Nhc Place At The Trace

F-F759

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 13 445525 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 445525 B. Wing 02/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Nhc Place at the Trace 8353 Highway 100 Nashville, TN 37221

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49269

Residents Affected - Some 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. Review of the facility policy titled, Cleaning Equipment, dated ,d+[DATE REDACTED], revealed .Equipment must be cleaned and/or sanitized after every use .Department inspections should be conducted to review sanitation, and immediate action should be taken to correct any problems that interfere with meeting sanitary standards .

Review of the facility policy titled, Griddles/Grills, dated ,d+[DATE REDACTED], revealed .After each use .For char-grills, use stiff brush to remove food particles from grate .

Review of the facility policy titled, Refrigerator and Freezer Storage, dated ,d+[DATE REDACTED], revealed .Refrigerator and frozen foods will be stored properly for optimal product safety .Foods will be stored in their original container or a NSF [National Sanitation Foundation] approved container or wrapped tightly in moisture-proof film, foil .clearly labeled with the contents and use by date .

Review of the facility policy titled, Machine Warewashing, dated ,d+[DATE REDACTED], revealed .Most tableware, utensils, adaptive equipment, pots and pans .can be effectively cleaned and sanitized in warewashing machines. Most warewashing machines sanitize by using either hot water or a chemical-sanitizing solution . High-Temperature Machines .rely on hot water to clean and sanitize. The temperature of the wash solution in dish machine that use hot water to sanitize may not be less than 165 [degree] F [Fahrenheit] .The temperature of the final sanitizing rinse must be at least 180 [degree] F .The temperature is measured using

a built-in thermometer to check the temperature of the water at the manifold, where the water sprays into the tank .Check each rack for soiled items as it comes out of the machine. Run dirty items through again until

they are clean. Most items will only need to pass if proper equipment and procedures are used .Keep the warewashing machine in good repair .If the temperature are not in the proper range, immediately call the appropriate service company and stop the operation of the machine . Manually finish the dishes if necessary, following manual warewashing guidelines .Use disposal (plates/utensils, etc.) for the next meal if necessary. Do not utilize the dish machine again until it is in good repair.

2. Review of the Registered Dietitian Nutritionist job description dated [DATE REDACTED], revealed .Reviews sanitation and safety of the FNS [Food and Nutrition Services] department routinely and provides guidance in finding solutions to any problems noted .Has a thorough understanding and practice of all regulations (local, state, and federal) which affect FNS including department. Must be able to work with and train staff to improve patient care and FNS services .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 13 445525 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 445525 B. Wing 02/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Nhc Place at the Trace 8353 Highway 100 Nashville, TN 37221

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Review of the Director of Food and Nutrition Services job description dated [DATE REDACTED], revealed .To ensure all functions of the FNS [Food and Nutrition Services] Department, both Administrative and Clinical duties are Level of Harm - Minimal harm or carried out accurately and appropriately .Responsible for development/adherence to policies and procedures potential for actual harm .cleaning schedules, and other food services management tools .Has a thorough understanding and practice of all regulations .which affect Evaluates trends and developments food safety and service practices and Residents Affected - Some techniques and investigates their adaptability to the FNS program .Inspects FNS department regularly to ensure that it is safe, secure, and sanitary .

3. Observation and interview in the Kitchen during the initial tour on [DATE REDACTED] at 10:26 AM, revealed the following:

a. 2 cooking pots hanging above the 3 compartment sink with black build up on the bottom of the pots.

b. a perforated pan with dried food particles on the side. The CDM (Certified Dietary Manager) confirm that

the perforated pan should be clean and free of food particles.

c. 2 small clear dessert bowls stacked inside each other with cantaloupe stuck between the 2 bowls in a storage bin. The CDM confirmed that the bowls should be clean and food should not be on the bowls.

d. a metal mixing kettle and a metal stand up mixer with build up of spillage and dried food particles.

e. plastic rolling containers with breadcrumbs, rice, and fish batter, soiled with dried food splatters on the exterior of the containers.

f. the bottom shelf of a metal prep table with dried spillage and dried food particles.

g. a metal drying rack with a build up of dried food and tan spillage on the sides and on the bottom of the rack.

h. the char-grill with thick carbon build up. The CDM confirmed that it was black build up.

i. the floor throughout the kitchen was soiled and with thick black build under the deep fryer.

j. 2 opened and undated loaves of wheat bread on a ledge above the serving line.

k. half loaf of white bread opened and undated on a ledge above the serving line.

l. 2 expired 4-ounce (oz) cups of grape juice dated [DATE REDACTED] stored in the reach in refrigerator.

m. 20 expired 4 oz cups of grape juice dated [DATE REDACTED] stored in the walk-in refrigerator.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 13 445525 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 445525 B. Wing 02/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Nhc Place at the Trace 8353 Highway 100 Nashville, TN 37221

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 4. Observation and interview in the kitchen on [DATE REDACTED] at 3:53 PM, the CDM confirmed that the dishwasher temperatures (temp) are supposed to be 160 degrees F at wash and 180 degrees F at rinse. The CDM Level of Harm - Minimal harm or stated, Staff are supposed to inform me or maintenance when the temp is too low, the water temp will come potential for actual harm down ,d+[DATE REDACTED] degrees and are instructed to wait ,d+[DATE REDACTED] minutes then restart (dishwasher) .

Residents Affected - Some Observation and interview in the Kitchen on [DATE REDACTED] at 10:02 AM, revealed [NAME] O was in the dish room running the dish washer and the dishwasher final rinse temp was not maintained and dropped to 151 degrees F. [NAME] R was asked, what's the process for reporting the dishwasher temperatures when they are not maintained. [NAME] R stated, I don't know the answer . [NAME] R returned with the CDM. The CDM was asked how he ensures that dishes are being sanitized properly if temperatures are not being maintained. The CDM confirmed that there was not any sanitation on the dishwasher since it is a high temp dishwasher and stated, Staff know to stop and let the water reheat after ,d+[DATE REDACTED] minutes.

Review of the Kitchen's Dishroom Record, dated ,d+[DATE REDACTED], revealed the rinse temperature was below 180 degrees on the following dates:

a. [DATE REDACTED] AM 169 degrees, evening 178 degrees

b. [DATE REDACTED] AM 175 degrees, noon 176 degrees

c. [DATE REDACTED] AM 171 degrees,

d. [DATE REDACTED] AM 174 degrees, noon 174 degrees, evening 177 degrees

e. [DATE REDACTED] AM 179 degrees, noon 177 degrees, evening 169 degrees

f. [DATE REDACTED] AM 175 degrees, noon 173 degrees, evening 175 degrees

g. [DATE REDACTED] noon 177 degrees, evening 179 degrees

h. [DATE REDACTED] noon 179 degrees, evening 178 degrees

i. [DATE REDACTED] AM 179 degrees

Observation and interview on [DATE REDACTED] at 10:16 AM, revealed the Regional Registered Dietitian (RD) had a test tray placed in the dishwasher with the final rinse temperature dropping to 160 degrees. The RD confirmed that there was an issue with the dishwasher and that someone would be contacted to assess the dishwasher. The RD confirmed that the facility would implement the use of disposable dining ware for serving meals.

5. Observation in the Kitchen on [DATE REDACTED] from 3:55 PM to 4:26 PM, revealed [NAME] N walking away from

the serving line multiple times, touching multiple items (including the warming oven handle) in the kitchen, without changing gloves or performing hand hygiene prior to returning to serving line. [NAME] N was observed obtaining 2 sweet potatoes from the warming oven with gloved hand and smashing 1 of the potatoes with gloved hand.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 13 445525 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 445525 B. Wing 02/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Nhc Place at the Trace 8353 Highway 100 Nashville, TN 37221

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 6. Review of the Named company invoice for the dishwasher dated [DATE REDACTED], revealed .a leak at the vacuum breaker was repaired .a temp probe was repaired for the energy recover system. The incoming power for the Level of Harm - Minimal harm or booster is missing .They need to get a[an] electrician to fix the incoming power for the booster . potential for actual harm

Review of the service report dated [DATE REDACTED], revealed .Back of House issue found .Machine [dishwasher] rinse Residents Affected - Some temp not meeting 180 degrees .Rinse Temperature: 144 [degrees] Fahrenheit .Monitoring rinse temp for compliance to protect guests, reputations, machine efficiency .Chemical Sanitation 50PPM [Parts Per Minute] .Monitoring chemical sanitation level for compliance to protect guests and reputation .Installed stacking pump to allow dishes to be sanitized while rinse temp is low .

7. Observation and interview in the kitchen on [DATE REDACTED] at 9:08 AM, revealed the stove eyes with thick carbon build up and a tan thick build up on the right front eye. The CDM stated that Ecolab came out last night and added a sanitizing line to the dishwasher. The CDM was asked regarding the testing of the sanitation of the dishwasher. The CDM stated that the facility does not have the sanitation test strips needed to test the dishwasher sanitation. The CDM confirmed that Ecolab performed a sanitation test prior to leaving. The CDM stated, I was perched the entire time that they were using the dishwasher to ensure the temps [temperatures] were not dropping.

Observation and interview in the kitchen on [DATE REDACTED] at 9:46 AM, revealed [NAME] M washing dishes in the dish room with a wash temp of 142 degrees. [NAME] M turned the dishwasher off and did not report low temperatures to anyone. The CDM was asked how he was ensuring the sanitation of trays and dishes with having 2 Covid residents in the facility. The CDM confirmed Ecolab ran sanitation to the dishwasher. The CDM was asked how he was ensuring the proper sanitation level without being able to test. The CDM stated, I see where you are coming from.

During an interview on [DATE REDACTED] at 12:08 PM, the Regional RD confirmed that she was first made aware of the issues with the dishwasher on [DATE REDACTED] and contacted the dishwasher manufacturer and Ecolab. The Regional RD was asked who made the decision to go back to using regular dishes and utensils. The Regional RD confirmed that she was not included in that decision.

During an interview on [DATE REDACTED] at 2:49 PM, revealed the RD confirmed that he has not been included in any conversations related to any issues with the dishwasher or any concerns related to the sanitation of the dishwasher this week or prior. The RD confirmed that was a concern related to covid residents and the issue with the dishwasher sanitation.

During an interview on [DATE REDACTED] at 3:38 PM, revealed the CDM, Regional RD, RD, and the Administrator were present. The CDM confirmed that opened food items should be labeled and dated. The CDM confirmed that expired food items should be discarded by the use by date. The CDM was asked if cookware or equipment should have thick carbon build up. The CDM stated, No. The CDM confirmed that there should not be dried food particles on clean dishes or cookware. The CDM confirmed that there should not be dried food particles, spillage, or dried substance build up on the sides or base of the rack, and mixing kettle and stand. The CDM confirmed that the dishwasher temperature logs should reflect appropriate temperatures in range and confirmed that staff should not leave the serving line and return without performing hand hygiene.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 13 445525 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 445525 B. Wing 02/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Nhc Place at the Trace 8353 Highway 100 Nashville, TN 37221

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51365 potential for actual harm Based on policy review, medical record review, observation, and interview, the facility failed to prevent the Residents Affected - Few spread of infections when 1 of 4 (Registered Nurse (RN) K) nurses failed to properly perform hand hygiene

during blood glucose monitoring and cleaned an injection site with a used alcohol pad during medication administration.

The findings include:

1. Review of the undated facility policy titled, Med Pass Education Tool, revealed, .Use proper hand hygiene prior to donning and after doffing gloves .Use proper hand washing technique .Use a clean towel to turn off water .

Review of the facility policy titled, 709 Hand Hygiene, dated April 2024 revealed, .To decrease the number of microorganisms, preventing cross contamination between staff and patients .Rinse your hands with water and use disposable towels to dry. Use towel to turn off the faucet .

2. Review of the medical record revealed Resident #278 was admitted to the facility on [DATE REDACTED], with diagnoses including Hypertensive Heart Disease, Congestive Heart Failure, Diabetes, and Cellulitis.

Review of the Social Services Noted dated 2/5/2025, revealed a Brief Interview for Mental Status assessment was performed on 2/5/2025, revealing a score of 11, indicating Resident #278 was moderately cognitively impaired.

Review of the Care Plan dated 2/4/2024, revealed .Diabetes .Monitor blood glucose levels as ordered and administer meds [medications]/insulin as directed .

Review of the Physician's Orders dated 2/3/2025 revealed insulin aspart U-100 insulin pen [a medication to lower blood glucose] .100 unit/mL [milliliter] .7 UNITS . subcutaneous .Take before lunch and dinner .[blood glucose monitoring] .Before Meals and At Bedtime .

Observation in Resident #278's room on 2/11/2025 at 11:41 AM, revealed RN K prepared to perform blood glucose monitoring, entered the bathroom, washed her hands, turned off water with her bare hand, and dried her hands with paper towel.

Observation in Resident #278's room on 2/11/2025 at 12:10 PM, revealed RN K prepared to administer an insulin injection, cleaned an area to the left lower abdomen with an alcohol pad, and placed the alcohol pad

on the over the bed table without a barrier. RN K picked the alcohol pad up off the overbed table and used

the same alcohol pad to wipe Resident #278's left lower abdomen, removed the needle cap, and administered the insulin into the abdomen.

During an interview on 2/12/2025 at 3:03 PM, RN K confirmed when performing handwashing the water should be turned off with a paper towel, not with her bare hand, and when cleaning an injection site an alcohol wipe should not be reused once placed on an over the bed table without a barrier.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 13 445525 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 445525 B. Wing 02/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Nhc Place at the Trace 8353 Highway 100 Nashville, TN 37221

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an interview on 2/12/2025 at 4:08 PM, the Director of Nursing confirmed an alcohol wipe should not be reused to clean an injection site if it has been laid on an over the bed table without a barrier and a paper Level of Harm - Minimal harm or towel should be used to turn off the water when performing hand washing. potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 13 445525