Deficiency Records for High Hope Care Center of Brenham
Updated as of June 01, 2021
This is not the most recent data for High Hope Care Center of Brenham. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-19 | 2020-01-30 | Y |
| 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 |
| 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 |
| 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 |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2019-08-09 | 2019-09-13 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-08-31 | 2019-09-13 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2019-08-31 | 2019-09-13 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-02 | 2019-07-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-07-02 | 2019-07-30 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-03-08 | 2019-04-12 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-03-08 | 2019-04-12 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2018-08-29 | 2018-10-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-08-29 | 2018-10-05 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-08-29 | 2018-10-05 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-08-29 | 2018-10-05 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-08-30 | 2018-10-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-08-30 | 2018-10-05 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-08-30 | 2018-10-05 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2018-08-30 | 2018-10-05 | Y |
| 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 | 2018-08-30 | 2018-10-05 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-08-30 | 2018-10-05 | Y |
| Provide and implement an infection prevention and control program. | Health | 2018-08-30 | 2018-10-05 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2017-08-09 | 2017-09-01 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2017-08-09 | 2017-09-01 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2017-08-09 | 2017-09-01 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2017-08-09 | 2017-09-01 | N |
| Honor a residents' rights as a residents of the nursing home, free of coercion and reprisal, and as citizens or residents of the United States. | Health | 2017-08-10 | 2017-09-01 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-08-10 | 2017-09-01 | N |
| Make sure that special or therapeutic diets are ordered by the attending doctor. | Health | 2017-08-10 | 2017-09-01 | N |
| Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. | Health | 2017-08-10 | 2017-09-01 | N |
| Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. | Health | 2017-08-10 | 2017-09-01 | 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 |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2017-08-09 | Not Fixed | N |
