NHC Place at the Trace

In the surveyor’s words

From the most serious findings on record at NHC Place at the Trace, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF812Feb 12, 2025

  Based on policy review, facility documentation review, job descriptions, observation, and interview, the facility failed to ensure food was stored and served under sanitary conditions when floors were soiled throughout the kitchen, cookware and equipment were soiled, when the dishwasher was not maintained at an appropriate temperature for sanitation, and when 1 of 1 staff (Cook N) failed to perform hand hygiene during tray line service. The facility had a census of 82 with 82 of those residents receiving a tray from the kitchen. The findings include: 1. […]

• No harm, potential for more than minimal, isolatedF761May 19, 2026

  Based on policy review, medical record review, observation, and interview, the facility failed to store medications in accordance with facility policy when 1 of 2 nurses (Licensed Practical Nurse (LPN) A) left medications unsecured and unattended for 1 of 5 (Resident #60) sampled residents observed during medication administration and when medications were found unsecured and unattended for 1 of 83 (Resident #61 ) sampled residents. The findings include: 1. Review of the facility policy titled, Medication Storage In The Facility, dated 2/25/2025, revealed .Medications and biologicals are stored safely, securely, and properly.The medication supply is only accessible to licensed nursing personnel.authorized to administer medications. 2. […]

• No harm, potential for more than minimal, isolatedF550Feb 12, 2025

  Based on policy review, observation, and interview, the facility failed to ensure to maintain or enhance residents' dignity and respect during dining when 6 of 9 (Unit Manager (UM) A, Certified Nursing Assistant (CNA) B, Licensed Practical Nurse (LPN) J, CNA F, Staffing Coordinator E, and CNA G) failed to knock and/or announce themselves before entering a resident's room and failed to use courtesy titles when addressing residents and when referring to residents. The findings include: 1.Review of the facility's undated sheet titled, Partner Education-Dignity Training, revealed .We all must show respect toward each patient and preserve the rights and needs of our patients at all times. […]

• No harm, potential for more than minimal, isolatedF689Feb 12, 2025

  Based on the medical record review, observation, and interview, the facility failed to ensure the environment was free of accident hazards when unsecured sharps were observed in 1 of 80 (Resident #47) occupied resident rooms. The findings include: Review of the medical record revealed Resident #47 was admitted to the facility on [DATE], with diagnoses including Supraventricular Tachycardia, Atrial Fibrillation, Hemiplegia and Hemiparesis and Cerebral Infarction. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #47 was cognitively intact, was dependent with toileting, required partial/ moderate assistance with transfers and bed mobility, setup or clean-up assistance with… […]

• No harm, potential for more than minimal, isolatedF759Feb 12, 2025

  Based on policy review, medical record review, observation, and interview, the facility failed to ensure 1 of 4 (Registered Nurse (RN) L) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 2 errors were observed out of 33 opportunities, resulting in a medication error rate of 6.06%. The findings include: 1. Review of the undated facility policy titled, Med Pass Education Tool, revealed .Anything that indicates slow-release or enteric coating .should NOT be crushed .Other common medications that should not be crushed .EC [Enteric Coated] aspirin [used to thin the blood] .Potassium tablets [a dietary supplement] . […]