Mt Hope Nazarene Retirement Community

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. The Interdisciplinary Team is responsible for the review and updating of the care plans. Review of Resident 8's clinical record revealed diagnoses that included jaw pain, anxiety disorder (a persistent feeling of worry, nervousness, or unease), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things). Review of Resident 8's care plan revealed an activities care plan…

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, 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). Findings include: Review of facility policy, titled Restorative Nursing Program (RNP), last revised June 2024, read, in part, Restorative care is promoted to enable residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being. A licensed nurse shall be appointed as the Restorative Nurse to oversee, coordinate and monitor the RNP. A Certified Nursing Aid will be appointed as the Restorative Aide to implement programs put in place by the restorative nurse. The Restorative Aide will complete task documentation as indicated by program requirements. Review of Resident 9's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders,…

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 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. Review of a Promedica Revocation of Hospice Benefit document dated October 10, 2023, revealed that Resident 23 started hospice care on April 3, 2023, and revoked hospice on October 10, 2023. Written communication received from…

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 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). Findings include: Review of facility policy, titled Continuous Positive Airway Pressure [CPAP- a method of respiratory therapy in which air is pumped into the lungs through the nose or nose and mouth during spontaneous breathing] disinfecting, effective June 24, 2019, revised October 1, 2023, read, in part, orders to clean and sanitize CPAP machines will be placed into the resident's treatment administration record. Review of Resident 45's clinical record documented they were admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD - a group of lung disease that block airflow and make it difficult to breathe), asthma (a condition in which a person's airway becomes inflamed,…

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 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. An interview with the Nursing Home Administrator, on November 16, 2022, at 10:38 AM, revealed the facility has created documents for posting with the required information that will presently be available for resident review. 28 Pa. Code 201.14 (a) Responsibility of licensee

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. 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. Review of Resident 32's SNF-ABN revealed the Resident was discharged from Medicare A skilled services on May 17, 2022. According the the SNF-ABN, Resident 32 would be responsible for the facility's rate 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.

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. 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. Review of the facility's admission packet revealed no documentation of the designation of a grievance official or the required information, to include the name and contact information. An interview with the Nursing Home…

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 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. Review of Resident 20's comprehensive plan of care revealed that enabler bars were not included in the comprehensive plan of care. On November 16, 2022, at 9:30 AM, a facility document was reviewed regarding the application of bilateral enabler bars to Resident 20's bed. Review of the document revealed that 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.

Based 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). Findings include: Review of facility policy Enabler Bar, effective date December 10, 2021, read, in part, enabler bar assessment will be completed upon admission and if the resident has a change in condition. Verbal/written consent will be obtained from resident or resident representative, and emergency contact will be called to obtain verbal/written consent. Review of Resident 18's clinical record revealed diagnoses that included stroke (damage to the brain from interruption of its blood supply), epilepsy (neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain), and hemiparesis (paralysis of one side of the body). Interview with Resident 18 on November 13, 2022, at approximately 12:02 PM, it was revealed that she utilized the…

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, 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). Findings include: Review of facility policy Enabler Bar, effective date December 10, 2021, read, in part, enabler bar assessment will be completed upon admission and if the resident has a change in condition. Verbal/written consent will be obtained from resident or resident representative, and emergency contact will be called to obtain verbal/written consent. Review of Resident 18's clinical record documented diagnoses that included stroke (damage to the brain from interruption of its blood supply), epilepsy (neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain), and hemiparesis (paralysis of one side of the body).…

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 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. Review of Resident 46's clinical record revealed diagnoses that included retention of urine (a condition in which you are unable to empty all the urine from your bladder) and hypertension (elevated blood pressure). Continued review of Resident 46's clinical record revealed the need for the use of an indwelling foley catheter ( a common type of indwelling catheter. It has soft,…

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 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). Findings include: Review of Resident 29's clinical record on November 13, 2022, at approximately 1:00 PM, revealed diagnoses including diabetes mellitus type 2 (disease in decreases the body's ability to utilize insulin for the transport of glucose from the blood stream into the cells for nourishment) and hypertension (elevated/high blood pressure). Review of Resident 29's quarterly Minimum Data Set (MDS - standardized assessment tool utilized to identify a residents' physical, mental, and psychosocial needs), with an assessment reference date of September 21, 2022, revealed in section N0300 Injections, Record the number of days that injections of any type were received during the last 7 days or since admission/entry or reentry if less than 7 days, was coded as 0 indicating Resident 29 had received no injections during the 7 days prior to September 21, 2022. Further, due to assessment response…

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 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). Findings include: Review of facility policy titled, Med[ication] Pass Policy, initial date March 1, 2012, last reviewed date October 24, 2022, revealed section 1. Documentation, stated, White dots that are on eye drops, ear drops, liquids, injectables, are there so that the nurse who first opens/uses the medication has a place to document his/her initials and the date and time. Unit dose boxes should have the nurse's initials and date and time that the box was opened. The Medication Administration Record (MAR) needs to be marked when a new box, bottle, inhaler, etc. is started. Place a mark with a colored marker on the day/time space when the container has been opened- this is for accountability purposes. PRN [as-needed] medications must have documentation on the front and back of the MAR. You must indicate…

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 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. Findings include: Based on observation of 34 medication opportunities, three medication errors were identified, which equated to an error rate of 8.82 percent. Review of facility policy titled, Med[ication] Pass Policy, last reviewed October 24, 2022, revealed that section 3. Medication Administration stated, Inhalers - wait one minute between puffs . During medication administration observations on November 14, 2022, at approximately 10:20 AM, Facility Employee 3 was observed preparing medications to be administered to Resident 45. During the observation, Facility Employee 3 retrieved polyvinyl alcohol 1.4% eye drops for administration. Observations of the polyvinyl alcohol 1.4% eye dropper revealed that it was previously opened. Observations revealed no open date was recorded on the pharmacy bag that contained the eye drops, nor on the container of eye drops. Facility Employee 3 was observed administering the…

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.