ElderGrade

Inspection citations at Mt Hope Nazarene Retirement Community

14 citations on record, 0 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2024 2 0
2023 2 0
2022 10 0
D September 5, 2024 Tag F0688 Corrected Oct 2024

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

No actual harm, potential for more than minimal harm

E September 5, 2024 Tag F0657 Corrected Oct 2024

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

No actual harm, potential for more than minimal harm

D November 2, 2023 Tag F0695 Corrected Dec 2023

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

No actual harm, potential for more than minimal harm

D November 2, 2023 Tag F0641 Corrected Dec 2023

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

No actual harm, potential for more than minimal harm

D November 16, 2022 Tag F0759 Corrected Dec 2022

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

No actual harm, potential for more than minimal harm

D November 16, 2022 Tag F0755 Corrected Jan 2023

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

No actual harm, potential for more than minimal harm

D November 16, 2022 Tag F0641 Corrected Jan 2023

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

No actual harm, potential for more than minimal harm

D November 16, 2022 Tag F0550 Corrected Dec 2022

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

No actual harm, potential for more than minimal harm

E November 16, 2022 Tag F0909 Corrected Dec 2022

Environmental Deficiencies

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

No actual harm, potential for more than minimal harm

E November 16, 2022 Tag F0700 Corrected Dec 2022

Quality of Life and Care Deficiencies

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

No actual harm, potential for more than minimal harm

E November 16, 2022 Tag F0656 Corrected Dec 2022

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

E November 16, 2022 Tag F0585 Corrected Dec 2022

Resident Rights Deficiencies

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

No actual harm, potential for more than minimal harm

E November 16, 2022 Tag F0582 Corrected Dec 2022

Resident Rights Deficiencies

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

No actual harm, potential for more than minimal harm

E November 16, 2022 Tag F0575 Corrected Dec 2022

Resident Rights Deficiencies

Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.

No actual harm, potential for more than minimal harm

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.