medication administration, food safety, infection control, and environmental conditions.
Findings
The facility was found deficient in maintaining residents' dignity during dining, ensuring a safe environment free from hazards, preventing medication errors, maintaining sanitary food service conditions, and implementing proper infection control practices. Multiple staff failed to use courtesy titles or knock before entering rooms, unsecured sharps were found, medication errors occurred due to crushing extended-release drugs, kitchen sanitation and dishwasher temperatures were inadequate, and hand hygiene lapses were observed.
Deficiencies (6)
F0550: Facility failed to maintain residents' dignity and respect during dining; staff did not knock or announce themselves before entering rooms and used inappropriate terms when addressing residents.
F0689: Facility failed to ensure environment was free from accident hazards when unsecured sharps were found in a resident's room.
F0759: Medication error rate exceeded 5% when nurse crushed extended-release potassium and delayed-release aspirin, resulting in 2 errors out of 33 opportunities.
F0760: Facility failed to ensure residents were free from significant medication errors related to crushing slow-release and enteric-coated medications.
F0812: Food was stored and served under unsanitary conditions; kitchen floors and equipment were soiled, dishwasher temperatures were below required levels, and staff failed to perform hand hygiene during tray line service.
F0880: Facility failed to prevent spread of infections when nurse failed to perform proper hand hygiene and reused an alcohol wipe during medication administration.
Report Facts
Medication error rate: 6.06
Facility census: 82
Dishwasher rinse temperature: 151
Expired food items: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN L | Registered Nurse | Named in medication error finding for crushing extended-release medications |
| RN K | Registered Nurse | Named in infection control finding for improper hand hygiene and reuse of alcohol wipe |
| Director of Nursing | Confirmed policies on dignity, medication administration, and infection control | |
| Cook N | Failed to perform hand hygiene during tray line service | |
| Certified Dietary Manager (CDM) | Confirmed kitchen sanitation issues and dishwasher temperature problems | |
| Regional Registered Dietitian (RD) | Involved in dishwasher sanitation concerns and food safety oversight |
Inspection Report
Enforcement
Deficiencies: 1
Date: Oct 20, 2023
Visit Reason
The inspection was conducted to review compliance with assisted care living facility regulations, specifically regarding resident assessments and record-keeping.
Findings
The facility failed to complete the required 72-hour assessments for three residents upon admission, constituting a violation of resident record regulations. A civil monetary penalty was assessed for this deficiency.
Deficiencies (1)
Tenn. Comp. R. and Reg. 0720-26-.12(4) Resident Records require a written assessment of the resident by direct care staff within 72 hours of admission. The facility failed to complete the 72-hour assessment for three residents upon admission.
Report Facts
Civil Monetary Penalty: 1500
Number of residents with incomplete assessments: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Marshall Ussery | Administrator | Named as the facility administrator in the document. |
| Jeremy Gourley | Senior Associate General Counsel | Signed the consent order on behalf of the Health Facilities Commission. |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Sep 18, 2019
Visit Reason
The inspection was conducted as a routine annual survey to assess compliance with regulatory requirements and identify deficiencies in care and facility operations.
Findings
The facility was found deficient in completing timely Minimum Data Set (MDS) assessments for residents with significant changes in condition, failure to implement baseline care plans including respiratory services, failure to update care plans, improper storage of respiratory equipment, failure to use hand sanitizer during meal delivery, and use of ineffective disinfectant for C Diff isolation rooms.
Deficiencies (6)
F 0637: The facility failed to complete timely Minimum Data Set (MDS) assessments within 14 days of the determination date for 4 of 7 residents reviewed with significant changes in condition.
F 0655: The facility failed to implement a baseline care plan including respiratory services within 48 hours of admission for 1 of 7 residents reviewed.
F 0657: The facility failed to update a resident's care plan to reflect the removal of a bedside commode for 1 of 41 residents reviewed.
F 0695: The facility failed to properly store a nebulizer mask in a plastic bag to prevent infection spread for 1 of 7 residents receiving respiratory services.
F 0812: The facility staff failed to use hand sanitizer when delivering lunch trays to 2 rooms during observation of 10 rooms.
F 0880: The facility failed to use an effective disinfectant solution to destroy Clostridium Difficile spores on floors in isolation rooms.
Report Facts
Residents reviewed: 7
Residents reviewed: 41
Rooms observed: 10
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 1
Rooms affected: 2
Residents affected: 1
Date of survey completion: Sep 18, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed lack of respiratory interventions on baseline care plan and failure to update care plans |
| RN #4 | Registered Nurse | Confirmed nebulizer mask was not stored in a bag |
| Housekeeper #1 | Housekeeper | Used incorrect disinfectant solution for C Diff isolation rooms |
| Director of Plant Operations | Director of Plant Operations | Confirmed use of wrong disinfectant solution for C Diff rooms |
| Administrator | Administrator | Confirmed cleaning solution used was not effective on C Diff spores |
| Certified Nurse Aide #7 | Certified Nurse Aide | Failed to use hand sanitizer when delivering lunch trays |
| Registered Respiratory Therapist | Registered Respiratory Therapist | Confirmed nebulizer equipment should be stored in a bag |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 19, 2018
Visit Reason
The inspection was conducted to investigate complaints related to failure to follow care plan interventions for oxygen protocol and infection control practices at the facility.
Complaint Details
The investigation was complaint-driven, focusing on failure to follow oxygen tubing change protocols and infection control procedures. The complaint was substantiated based on observations, interviews, and medical record reviews.
Findings
The facility failed to follow care plan interventions for oxygen tubing changes and dating for multiple residents, failed to maintain infection control protocols including use of PPE during meal tray passes, and had inconsistent communication regarding tubing change frequency between respiratory therapists and nursing staff.
Deficiencies (2)
F 0656: The facility failed to develop and implement a complete care plan that meets all resident needs, specifically failing to change and date oxygen tubing weekly for 2 of 39 residents reviewed.
F 0880: The facility failed to provide and implement an infection prevention and control program, including failure to use PPE when entering isolation rooms and failure to change and date respiratory equipment tubing weekly for 4 of 15 residents receiving respiratory treatment.
Report Facts
Residents reviewed for oxygen protocol: 39
Residents affected by oxygen protocol failure: 2
Residents receiving respiratory treatment reviewed: 15
Residents affected by respiratory equipment tubing failure: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Interviewed regarding oxygen tubing change policy and infection control failures |
| RT #1 | Respiratory Therapist | Interviewed about respiratory equipment tubing change schedule and practices |
| LPN #1 | Licensed Practical Nurse | Interviewed about oxygen tubing change orders and policy confusion |
| RN #1 | Registered Nurse | Interviewed about oxygen tubing and nebulizer equipment dating and storage |
| CNA #1 | Certified Nurse Aide | Observed and interviewed regarding oxygen tubing handling and storage |
| CNA #2 | Certified Nurse Aide | Observed and interviewed regarding oxygen tubing dating |
| CNA #3 | Certified Nurse Aide | Observed failing to use PPE when entering isolation room |
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