Hope Health and Rehab

Based on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 32 residents who reside in the facility. Surveyor observed [NAME] E use the same dirty alcohol wipe to sanitize a thermometer while testing the temperature of several foods. Surveyor observed DA D (Dietary Aide) washing dirty dishes causing his clothing to get wet and then Surveyor observed DA D carrying clean dishes up against his dirty/wet clothing to put them away. Surveyor also observed DA D to not wash his hands after cleaning dirty dishes and before putting away clean dishes. Surveyor observed food in the resident refrigerator to be undated and unlabeled. Staff were unsure of when the food was placed in the refrigerator. Evidenced by: Example 1: Facility policy, titled Food Service Department, dated 2/18/18, does not include to cover clothing when spraying food debris off dirty dishes and then remove the cover when handling clean dishes. It also does not include to wash hands…

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 did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made to the State Agency, this affected 1 of 18 residents (R18). R18 voiced concern on 2/10/26 that CNA F (Certified Nursing Assistant) was rough with her, this was not reported to the State Agency. R18 voiced concern on 2/21/26 that Agency CNA H was rough with her, this was not reported to the State Agency. This is evidenced by: The Facilities Policy and Procedure entitled Abuse Prevention, Investigation, and Reporting Policy dated 2/16/26, documents in part: .Allegations, suspicions, observations, or reports of misconduct will be taken seriously, addressed immediately, thoroughly investigated, and reported in accordance with federal and state law .Reporting Requirements, In accordance with federal regulation, the Administrator or designee will report allegations of abuse, neglect,…

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 did not ensure each resident received the necessary care and services in accordance with professional standards of practice to meet each resident's physical needs for 1 of 3 sampled residents (R1).R1 had a change in condition. The facility did not assess or have ongoing monitoring of R1's change in condition. R1 was eventually sent to the hospital with a distal fracture of the left femur (leg bone).This is evidenced by: On 12/2/25 at 12:28 PM, Surveyor spoke to DON B (Director of Nursing) and requested the facility's change in condition policy and procedure. DON B stated the facility does not have a change in condition policy and procedure. DON B indicated the facility follows the standard of practice for nursing. According to the National Library of Medicine from the National Institute of Health (www.ncbi.nlm.nih.gov), the nursing process, according to ANA (American Nursing Association) Standards of Professional Nursing Practice, includes assessment. 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.

Based on observation, interview, and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect 26 of 27 residents. Surveyor observed dust in the facility's stove hood, over open food being prepared for resident meals. Surveyor observed food to have been removed from the original packaging and not sealed or dated with an expiration date, an open date, or a use by date. Surveyor observed a box of potatoes on the floor in the dry food storage area. Evidenced by: Example 1 Facility's Cooks Weekly Cleaning Tasks sheet, undated, states in part: Sunday, Hood cleaning above stove, AM cook, take vent down run thru dishwasher. Clean all nozzles free of dust or dirt . On 4/21/25 around 9:30 AM, Surveyor and DM G (Dietary Manager) observed facility stove hood. Surveyor and DM G observed a layer of dust to be on the sprinkler pipes and the grease trap directly above the burners/food preparation area. DM G indicated there is potential for the dust to dislodge and fall into 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 did not provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident. This affects 1 sampled resident (R6) and 5 supplemental residents (R5, R15, R17, R23, R25) reviewed for activities. R5, R6, R15, R17, R23, and R25, voiced concerns during Resident Council of the facility's activity program regarding evenings and weekends. Evidenced by: The facility does not have a policy for activity programming. Example 1 On 4/22/25 at 3:00 PM, Surveyor reviewed the activity calendars from December 2024 through March 2025. The facility activity calendar for December 2024 states, in part: Fridays: handwritten on provided calendar states AA (Activity Assistant name) 4-7pm with a line through all Fridays *It's important to note calendar does not specify what AA is doing during this time. Saturdays: no activities listed Sundays: no activities listed The facility activity calendar for…

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 did not immediately notify and consult with a resident's physician when there was a significant change in condition. This occurred for 1 of 16 residents (R8) reviewed for notification of change in condition. R8 had blood sugars below ordered parameter of 70 without notification of physician. Evidenced by: The facility's Physician Notification policy, dated 4/12/17, states, in part: Purpose: To provide guidance to licensed nurse as to when and how to notify a physician/practitioner of changes in resident status.Procedure: .Take into consideration: immediate notification includes any symptom, sign, or apparent discomfort that is acute or sudden in onset, and a marked changed in relation to usual symptoms and signs . Surveyor requested a blood sugar parameter policy. No policy was provided. On 4/21/25 at 10:07 AM, Surveyor interviewed R8 during resident screening. R8 stated that R8 had recently been having low blood sugars in the morning; I think it was 48 this…

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 did not ensure that residents are provided foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) for 1 of 3 residents (R8) reviewed for diabetic foot checks. R8 was not provided routine diabetic foot checks. Evidenced by: The facility did not provide a policy for diabetic foot checks. R8 admitted to the facility on [DATE] and has diagnoses that include: acute osteomyelitis, left ankle and foot (infection in the bone); type 2 diabetes mellitus (a disorder which affects the body's ability to produce enough insulin or to effectively use the insulin it produces which can raise blood sugar levels); peripheral vascular disease (a condition where blood flow to the extremities, primarily legs and feet, is restricted due to narrowed or blocked blood vessels, which can lead to slowed healing of wounds). R8's progress notes show a Brief Interview for Mental Status (BIMS)…

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 did not ensure each resident received adequate supervision to prevent accidents for 1 of 1 residents (R334) reviewed. R334 was observed smoking in the street, not disposing of cigarette materials properly, and not returning materials to staff after returning from smoking. Evidenced by: The facility policy, Smoking Policy, effective date 11/27/2024, included, in part: Policy: It is the policy .to not allow smoking, including e-cigarettes, vapes, cigars etc. on .property. Procedure: *No residents are permitted to smoke in the facility or on the facility property, including the facility side walk [sic], courtyard or other green spaces, driveway, parking lot, or entrances to the parking lot. *Staff will not assist residents to smoke, but will review resident safety to determine whether resident is competent to smoke independently. Residents who wish to smoke will need to be assisted by a family member, resident representative, or other loved one if…

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 did not provide a suitable, nourishing snack to residents who want to eat outside of scheduled meal service times for 1 of 1 resident (R8) reviewed for nightly snacks. R8 had blood sugars below ordered parameter of 70 and was not receiving a routine nightly snack. Evidenced by: The facility's Resident Diet policy, dated 1/14/25, states, in part: Purpose: To outline how the dietary department provides each member a nourishing, palatable, well-balanced diet that meets daily nutritional and special dietary needs.dining program for residents includes service of three meals per day , and a snack program. Snacks If not prohibited by the resident's diet, condition or physician order, bedtime snacks are offered routinely to all residents.Snacks will conform to the residents' therapeutic or texture modified diet. On 4/21/25 at 10:07 AM, Surveyor interviewed R8 during resident screening. R8 stated that R8 had recently been having low blood sugars in the morning; I think…

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 did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 1 residents (R8) reviewed for infection control with personal cares. CNA K (Certified Nursing Assistant) had a breach in infection control when performing pericare (cleansing of the genital area). Evidenced by: The facility's Standard Precautions policy, dated 4/10/24, states, in part: Purpose: The objectives of this policy is to communicate the requirements and expectations regarding the use of standard precautions to prevent the transmission of infection throughout the facility. Standard: Standard precautions are a set of infection control practices used to prevent transmission of diseases that can be acquired by contact with blood, body fluids, non-intact skin (including rashes), and mucous membranes. Standard precautions will be used when providing care to all residents, whether…

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 did not ensure each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated, or the resident has already been immunized for 1 of 5 residents (R7) reviewed for immunizations. R7 was not offered the pneumococcal vaccination. Evidenced by: The facility's Pneumococcal Conjugate Immunization policy, dated 4/9/24, states, in part: It is the goal of facility to reduce morbidity and mortality related to pneumonia through various measures, including by educating all residents on pneumococcal conjugate vaccination and offering the opportunity for vaccination in accordance with current Centers for Disease Control and Prevention (CDC) recommendations and CMS regulatory requirements . All residents of the facility will be educated on current CDC recommendations for pneumococcal conjugate vaccination, upon admission and annually, and will be offered the opportunity to receive immunization if they are not currently up-to-date (as…

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 did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 34 residents. Surveyor observed Mighty Shakes to be in the refrigerator for more than the manufacturer's recommendations of 14 days. Surveyor observed hairlike dust moving in the air exchange, in the facility's stove hood, over open food being prepared for resident meals. Surveyor observed a dented can in circulation. Surveyor observed food to have been removed from the original packaging and not dated with an expiration date, an open date, or a use by date. Evidenced by: Example 1 Hormel Mighty Shakes manufacturer's recommendations for storage and handling, includes Store frozen. Thaw at or below 40 degrees Fahrenheit. Used thawed product within 14 days. Keep refrigerated. On 3/13/24 at 8:42 AM, Surveyor observed a half of a case of strawberry mighty shakes and 4 cartons of orange mighty shakes in the facility refrigerator. These shakes did not have a thaw date 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility did not ensure each resident had a safe, clean, comfortable, and homelike environment or ensure housekeeping provided necessary services to maintain a sanitary, orderly, and comfortable area for 1 of 15 sampled residents (R31). R31 voiced concerns regarding the wall in her room needing to be repaired and painted. Surveyor observed R31's tan painted wall, alongside R31's bed, to have large white patched areas and some small holes where screws used to sit. Evidence by: R31 admitted to the facility on [DATE]. Her most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 1/30/24, indicates R31's speech is clear with distinct intelligible words. R31's MDS also indicates she can make herself understood with her ability to express ideas and wants verbally and nonverbally and she usually understands verbal content. R31's Brief Interview for Mental Status (BIMS) score is a 7 out of 15, indicating severe cognitive impairment. On 3/14/24 at 9:17 AM, R31…

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.