Mt Hope Nazarene Retirement Community

Inspectors wroteBased on facility policy review, observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for two of 14 residents reviewed (Residents 8 and 40).

Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one of four residents reviewed for limited range of motion (Resident 9).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for one of 13 residents reviewed (Resident 23). Findings Include: Review of Resident 23's clinical record revealed diagnoses that included chronic diastolic heart failure (a condition in which your heart's main pumping chamber becomes stiff and unable to fill properly) and essential hypertension (high blood pressure). Review of Resident 23's admission MDS (Minimum Data Set is part of federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated July 8, 2023, revealed that Section O0100, Special Treatments, Procedures, and Programs (K. Hospice Care, 1. While not a resident of this facility and within the last 14 days) was marked No. [...]

Inspectors wroteBased on review of facility policy, observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice of one of 13 residents reviewed (Resident 45).

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to post a list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, and adult protective services, in a form and manner accessible and understandable to residents / resident representatives for two of two resident areas observed (First and Second Floors). Findings Include: Observations on the facility's first and second floors, on November 15, 2022, at 11:32 AM, revealed postings on behalf of residents did not include the required State agencies and advocacy groups elements, including mailing and email addresses. [...]

Inspectors wroteBased on document review and staff interview, it was determined that the facility failed to ensure each resident is informed periodically during the resident's stay of services available in the facility and charges for those services, including any charges for services not covered under Medicare/Medicaid, for two of three residents reviewed at the end of their Medicare A stay (Residents 13 and 32). Findings Include: Review of Resident 13's Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage form (SNF-ABN) revealed the Resident was discharged from Medicare A skilled services on August 20, 2022. According to the SNF-ABN, Resident 13 would be responsible for the facility's rate of charges not covered under Medicare or Medicaid. Further review of the SNF-ABN reveled Resident 13, nor the Resident's Responsible Party were informed of the charges no longer covered. [...]

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to notify residents individually or through postings in prominent locations throughout the facility of the right to file grievances, orally or in writing; the right to file grievances anonymously; the contact information of the grievance official, with whom a grievance can be filed, including his or her name, business address (mailing and email), and business phone number, for two of two resident areas reviewed (First and Second floors) and review of the facility's admission packet. Findings Include: Observations on the first and second floors, on November 14, 2022, at 9:48 AM, and November 15, 2022, at 10:52 AM, revealed no information posted regarding the facility's designated greivance official or the required information, to include the name and contact information. [...]

Inspectors wroteBased on observation, clinical record review, facility document review, and staff interviews, it was determined that the facility failed to ensure the development and implementation of a comprehensive plan of care for one of 13 residents reviewed (Resident 20).

Inspectors wroteBased on policy review, observation, record review, and interviews, the facility failed to complete a risk benefit analysis and obtain consent for use of an enabler bar for three of three residents reviewed (Residents 18, 20, and 46).

Inspectors wroteBased on policy review, observation, record review, and interviews, it was determined that the facility failed to conduct regular inspections of bed rails/enabler bars to identify areas of possible entrapment for three of three residents reviewed (Residents 18, 20, and 46).

Inspectors wroteBased on observation, policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure each resident the right to be treated with respect, dignity, and care in a manner that promotes maintenance or enhancement of his or her quality of life for one of 13 residents reviewed (Resident 46). Findings Include: Review of the facility's policy, titled Quality of Life and Dignity for Resident, recently reviewed October 1, 2022, reads, in part, The resident has the right to a dignified existence. Also, A facility must treat each resident with respect and dignity and care .in a manner and environment that promotes maintenance or enhancement of his or her quality of lie. [...]

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure accuracy of the resident assessment for one of 13 residents reviewed (Resident 29).

Inspectors wroteBased on observations, facility documentation, policy review, and staff interviews, it was determined that the facility failed to ensure multi-use medications were dated upon opening for one of two medication storage carts reviewed (second floor medication cart one of two).

Inspectors wroteBased on observation, product manufacturer label, and facility policy review, it was determined that the facility failed to ensure a medication rate of less than 5 percent.