A list of the most recent deficiencies for High Hope Care Center of Brenham. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-01-10 | 2023-02-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-01-10 | 2023-02-01 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-01-10 | 2023-02-01 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2023-01-10 | 2023-02-01 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-10-05 | 2022-11-03 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-07-15 | 2021-08-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-07-15 | 2021-08-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-07-15 | 2021-08-12 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-07-15 | 2021-08-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-15 | 2021-08-12 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-07-15 | 2021-08-12 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-08-09 | 2019-09-13 | N |
| 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. | Health | 2019-08-09 | 2019-09-13 | N |
| Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Health | 2019-08-09 | 2019-09-13 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-08-09 | 2019-09-13 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-08-09 | 2019-09-13 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-08-09 | 2019-09-13 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-08-09 | 2019-09-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-08-09 | 2019-09-13 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-08-09 | 2019-09-13 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-08-09 | 2019-09-13 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2019-08-09 | 2019-09-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-09 | 2019-09-13 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-08-09 | 2019-09-13 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-08-09 | 2019-09-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-08-09 | 2019-09-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-09 | 2019-09-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-08-09 | 2019-09-13 | N |
| 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. | Health | 2019-08-09 | 2019-09-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-09 | 2019-09-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-08-09 | 2019-09-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-08-09 | 2019-09-13 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-08-09 | 2019-09-13 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-08-09 | 2019-09-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-09 | 2019-09-13 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2019-08-09 | 2019-09-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-09 | 2019-09-13 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-08-09 | 2019-09-13 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-08-09 | 2019-09-13 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-08-08 | 2019-09-13 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-08-08 | 2019-09-13 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-08-08 | 2019-09-13 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-08-08 | 2019-09-13 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-08-08 | Not Fixed | N |
