Mt Hope Nazarene Retirement Community

In the surveyor’s words

From the most serious findings on record at Mt Hope Nazarene Retirement Community, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF657Sep 5, 2024

  Based 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). Findings include: Review of facility policy, titled Comprehensive Care Plan, last revised June 10, 2024, read, in part, The Comprehensive Care Plan will describe treatments and services to assist the resident to attain or maintain the highest level of physical, mental, emotional, and psychosocial wellbeing. Care Plans will be revised as information about the resident and the resident's condition changes. […]

• No harm, potential for more than minimal, patternF575Nov 16, 2022

  Based 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. […]

• No harm, potential for more than minimal, patternF582Nov 16, 2022

  Based 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. […]

• No harm, potential for more than minimal, patternF585Nov 16, 2022

  Based 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. […]

• No harm, potential for more than minimal, patternF656Nov 16, 2022

  Based 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). Findings include: Review of Resident 20's clinical record on November 13, 2022, at approximately 11:30 AM, revealed diagnoses including unspecified dementia (irreversible, progressive degenerative disease of the brain that results in decreased contact with reality and decreased ability to perform activities of daily living) and hypertension (elevated/high blood pressure). During observations on November 13, 2022, Resident 20 was observed lying in bed with bilateral enabler bars affixed to the Resident's bed frame. […]