Nhc Place At The Trace

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. Review of the medical record revealed Resident #60 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease and Parkinsons. Review of the Physician's Orders dated 11/21/2025, revealed orders for the following medications: a.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 11/2027, 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 11/2017, revealed .After each use .For char-grills, use stiff brush to remove food particles from grate . Review of the facility policy titled, Refrigerator and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. We expect that you will provide patients with a comfortable and pleasant environment .Respect your privacy, dignity, and confidentiality . 2. Review of the facility's policy titled, USE OF COURTESY TITLES, dated 6/2006, revealed .It is the policy of this center to use courtesy titles .when addressing patients in all written records and communication . 3. Observation during dining on the 500 Hall on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 personal hygiene, used a wheelchair and walker for mobility and received anticoagulants. Review of the Care Plan dated 11/29/2024, revealed .Anticoagulant . At Risk for Bleeding . Approach .Use electric razor . Review of Physician's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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] . 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 .Potassium tablets . 2. Review of the medical record revealed the Resident #77 was admitted to the facility on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of rosemontpharma.com, policy review, medical record review, interview, and observation, the facility failed to ensure residents were free from significant medication errors for 1 of 4 sampled residents (Resident #77) reviewed. The findings include: 1. Review of the rosemontpharma.com article titled, Information For Patients On The Dangers Of Tablet Crushing, dated 9/2023, revealed . The clinical consequences for the patient of crushing tablets or opening capsules can mean that the drug is less effective or more likely to cause side effects. When crushing disrupts a drug's sustained-release properties, the active ingredient is no longer released and absorbed gradually, resulting in overdose. When a gastro-resistant layer is destroyed by crushing, underdosing is likely . Enteric coatings .These stop the drug breaking down in the stomach, to protect either the stomach or the drug, or to enable it to be released further along the digestive process . Modified or prolonged release .These drugs - also…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to prevent the 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], with diagnoses including Hypertensive Heart Disease, Congestive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to complete a timely Minimum Data Set (MDS) Assessment for 4 (#9, #19, #45, #53) of 7 residents reviewed. The findings include: Medical record review revealed Resident #9 was admitted to the facility on [DATE] with diagnoses which included Dementia without Behavioral Disturbance. Medical record review of Resident #9's Physicians Orders dated 3/22/19 revealed, .[named] Hospice start of service 3/22/19 .Patient Terminal Diagnosis End Stage Dementia . Medical record review of Resident #9's admission MDS dated [DATE] revealed the resident was not receiving hospice care. Medical record review of Resident #9's Significant Change in status MDS revealed the Accelerated Rehabilitative Disposition (ARD) date was 3/27/19 and was captured for Hospice care. Further review revealed the MDS Assessment was electronically signed and completed on 4/16/19, not completed within 14 days of the ARD date (determination period). Medical record review revealed Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on facility policy review, medical record review, observation and interview the facility failed to implement a base line care plan to include respiratory services for 1(#340) of 7 residents reviewed. The findings include: Review of facility policy, Care Plans - Baseline, dated December 2016 revealed .A baseline plan of care to meet the resident's immediate needs shall be developed with forty-eight (48) hours of admission .The Interdisciplinary Team will review the healthcare practitioner's orders .and implement a baseline care plan .including but not limited to: Initial goals based on admission orders, Physician orders, Dietary orders, Therapy services, Social services .The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan . Medical record review revealed Resident #340 was admitted to the facility with diagnoses which included Pneumonia, Acute Respiratory Failure with Hypoxia, Dependence on Supplemental Oxygen, Chronic Obstructive Pulmonary Disease. Medical record review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review and interview, the facility failed to update a care plan for 1 (#53) of 41 residents reviewed. The findings include: Facility policy review, Updating and Revising Care Plans, updated 10/1/16, revealed .Care plans are updated as needed .New problems are handled as they arise, and are to be added to the current care plan even if the change in condition is not considered significant enough for a complete revision . Medical record review revealed Resident #53 was admitted to the facility on [DATE] with diagnoses which included Displaced Intertrochanteric Fracture of Right Femur, History of Falling, Muscle Weakness and Difficulty in walking. Medical record review of Resident #53's Fall Care Plan revised on 2/6/19 revealed no bedside commode intervention in place. Continued review revealed the care plan was revised on 2/10/19 to remove bedside toilet from room. Interview with Director of Nursing on 9/18/19 at 8:46 AM in the conference room confirmed Resident #…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation and interview, the facility failed to properly store a nebulizer mask to prevent the spread of infection for 1 (#340) of 7 residents who received respiratory services. The findings include: Facility policy review, Specific Medication Administration Procedures, dated 6/2016 revealed, .store in a plastic bag with the resident's name and date on it . Medical record review revealed Resident #340's was admitted to the facility on [DATE] with diagnoses which included Pneumonia, Acute Respiratory Failure with Hypoxia, Dependence on Supplemental Oxygen, Chronic Obstructive Pulmonary Disease. Medical record review of Resident #340's Physician Orders dated 9/17/19 revealed, .albuterol solution [bronchiodialtor] for nebulization, 2.5 mg [milligram]/3 ml [milliliters] (0.83%) .1 inhalation Every 4 Hours-PRN [as needed]. Medical record review of Resident #340's Physician Orders dated 9/17/19 revealed, . ipratropium-albuterol solution [bronchiodialtor] for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, observation and interview the facility staff failed to use hand sanitizer while delivering lunch trays to 2 rooms (434 and 435) of 10 rooms observed. The findings include: Review of the facility policy, Handwashing dated 6/03, revealed .When to wash hands: i. before passing out trays or handling food . Observation on 9/16/19 at 12:03 PM on the 1st floor revealed Certified Nurse Aide (CNA) #7 left room [ROOM NUMBER] without using hand sanitizer or washing hands after delivering a lunch tray. Continued observation revealed CNA #7 retrieved a tray from the tray cart and went into room [ROOM NUMBER] to deliver a lunch tray without sanitizing or washing her hands. Interview with CNA #7 on 9/16/19 at 12:07 PM on the 1st floor when asked what was the facility policy for handwashing stated .I would wash my hands but I just went in there to set a tray down . Continued interview with CNA #7 stated .you are suppose to wash or use hand sanitizer when coming in and out of the room . Interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, resource article for cleaning agent, observation and interviews, the facility failed to use proper floor cleaning disinfectant solution to destroy Clostridium Difficile (C Diff) bacterial spores to prevent the spread of infection. The findings include: Facility policy review, Proper Cleaning Procedures, undated, revealed it was not specific to C Diff spores. Review of article, Efficacy of cleaning products for C Difficile associated diarrhea in geriatric rehabilitation, Canadian Family Physician, dated May 2010, revealed, .Of the agents tested, those containing high levels of chlorine (5000 milligrams/Liter free chlorine) showed consistent efficacy against C Difficile spores . Observation on 9/18/19 at 8:11 AM in room [ROOM NUMBER] revealed Housekeeper #1 cleaning isolation room using disinfectant germicidal spray to clean the floor and shower stall. Observation on 9/18/19 at 8:20 AM in room [ROOM NUMBER] revealed the disinfectant cleaning agent label listed no bleach…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.