Hope Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the care plans were updated as residents' care and needs changed for two sampled residents (Residents #59 and #161) out of 8 sampled residents. The facility census was 13 residents. 1. Review of Resident #59's Face Sheet showed the resident was admitted on [DATE], with diagnoses including Post Traumatic Stress Disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), malnutrition, depression, high blood pressure, diabetes, low back pain and neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment tool to be completed by facility staff for care planning, dated 11/3/23, showed the resident: -Was alert and oriented with no confusion or behaviors. -Had no upper or lower extremity impairments and ambulated independently. -The resident had no…

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 interview and record review, the facility failed to transcribe medication orders accurately and periodically reconcile physician orders when an antipsychotic medication was added to a resident's medical record without an order for one resident (Resident #161) of 5 residents sampled for unnecessary medications. The facility census was 13. A policy for order transcription and medication reconciliation was requested on 6/13/24 but was not received prior to exit. 1. Review of #161's face sheet showed diagnoses including seizures, dementia without behavioral disturbances, adjustment disorder (excessive reactions to stress that involve negative thoughts, strong emotions, and changes in behavior), stroke, and insomnia (difficulty sleeping). Review of the resident's hospice facility admission orders, dated 4/10/24 and signed by a hospice Registered Nurse (RN), showed: -The resident was admitted to hospice services on 4/10/24. -A section of the orders titled Comfort Kit orders had standing orders and instructions to circle NO for all declined orders and draw a line through 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 observation, interview and record review the facility failed to ensure initial and quarterly smoking assessments were completed to establish a resident's capacity for smoking and establish a baseline for the resident's ability to smoke, determine assistance as necessary, and ensure safe smoking habits were in place and continuing for two sampled residents (Residents #3 and #59) out of 9 residents who smoked in the facility. The resident sample was 8 residents. The facility census was 13 residents. Review of the facility Smoking policy and procedure, dated 9/25/23, showed the purpose was to establish a healthy environment for residents, visitors and employees. Additionally, the facility must comply with federal, state and local regulations regarding smoking in healthcare facilities. The policy showed: -Residents may smoke outside of the building in designated areas and away from the facility's exterior doors. -Employees are responsible for reminding residents, visitors and other employees of the smoking…

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 ensure medications were administered without significant errors when staff administered Lorazepam (a controlled medication given for anxiety) two times within one and one-half hours. This affected one resident (Resident #160) out of seven sampled residents for medication pass. The facility census was 13. A facility policy titled Medication Administration-General Guidelines, dated 9/1/2006, showed: -Medications were to be administered per physician orders. -Medications were to be administered within 60 minutes of the ordered time. -The individual who administered the medication was to document the administration directly after the medication was given. 1. Review of Resident #160's Physician Order Sheet (POS), obtained 6/13/24, showed: -An order for Carbidopa-Levodopa (a medication given for tremors) 25 milligrams (mg) Carbidopa/100 mg Levodopa, four times daily (9:00 A.M., 12:00 P.M., 5:00 P.M., and 9:00 P.M.) -An order for Lorazepam (a controlled medication given for anxiety) 0.5 mg, three times daily (between…

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 observation and interview, the facility failed to maintain the floor area behind and under the dishwasher free of food debris and grime;to maintain the floor behind the reach in fridge with the clear glass, free of food debris; to maintain the toaster free of a heavy buildup of bread crumbs; to maintain the six burner stove free from a buildup of burnt--on grime; to prevent a buildup of dust on sprinkler head and the emergency light fixture in the kitchen; to maintain the gasket (a piece of rubber or some other material that is used to make a tight seal between two parts that are joined together) of a freezer in storage room [ROOM NUMBER] in good repair; to prevent an opened bag of corn meal from being stored in dietary storage room [ROOM NUMBER]; to maintain the floor of dietary storage room free of debris; and to ensure the Dietary Aide (DA) A checked the temperature of a hamburger, a potentially hazardous food (PHF - foods that must be kept at a particular temperature to minimize the growth of food…

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 observation and interview, the facility failed to maintain the handrails located at the following locations: outside resident rooms [ROOM NUMBERS], outside resident room [ROOM NUMBER], between resident rooms [ROOM NUMBERS], and between resident rooms [ROOM NUMBERS]. The facility census was 14 residents. 1. Observations with the Maintenance Director (MD) on 1/26/23, showed: - At 12:09 P.M., the two hand rails outside resident rooms [ROOM NUMBERS], moved back and forth when they were held. - At 12:14 P.M., the hand rail outside resident room [ROOM NUMBER], moved back and forth, when it was held. - At 12:20 P.M., the hand rail on the wall between resident rooms [ROOM NUMBERS], moved back and forth when it was held. - At 12:29 P.M., the hand rail on the wall outside resident rooms [ROOM NUMBERS], moved back and forth when it was held. During an interview on 1/30/23 at 2:22 P.M., the MD said he/she: - Checked the hand rails as he/she walked by the hand rails. - Checked the handrails as much as he/she could.…

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 observation, interview and record review, the facility failed to maintain the wall mounted fans in resident rooms 10, 11, 8, 12, 7, 4 and 2 free of a heavy buildup of dust and to maintain a stand-up lift used to transfer one sampled resident (Resident #6) free from a crack in the base out of nine sampled residents. The facility census was 14 residents. 1. Observations with the Maintenance Director (MD) on 1/26/23 between 11:10 A.M. to 12:29 P.M., showed resident's rooms 10, 11, 9, 12, 8, 7, 4 and 2 had wall mounted fans and all had a heavy build up of dust on the fan blades and plastic grate. Record review of Resident #214's, quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning) dated 4/15/22, showed he/she was cognitively intact with a Brief Interview for Mental Status (BIMS - an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident ' s attention, orientation and…

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 observation, interview and record review, the facility failed to ensure proper behavioral health management was implemented and support services were offered to assist in promoting healthy psychosocial functioning and failed to initiate interventions that would prevent negative interactions/incidents between two sampled residents (Resident #4 and #10) who were in a relationship, and two sampled residents (Resident #4 and Resident #12), who had a physical altercation out of nine sampled residents. The facility census was 14 residents. 1. Record review of Resident #4's undated face sheet showed he/she was admitted to the facility with the following diagnoses: -Other Recurrent Depressive Disorders (a mental health disorder characterized by a feeling of profound and persistent sadness or disrepair and is frequently accompanied by a loss of interest in things that were once pleasurable). -Other Psychoactive Substance Abuse, Uncomplicated (A drug or other substance that affects how the brain works and causes…

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 interview, the facility failed to maintain an exhaust pipe in the attic space over the storage room, in good repair to prevent that pipe from emitting steam into the attic area. This practice potentially affected at least five residents who resided in that part of the facility. The facility census was 14 residents. 1. Observation with the Maintenance Director (MD) on 1/26/23 at 10:43 A.M., showed: - One exhaust pipe in the attic area which emitted steam which caused several of the nearby wood beams to become wet. - The pipe was warm when it was held. During an interview on 1/26/23 at 10:47 A.M., the MD said that pipe came from the furnace room and he/she did not know that pipe emitted steam which could possibly cause some decay on the wood beams.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the Ombudsman (a network of ombudsmen volunteers serving residents of nursing homes and residential care facilities to provide support and assistance with their problems or complaints) for one sampled resident's (Resident #1) discharge to the hospital out of nine sampled residents. The facility census was 14 residents. Record review of the facility's undated Bed Hold policy and procedure showed: -Documentation related to the resident's bed hold rights and financial responsibilities and the responsibilities of the facility regarding bed holds. -The document did not show that part of the policy was to notify the Ombudsman of all discharges/transfers from the facility and it did not show that notification should be completed at least monthly. 1. Record review of Resident #1's Face Sheet showed the resident was admitted on [DATE], with diagnoses including human immunodeficiency virus (HIV- a virus that attacks the body's immune system, preventing…

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 observation, interview and record review, the facility failed to ensure the bed hold notice was provided to one sampled resident (Resident #1) or his/her responsible party when he/she was sent to the hospital, out of nine sampled residents. The facility census was 14 residents. Record review of the facility's undated Bed Hold policy and procedure showed: -A resident's bed will be held without charge for up to three days for each hospitalization. Thereafter, a resident will be charged the then current normal daily room rate for each day. -Residents who have a reserved bed during their hospitalization will be re-admitted to the facility immediately upon discharge from the hospital if the facility can continue to meet the needs of the resident and if payment of the then current daily rate for each day of hospitalization has been made. -Residents who do not have a reserved bed will be assessed upon discharge from the hospital if the facility can continue to meet the needs of the resident. If no bed is…

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 interview and record review, the facility failed to ensure a comprehensive Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) was completed and submitted timely for one sampled resident (Resident #214) out of nine sampled residents. The facility census was 14 residents. Record review of the facility's policy titled Resident Assessments, dated November 2019, showed MDS assessments were to be conducted at time of admission, quarterly, and with any change in condition. 1. Record review of Resident #214's Face Sheet showed he/she was admitted to the facility on [DATE]. Record review of the resident's Centers for Medicare and Medicaid (CMS) MDS database submissions showed: -An Annual MDS assessment with an Assessment Reference Date (ARD) of 1/14/22. -A Quarterly MDS assessment with an ARD of 4/15/22. -NOTE: No MDS assessments of any type had been completed for the resident since April 2022. Record review of the resident's facility electronic…

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 interview and record review, the facility failed to ensure that a comprehensive-care-plan was reassessed and updated to indicate adequate and appropriate interventions to meet the resident's medical, mental, and psychosocial needs specifically for the consumption of alcohol and the subsequent behaviors exhibited for two sampled residents (Resident #4 and #10) out of nine sampled residents. The facility census was 14 residents. 1. Record review of Resident #4's undated face sheet showed he/she was admitted to the facility with the following diagnoses: -Other Recurrent Depressive Disorders (a mental health disorder characterized by a feeling of profound and persistent sadness or disrepair and is frequently accompanied by a loss of interest in things that were once pleasurable). -Other Psychoactive Substance Abuse, Uncomplicated (A drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior). Record review of the resident's social service…

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 observation, interview and record review, the facility failed to acknowledge, assess and provide supportive services for one sampled resident (Resident #1), who informed staff of past trauma, and to develop a care plan that showed interventions the facility staff would take to try to protect the resident and prevent trauma from recurring, out of nine sampled residents. The facility census was 14 residents. The facility did not have a behavior management policy/procedure. 1. Record review of Resident #1's Face Sheet showed he/she was admitted to the facility on [DATE], with diagnoses including depression. There was no documentation showing the resident had a diagnosis of post traumatic stress disorder (PTSD- a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event. Symptoms may include nightmares or unwanted memories of the trauma, avoidance of situations that bring back memories of the trauma, heightened reactions, anxiety, or depressed mood). Record review 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain physician's order for the use of two half side rails; and to complete a comprehensive side rail safety assessment to determine if the two half side rails were a restrainting device for one sampled resident (Resident #8) who had impaired bed mobility out of nine sampled residents. The facility census was 14 residents. Record review of the Facility Physical Restraint policy dated 10/14/19 showed: -Required to have a physician's order for use of any restraints to include when the restraints are to be used, type of restraints and medical symptoms for use and the purpose of the resident restraints. An example would be use of side rails (metal or plastic bars positioned along the side of a bed, also commonly known as side rails) to increase bed mobility (is the moving to and from a lying position, turning from side-to-side and positioning the body while in bed). -The interdisciplinary team (IDT) will document evidence in the resident'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 interview and record review, the facility failed to ensure appropriate and adequate social service assistance specifically for psychiatric and alcohol abuse treatment was provided for one sampled resident (Resident #4) out of nine sampled residents. The facility census was 14 residents. 1. Record review of Resident #4's undated face sheet showed the resident admitted to the facility with the following diagnoses: -Other Recurrent Depressive Disorders (a mental health disorder characterized by a feeling of profound and persistent sadness or disrepair and is frequently accompanied by a loss of interest in things that were once pleasurable). -Other Psychoactive Substance Abuse, Uncomplicated (A drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior). Record review of the resident's progress note dated 10/15/22 showed the resident was very inebriated. (effected by alcohol or drugs especially to the point where physical and mental control is markedly diminished). Record review of the resident's progress note…

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 ensure there were recipes available for dietary staff to process recipes for the pureed (cooked food that has been ground pressed, blended or sieved to the consistency of a creamy paste or liquid) items of the meal and to follow the menu for the following meals due to the ingredients not being available: the lunch meal on 1/23/23, the supper meal on 1/24/23, and the lunch meal on 1/25/23. The facility census was 14 residents. 1. Observation on 1/24/23 at 11:55 A.M., showed: -The Dietary Manager (DM) placed one serving of taco meat (with no other liquid or ingredients) into the food processor and pureed the taco meat. - There was open recipe book for pureed food. - During a taste test with the DM, the texture of the taco meat was not a smooth texture, and was still gritty as confirmed with the DM. During an interview on 1/24/23 at 12:23 P.M., the DM said he/she may not have a recipe book for the pureed version of today's meal. He/she looked but did not find a recipe for the pureed items of that meal. 2. Record…

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.