Hope Care Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate sanitation of dish and cookware when the facility's dish machine was not dispensing an adequate amount of chemicals to sanitize the food prep and service items. The facility census was 16 residents. A policy regarding dishwasher maintenance or chemical disinfecting was requested and not received.1. Review of the facility's blank Daily Dietary Checklist, undated, showed the kitchen staff were to record water temperature and parts per million (PPM-a unit of concentration that expresses the amount of a substance within a million parts of a solution or mixture) of the sanitizer agent. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain two handrails firmly attached to the wall outside of resident rooms [ROOM NUMBERS]. This practice potentially affected at least 4 residents who resided in those rooms. The facility census was 16 residents.1. Observation on 9/5/24 at 11:38 A.M. and on 9/8/25 at 11:17 A.M., showed two handrails outside of resident rooms [ROOM NUMBERS] which were not firmly attached to the wall. During an interview on 9/8/25 at 11:17 A.M., the Maintenance Director said:-The handrail had not been loose that long.-A resident from resident room [ROOM NUMBER] used the handrail when he/she left his/her room. During an interview on 9/9/25 at 2:25 P.M., the Maintenance Supervisor said the handrails were checked once per month.

Inspectors wroteBased on observation and interview, the facility failed to prevent the presence of a black substance on the ceiling and failed to repair an eight foot (ft.) long area where a black substance leaked from the ceiling of Furnace room [ROOM NUMBER]. The facility also failed to maintain an outdoor handrail supporting system outside of the kitchen in good repair due to the crumbling of the concrete area which supported that handrail. This practice affected one non-resident use area and at least 7 residents who resided in that area of the facility, that would use the exit discharge (the portion of the means of egress between the building exit and the public way, street, alley, or other similar parcel of land essentially open to the outside air deeded, dedicated, or otherwise permanently appropriated for public use) which went through the service area next to the kitchen. [...]

Inspectors wroteBased on observation and interview, the facility failed to retain operable thermometers in all refrigerators and/or freezers to confirm adequate temperature ranges; failed to maintain plastic cutting boards in good condition to avoid food safety hazards (cross-contamination); and failed to separate damaged foodstuffs, in accordance with State of Missouri rules and regulations, established national guidelines, and professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility's census was 13 residents with a licensed capacity for 16 residents at the time of the survey. 1. Observations on 6/11/24 at 10:53 A.M., during the facility basement inspection, showed there was no thermometer in the freezer in the Food Storage room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain a comprehensive infection prevention and control program designed to help prevent the development and transmission of Legionella (a [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis, all illnesses caused by Legionella, including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) and/or other water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease), and failed to provide documented assessments for such an outbreak with accepted response protocols, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow facility policies and procedures for checking the Nurse Aide Registry for federal indicators of abuse as part of the Criminal Background Check (CBC) and in accordance with state requirements for two of four employees sampled for the criminal background screening. The facility census was 13 residents. Review of the facility's revised Abuse and Neglect policy and procedure dated 1/1/2024, showed: -All potential employees will be screened and trained to ensure that individuals with a documented history of abuse or other inappropriate conduct are not hired, and that all employees are properly trained regarding abuse of residents. -All employees will be screened prior to contact with facility residents, and quarterly, as follows: Federal Indicator List. 1. Review of two employee records showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the annual comprehensive Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) were completed timely for four sampled residents (Residents #59, #57, #1, #4) out of 8 sampled residents and one supplemental resident (Resident #160). 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 MDS assessments showed: [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure Minimum Data Sets (MDS, a federally mandated assessment tool to be completed by facility staff for care planning) were completed quarterly for 8 residents (Residents #3, #5, #59, #57, #4, #1, #2, and #161) out of 8 sampled residents. The facility census was 13 residents. 1. Review of Resident #3's Face Sheet showed the resident was admitted on [DATE], with diagnoses including urinary tract infection, diabetes, vitamin deficiency, glaucoma (a disease that damages your eye's optic nerve that can cause blindness), high blood pressure, heart disease, paraplegia (paralysis that affects all or part of the trunk, legs, and pelvic organs), pain and edema (fluid in the tissues). Review of the resident's MDS assessments showed: -The resident's last Annual assessment was completed on 6/25/2023. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff administered medications with a rate less than 5%. Facility staff made eight medication errors out of 29 attempts, resulting in a medication error rate of 27.59%. This affected three of seven sampled residents (Residents #2, #4, and #160) 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. Resident #160's Physician Order Sheet (POS), obtained 6/13/24, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the completion of a necessary significant change Minimum Data Set (MDS, a federally mandated comprehensive assessment) for one resident with a hospice admission (Resident #161) out of 8 sampled residents. The facility census was 13. Review of a facility policy titled Minimum Data Set Assessments, dated 6/13/24, lacked information regarding triggering an MDS assessment and timing of assessments. Review of the MDS 3.0 Resident Assessment Instrument (RAI) Manual (a federally published guide for facility staff to complete and submit MDS assessments accurately and timely) instructed facilities to set a Significant Change Assessment Reference Date (ARD, the date of assessment initiation) no later than 14 days following the determination that a significant change had occurred. [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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; [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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). [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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). [...]

Inspectors wroteBased 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. [...]