High Hope Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interviews the facility failed to provide quarterly statements for resident personal funds accounts for 1 (#17) resident out of 5 residents reviewed for personal funds. Findings: Review of Resident #17's EMR (electronic medical record) revealed an admit date of 08/10/2023 with diagnoses that included major depressive disorder, panic disorder and sleep apnea. Further review revealed she was her own Responsible Party (RP). Review of Resident #17 EMR revealed an MDS (Minimum Data Set) assessment dated [DATE] that revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating the resident was cognitively intact. On 03/16/2026 at 10:34 a.m., during an interview with Resident #17. She stated she had personal funds in an account at the facility. Resident #17 further reported she had never received a quarterly statement since being at the facility. On 03/17/2026 at 11:15 a.m., an interview was conducted with S2AC, she reported she was responsible for ensuring the resident…

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 record review and interviews, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment related to PASARR (Preadmission Screening and Resident Review) Level II determinations for 2 (#7, #58) out 3 resident reviewed for PASARR. Findings: Resident #7 A review of Resident #7's EMR (electronic medical record) revealed an admission date of 05/04/2024 with diagnoses that included, but were not limited to, unspecified psychosis not due to a substance or known physiological condition, major depressive disorder, recurrent severe without psychotic features, and generalized anxiety disorder. Further review of Resident #7's EMR revealed a PASRR Level II Evaluation Summary and Determination with an issue date of 09/30/2024. Review of Residents #7's comprehensive MDS assessment with an Assessment Reference Date (ARD) of 05/15/2025 revealed the PASARR Level II status was coded as not indicated. On 03/18/2026 at 10:30 a.m., an interview was conducted with S7MDS who was responsible for resident MDS assessments. S7MDS stated that she was unaware of Resident #7's…

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, record review, and interview, the facility failed to ensure all drugs and biologicals remained locked in stored compartments of 1 medication cart when unattended during medication pass.Findings:On 03/18/2026, review of the facility's Medication Storage policy and procedure indicated Date Reviewed/Revised: 2026. The policy read, in part, All drugs and biologicals will be stored in locked compartments (i.e., medication carts. and During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.On 03/17/2026 at 2:51 p.m., when approaching the Hall W nurses' station, Med Cart A was observed midway down the hallway. There was no nurse in sight. Approaching the cart, it was observed that the back of the cart was near the wall of the hallway, with the front face of the cart facing the center of the hallway and providing access to the drawers of the cart. No nurse attended the cart or was within line of sight of the cart. The locking mechanism for the drawers was protruding…

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 observations, interviews and review of the facility's policy and procedures, the facility failed to store food in accordance with professional standards for food service, and ensure sanitary conditions were maintained in the kitchen as evidenced by: bulk items, juice, and snacks stored without the used by/expiration date, and without the date the items were delivered and/or opened; andbuildup of grime and water stains on bottom shelf of a food preparation table and dish covers storage rack. This deficient practice had a potential to affect 90 residents who consumed food from the kitchen. Findings: 1. On 03/16/2026, a review of the facility's policy titled, Storage of Food and Non-Food Items with last reviewed date of 02/27/2026, read in part, Policy: All food or non-food items are stored in a safe and sanitary manner .Procedure: 1. Dry Storage .E. Food items are marked with the date of delivery as they are stored. Boxes, cans and bags are marked individually.On 03/16/2026 at 8:56 a.m., a tour of the dry…

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, interview and record review, the facility failed to maintain an effective infection control program by failing to ensure laundry staff wore appropriate personal protective equipment (PPE) while sorting soiled laundry to prevent the spread of infection.Findings:A review of the facility's policy titled Laundry and Bedding, Soiled, last reviewed 01/27/2026, read as follows; Onsite Laundry Processing 1. Hand hygiene products, as well as appropriate PPE (i.e., gloves and gowns) are available and used while sorting and handling contaminated linens.During a tour of the facility's laundry room on 03/17/2026 at 2:05 p.m., S4LS, a laundry staff member, was observed sorting visibly soiled laundry. At that time, S4LS was not wearing a disposable gown. He confirmed that the laundry was from residents and was soiled. S4LS further acknowledged that a disposable gown should have been worn while sorting soiled resident laundry but was not.On 03/17/2026 at 2:07 p.m., an interview was conducted with the housekeeping and laundry supervisor identified as S5HS, who affirmed that…

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 record reviews and interviews, the facility failed to notify the State's Long-Term Care Ombudsman of emergency transfers in writing for 1 (#1) of 3 (#1, #2, #3) sampled residents reviewed for transfer and discharge requirements. Findings: Review of Resident #1's Electronic Medical Record (EMR) revealed, in part, Resident #1 was admitted to the facility on [DATE]. Further review of the EMR revealed Resident #1 had an emergency transfer to a local hospital on [DATE]. Review of the facility's Ombudsman notification list of emergency transfers dated 03/01/2025-03/31/2025, Resident #1's transfer on 03/04/2025 was not listed and there was no further evidence the Ombudsman had been notified of the transfer. On 07/09/2025 at 12:30 p.m., a concurrent records review and interview was conducted with S1SSD (Social Services Director). S1SSD confirmed that the accuracy of the State's Long-Term Care Ombudsman list of emergency transfers was her responsibility. S1SSD reviewed Resident #1's EMR and confirmed she had an…

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 record reviews and interviews, the facility failed to ensure that residents who required dialysis received such services consistent with professional standards of practice for 1 (Resident #25) out of 1 (Resident #25) residents reviewed for dialysis services by failing to collaborate with the dialysis provider through dialysis communication forms. Findings: On 02/19/2025, a review of the facility's policy titled Hemodialysis, last reviewed January 2025, indicated; The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include: the ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. A review of Resident #25's medical record revealed an admission date of 10/14/2020 with diagnosis that include, in part but not limited to; end stage renal disease, metabolic encephalopathy, and acute on chronic diastolic congestive heart failure. A review of Resident #25's…

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 record review and interviews, the facility failed to refer residents with a newly diagnosed mental disorder to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 1 (#36) out of 3(#31, #36, #53) sampled residents investigated for PASARR in a final sample of 33 residents. Findings: On 02/19/2025, a review of the facility's policy titled, Resident Assessment - Coordination with PASARR Program last reviewed January 2025, indicated 1. Negative Level I Screen permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. A review of Resident #36's record revealed an admission date of 02/09/2022…

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 record review and interview, the facility failed to notify the State Long Term Care Ombudsman of facility-initiated transfers for 1 (Resident #73) out of 3 (#17, #56, #73) sampled residents. The deficient practice has the potential to affect a census of 92. Findings: Review of the facility's policy titled, Discharge the Resident, read in part, #5. For each emergency to the hospital, the SSD (Social Service Designee) will report to state ombudsman, in a monthly report and documented on the emergency transfer log. Review of Resident #73's medical record revealed that the resident was admitted to the facility on [DATE] with diagnoses that read in part; Partial Traumatic Amputation of Right Foot, Level Unspecified, Aphasia, Acute Osteomyelitis Right Ankle and Foot, Metabolic Encephalopathy, Cerebral Vascular Accident, Peripheral Vascular Disease, Chronic Obstructive Pulmonary Disease, Major Depressive Disorder and Anxiety. Review of Resident #73's nurses' notes revealed on 01/11/2024 at 1:30 p.m., 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.

Based on record reviews and interview, the facility failed to ensure there was a sufficient number of skilled licensed nurses, nurse aides, and other nursing personnel to provide care and respond to each resident's basic needs. The facility failed to provide the minimum required staffing hours for 2 of 13 weekends reviewed. Findings: Review of the facility's PBJ (Payroll Based Journal) Staffing Data Report for FY (Fiscal Year) Quarter 4 2023 (July 1 to September 30) revealed the submitted weekend staffing data was excessively low. Review of the facility's staffing pattern reports for the month of November 2023 revealed the facility provided 200.68 hours on 11/05/2023 and were required to provide 220.9 hours. Further review revealed the facility provided 195.71 hours on 11/12/2023 and was required to provide 204.45 hours. On 02/20/2024 at 3:30 p.m., an interview was conducted with S5ADM (Administrator). S5ADM reviewed the facility's staffing pattern for the month of November 2023 and acknowledged the facility did not provide the minimum hours required on 11/05/2023 and 11/12/2023.

Based on observations, interviews and record review, the facility failed to serve food in accordance with professional standards for food service safety as evidenced by failing to ensure that dietary staff utilized the appropriate facial hair covering while working in the kitchen and food service area. This deficiency had the potential to affect 90 residents who consumed food prepared in the kitchen. Findings: A review of the facility's Policy and Procedure titled Employee Hygiene and Personal Cleanliness was conducted. The policy included, in part: Employees must wear a hairnet at all times, covering all hair. On 02/18/2024 at 8:45 a.m., an observation was conducted of S4DA (Dietary Aide) working in the kitchen washing dishes. S4DA was observed with a full beard and mustache that was not covered. On 02/18/2024 at 10:30 a.m., a follow up visit to the kitchen was performed. An observation was conducted of S4DA as he worked in and around the food service line area as food was being prepared for the lunch meal without a facial hair net covering his beard. S3DM (Dietary Manager) was…

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.