Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Nhc Place At The Trace during CMS and state inspections, most recent first.
The facility failed to maintain sanitary conditions in the kitchen, with soiled cookware, equipment, and floors, and improper food storage. The dishwasher did not reach the required temperature for sanitation, and staff failed to report low temperatures or perform hand hygiene during tray service. The CDM and RD confirmed these deficiencies, highlighting a lack of communication and oversight.
The facility failed to maintain residents' dignity during dining as staff entered rooms without knocking and used informal terms instead of courtesy titles. Despite policies emphasizing respect and dignity, staff, including a UM, CNAs, an LPN, and a Staffing Coordinator, did not adhere to these guidelines, as confirmed by the DON.
A facility failed to maintain a hazard-free environment when two disposable razors were found unsecured in a resident's bathroom. The resident, who was on anticoagulant therapy and at risk for bleeding, was supposed to use an electric razor as per their care plan. The DON confirmed the razors should have been stored properly, and a CNA stated the resident used an electric razor, highlighting a lapse in protocol adherence.
A registered nurse in an LTC facility committed two medication errors by crushing extended-release potassium chloride and delayed-release enteric-coated aspirin, contrary to facility policy. This resulted in a medication error rate of 6.06%. The resident involved had multiple health conditions and was cognitively intact. The nurse expressed uncertainty about the appropriateness of crushing these medications, which was later confirmed as incorrect by the Director of Nursing.
A resident in an LTC facility received crushed medications that should not have been altered, including aspirin delayed release and potassium chloride extended release. The RN involved was unsure about the protocol, and the DON confirmed that such medications should not be crushed, leading to a significant medication error.
An RN in an LTC facility failed to follow proper hand hygiene and infection control protocols during blood glucose monitoring and insulin administration for a resident. The RN turned off the water with bare hands after washing and reused an alcohol pad after placing it on an unprotected surface, contrary to facility policies.
Sanitation and Hygiene Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, leading to multiple deficiencies. Observations revealed that cookware and equipment were soiled, with black build-up on cooking pots, dried food particles on a perforated pan, and cantaloupe stuck between dessert bowls. Additionally, plastic containers and metal racks were found with dried food splatters and spillage. The char-grill and stove eyes had thick carbon build-up, and the kitchen floor was soiled with black build-up under the deep fryer. Opened and undated loaves of bread and expired grape juice were also found in storage areas. The facility's dishwasher was not maintained at the appropriate temperature for sanitation. The dishwasher's final rinse temperature consistently fell below the required 180 degrees Fahrenheit, with records showing multiple instances of non-compliance. Staff were observed not following proper procedures for reporting low temperatures, and there was a lack of sanitation testing due to the absence of test strips. Despite the installation of a sanitizing line by Ecolab, the facility continued to face issues with ensuring proper sanitation levels. Staff hygiene practices were also found lacking, as one staff member failed to perform hand hygiene during tray line service. The staff member was observed touching multiple items in the kitchen without changing gloves or washing hands before returning to the serving line. Interviews with the Certified Dietary Manager (CDM) and Regional Registered Dietitian (RD) confirmed the deficiencies and highlighted a lack of communication and oversight in addressing the issues, particularly concerning the dishwasher's sanitation and the presence of COVID-19 residents in the facility.
Failure to Maintain Resident Dignity and Respect During Dining
Penalty
Summary
The facility failed to maintain or enhance residents' dignity and respect during dining times, as observed in multiple instances involving staff members. Staff members, including a Unit Manager, CNAs, an LPN, and a Staffing Coordinator, entered residents' rooms without knocking or announcing themselves, which is a breach of the residents' right to privacy and dignity. Additionally, staff members failed to use courtesy titles when addressing or referring to residents, opting instead for informal and potentially disrespectful terms such as 'sweetheart,' 'girlie,' and 'Boo Boo.' These actions were observed during dining times on the 500 Hall, affecting several residents. The facility's policies, including the 'Partner Education-Dignity Training' and 'USE OF COURTESY TITLES,' emphasize the importance of respecting residents' privacy, dignity, and confidentiality, and require the use of courtesy titles in all communications. Despite these policies, staff members did not adhere to these guidelines, as confirmed by the Director of Nursing during an interview. The DON acknowledged that staff should knock and announce themselves before entering a resident's room and confirmed that residents should be addressed with courtesy titles, not pet names.
Unsecured Razors Found in Resident's Room
Penalty
Summary
The facility failed to ensure the environment was free of accident hazards when unsecured sharps were observed in a resident's room. Specifically, two blue disposable razors were found in a wash basin on the counter in the bathroom of a resident's room. This resident, who was admitted with diagnoses including Supraventricular Tachycardia, Atrial Fibrillation, Hemiplegia, Hemiparesis, and Cerebral Infarction, was cognitively intact and used a wheelchair and walker for mobility. The resident was also on anticoagulant therapy, which increased the risk of bleeding. The care plan for the resident indicated the use of an electric razor due to the risk of bleeding associated with anticoagulant use. However, during observations, the disposable razors were found unsecured in the resident's bathroom. The Director of Nursing confirmed that the razors should not have been left out and should have been stored in a drawer. A Certified Nursing Assistant also confirmed that the resident used an electric razor and had never been seen with a bladed razor, indicating a lapse in adherence to the care plan and facility protocols for accident prevention.
Medication Administration Error Due to Crushing of Medications
Penalty
Summary
The facility failed to ensure that medications were administered with a medication error rate of less than 5%, as evidenced by the actions of one registered nurse (RN L) who committed two medication errors out of 33 opportunities, resulting in a 6.06% error rate. The errors were observed during a medication administration session where RN L crushed medications that should not have been crushed, specifically extended-release potassium chloride and delayed-release enteric-coated aspirin. This action was contrary to the facility's policy, which clearly states that slow-release or enteric-coated medications should not be crushed. The incident involved a resident with multiple diagnoses, including osteoporosis, fibromyalgia, chronic kidney disease, and chronic atrial fibrillation, among others. The resident was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15. During the medication administration, RN L crushed the medications and administered them with applesauce, leading to the medication errors. When questioned, RN L expressed uncertainty about the appropriateness of crushing these medications, indicating a lack of adherence to the facility's medication administration policies. The Director of Nursing later confirmed that such medications should not be crushed.
Improper Crushing of Medications Leads to Significant Error
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the improper administration of medications to a resident. The resident, who was admitted with multiple diagnoses including age-related osteoporosis, chronic kidney disease, and long-term use of aspirin, was prescribed aspirin delayed release and potassium chloride extended release. During a medication administration observation, a registered nurse crushed these medications, which were then mixed with applesauce and administered to the resident. This action was contrary to the facility's policy and the information provided by rosemontpharma.com, which both indicated that slow-release or enteric-coated medications should not be crushed. The registered nurse involved in the incident expressed uncertainty about whether the medications should be crushed, suggesting it was up to the provider and pharmacy. The Director of Nursing later confirmed that such medications should not be crushed, highlighting a lapse in adherence to medication administration protocols. This deficiency was identified during a review of the facility's practices, policies, and interviews with staff, revealing a significant medication error that could potentially impact the effectiveness and safety of the resident's treatment regimen.
Infection Control Breach by RN During Care
Penalty
Summary
The facility failed to prevent the spread of infections due to improper hand hygiene practices by a registered nurse (RN). During an observation, RN K was seen performing blood glucose monitoring for a resident without following proper hand hygiene protocols. Specifically, after washing her hands, RN K turned off the water with her bare hand instead of using a paper towel, as required by the facility's hand hygiene policy. This action could potentially lead to cross-contamination, as the policy clearly states the importance of using a towel to turn off the faucet to prevent the spread of microorganisms. Additionally, RN K did not adhere to proper infection control practices during medication administration. While preparing to administer an insulin injection to a resident with multiple diagnoses, including diabetes, RN K used an alcohol pad to clean the injection site. However, she placed the alcohol pad on an overbed table without a barrier and then reused it to clean the injection site, which is against the facility's infection control policy. Both RN K and the Director of Nursing confirmed that these actions were not in compliance with the facility's protocols, highlighting a failure in maintaining proper infection prevention and control measures.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Nashville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Meadows | 2.6 mi | ★★★★★ | 0 | 0 |
| West Meade Place | 5.6 mi | ★★★★★ | 9 | 0 |
| Woodcrest At Blakeford | 9.1 mi | ★★★★★ | 10 | 0 |
| Green Hills Center For Rehabilitation And Healing | 9.4 mi | ★★★★★ | 0 | 0 |
| Franklin Wellness And Rehabilitation Center | 9.6 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.