Inspection visit
Inspection
4 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to ensure 1of 18 residents reviewed with limited
range of motion (Resident #11), received appropriate treatment and services to prevent a decline in range
of motion.
The facility failed to ensure Resident #11 had interventions in place for his bilateral hand contractures (A
permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to
shorten and stiffen and a decrease in ROM) to prevent further decline of the range of motion in his hands.
This failure could place residents with contractures at risk for decrease in mobility, range of motion, and
contribute to worsening of contractures.
Findings Include:
Review of Resident #11's Face Sheet dated 03/15/2023 reflected a [AGE] year-old male admitted to the
facility on [DATE] with the following diagnosis Hemiplegia and Hemiparesis following cerebral infarction
affecting right dominant side (Hemiplegia and hemiparesis are related conditions that cause weakness or
paralysis on one side of the body), Alzheimer's Disease (A type of brain disorder that causes problems with
memory, thinking and behavior. This is a gradually progressive condition.) and Parkinson's Disease (A
progressive disorder that affects the nervous system and the parts of the body controlled by the nerves.)
Review of Resident #11's Quarterly MDS dated [DATE] reflected Resident #11 was assessed to have a
BIMS score of 0 indicating severe cognitive impairment. Resident #11 was further assessed to have range
of motion impairments of the upper and lower extremity on one side.
Review of Resident #11's Comprehensive Care Plan reflected a focus area dated 06/14/2023 Resident #11
has functional limitations due to contracture to bilateral hands. Interventions included For hand/finger
contractures, keep fingernails cut short to prevent skin breakdown to palm, place handroll in contracted
hand/fingers daily. Remove during bath and as needed and wash hand. Dry hand thoroughly before placing
handroll back in hand .
Review of Resident #11's Consolidated Physician orders reflected an order dated 11/14/2023 Check that
hand rolls are in both hands. Reapply if they are out . Further review reflected another order dated
11/16/2023 which reflected Cleanse hands and apply hand rolls in both hands every day and evening shift.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 6
Event ID:
676316
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676316
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/30/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
High Hope Care Center of Brenham
401 East Blue Bell Road
Brenham, TX 77833
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Review of Resident #11's TAR for November 2023 reflected documentation that the physician order cleanse
Resident #11's hands and apply hand rolls in both hands every day and evening shift was completed with
the start date of 11/17/2023.
Observation on 11/28/2023 at 11:40 AM revealed Resident #11 in bed. Resident #11 had hand
contractures to bilateral hands. Resident #11's fingernails to both hand was observed to be extending past
the tip of his fingers.
Observation on 11/28/2023 at 3:00 PM revealed Resident #11 in bed. Resident #11 had hand contractures
to bilateral hands. Resident #11's fingernails to both hand was observed to be extending past the tip of his
fingers.
Observation and interview on 11/29/2023 at 10:25 AM revealed CNA C and D in Resident #11's room to
provide incontinent care. Resident #11 was observed to not have hand rolls in either of his hands. CNA C
stated after Resident #11 was provided care, that he should have hand rolls in both of his hands at all times
to prevent his fingers from digging into his hands. CNA C stated she did not know why his hand rolls were
not in his hands. CNA C then looked around room and stated sometimes Resident #11's hand rolls get dirty
and get sent to the laundry.
In an interview on 11/29/2023 at 10:30 AM CNA D stated Resident #11 should have his hand rolls in at all
times and they usually use wash cloths. She stated she was not sure why Resident #11 did not have the
rolls in his hands.
In an interview on 11/29/2023 at 10:35 AM the DON stated after observing Resident #11's hands, that
Resident #11 should have hand rolls in both hands and stated his fingernails were a little long and could
dig into his palms. The DON stated the nurses, or the nurse aides could put Resident #11's hand rolls in
and both should check when they were in the room to ensure they were in place. She further stated the
hand rolls were used to prevent pressure ulcers and without them Resident #11 could develop pressure
ulcers.
Review of the facility's policy Resident Mobility and Range of Motion dated 07/2017 reflected 1. Residents
will not experience an avoidable reduction in range of motion (ROM). 2. Residents with limited range of
motion will receive treatment and services to increase and/or prevent a further decrease in ROM. 3.
Residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or
improve mobility unless reduction in mobility is unavoidable . 6. Interventions may include therapies, the
provision of necessary equipment, and/or exercise and will be based on professional standards of practice
and be consistent with state law and practice acts .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676316
If continuation sheet
Page 2 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676316
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/30/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
High Hope Care Center of Brenham
401 East Blue Bell Road
Brenham, TX 77833
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to provide respiratory care consistent with
professional standards of practice for 2 of 4 residents (Resident #11 and Resident #45) reviewed for
respiratory care.
Residents Affected - Few
A) The facility failed to ensure Resident #11's oxygen concentrator filter were kept clean for his use.
B) The facility failed to ensure Resident #45's oxygen concentrator filter were kept clean for his use.
These failures could place all residents who use respiratory equipment at risk for respiratory infections.
Findings included:
A) Review of Resident #11's Face Sheet dated 03/15/2023 reflected a [AGE] year-old male admitted to the
facility on [DATE] with the following diagnosis Chronic obstructive pulmonary disease (COPD) (a common,
preventable and treatable disease that is characterized by persistent respiratory symptoms like progressive
breathlessness and cough.), Hemiplegia and Hemiparesis following cerebral infarction affecting right
dominant side (Hemiplegia and hemiparesis are related conditions that cause weakness or paralysis on
one side of the body), Alzheimer's Disease (A type of brain disorder that causes problems with memory,
thinking and behavior. This is a gradually progressive condition.) and Parkinson's Disease (A progressive
disorder that affects the nervous system and the parts of the body controlled by the nerves.)
Review of Resident #11's Quarterly MDS dated [DATE] reflected Resident #11 was assessed to have a
BIMS score of 0 indicating severe cognitive impairment. Resident #11 was assessed to have oxygen use
during the assessment period.
Review of Resident #11's Comprehensive Care Plan reflected a focus area dated 06/14/2023 Resident #11
has COPD. Interventions included .Oxygen settings-O2 vial nasal cannula at 3 LPM PRN .
Review of Resident #11's Consolidated Physician orders reflected an order dated 04/06/2022, O2 at 3 LPM
keep O2 sats >92%. Further review reflected an order dated 11/21/2022 change out oxygen tubing,
humidifier, and nasal canula. Clean filters on the concentrator every night shift every Sunday for infection
control.
Observation on 11/28/2023 at 10:00 AM revealed Resident #11 in bed. Resident #11 was on oxygen with
the oxygen concentrator set at 3LPM. Further observation revealed the air intake filters on the concentrator
to be covered with a thick gray substance.
B) Review of Resident #45's Face Sheet reflected a [AGE] year-old male admitted to the facility on [DATE]
with the following diagnoses Acute respiratory failure with hypoxia (is a life-threatening condition where the
lungs cannot provide enough oxygen to the body or remove enough carbon dioxide.) and pulmonary
hypertension (A condition in which high blood pressure affects arteries of the lungs, and right side of the
heart. This results in chest pain and shortness of breath.)
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676316
If continuation sheet
Page 3 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676316
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/30/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
High Hope Care Center of Brenham
401 East Blue Bell Road
Brenham, TX 77833
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Review of Resident #45's quarterly MDS dated [DATE] reflected Resident #45 was assessed to have a
BIMS score of 15 indicating he was cognitively intact. Resident #45 was assessed to use oxygen therapy
continuously.
Review of Resident #45's Comprehensive Care Plan reflected a focus area dated 08/17/2023 Resident #45
is at risk for shortness of breath related to COPD . Interventions included O2 at 4 LPM via nasal cannula
continuously
Review of Resident #45's Consolidated Physician orders reflected an order dated 07/07/2023 O2 vial nasal
cannula at 4 LPM. Further review of Resident #45's physician orders reflected an order dated 07/04/2023 to
change O2 tubing, humidification bottle and to cleanse concentrator filters weekly.
Observation and on 11/28/2023 at 9:56 AM revealed Resident #45 in room up in his chair with oxygen on at
4 LPM. Further observation revealed the air intake filters on the concentrator to be covered with a thick gray
substance.
Observation and interview on 11/28/2023 at 2:16 PM, LVN E in an observation with surveyor of Resident
#11 and Resident 45's oxygen concentrator filters stated the filters were dirty and defiantly needed to be
cleaned. She stated the night nurse usually was in charge of that task bust anyone can clean them. She
stated they were supposed to be cleaned weekly.
In an interview on 11/28/2023 at 2:40 PM the DON stated the night nurse was supposed to clean the
oxygen concentrator weekly. She further stated she called up to the facility and asked if she had completed
the task including changing the oxygen tubing and she stated she had. The DON after observing the
oxygen concentrator filters stated they needed to be cleaned, and it placed residents at risk for upper
respiratory infections.
Review of the facility's policy for Oxygen Administration dated 10/2010 reflected The purpose of this
procedure is to provide guidelines for safe oxygen administration . The policy did not address cleaning or
maintain procedures.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676316
If continuation sheet
Page 4 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676316
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/30/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
High Hope Care Center of Brenham
401 East Blue Bell Road
Brenham, TX 77833
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0914
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to ensure each room was designed or equipped
to assure full visual privacy for 11 (Rooms 13, 17, 35, 39, 40, 41, 55, 56, 63, 72, and 79) of 11 dual
occupancy rooms reviewed for privacy in the facility.
Residents Affected - Some
The facility failed to ensure that dual occupancy rooms were provided with ceiling suspended curtains,
which extended around the bed, to provide total visual privacy.
This failure could lead to a lack of privacy for residents, allow residents' private medical treatment to be
observed by roommates or others, and lead to a decline in psychosocial well-being.
Findings included:
Observation on 11/28/2023 at 2:28 PM of rooms [ROOM NUMBERS] revealed that each room had dual
occupancy with an A and B bed in each. The rooms had a single ceiling to floor curtain that divided the
center of the room but stopped approximately four feet from the opposite wall. The rooms did not have a
second connecting curtain or partition that would allow for bed A or B to have total visual privacy.
Observation on 11/28/2023 at 2:32 PM of rooms [ROOM NUMBERS] revealed that each room had dual
occupancy with an A and B bed in each. The rooms had a single ceiling to floor curtain that divided the
center of the room but stopped approximately four feet from the opposite wall. The rooms did not have a
second connecting curtain or partition that would allow for bed A or B to have total visual privacy.
In an interview on 11/29/2023 at 10:40 AM, RN A was asked about the partial center divide curtain in the
dual occupancy rooms. RN A stated that they were to knock before entering the room but stated that not
having a curtain at the bottom of either resident bed could pose a privacy issue for the resident. RN A
stated that there was no way to ensure full privacy for residents in a dual occupancy room with the single
curtain.
In an interview on 11/29/2023 at 3:25 PM the DON was asked about the lack of full privacy in the rooms.
The DON stated that the dual occupancy rooms only have a partial divider. The DON stated that staff had
been instructed to ensure doors were closed and that they knock before entering. The DON stated that
there was not full privacy available in the dual occupancy rooms and that it could pose a privacy issue for
residents.
Observations on 11/30/2023 at 7:45 - 7:50 AM revealed that Rooms 35, 40, 55, 56, 63, 72, and 79 were
also dual occupancy rooms and only had one partial center room divide curtain present, which did not allow
for full privacy.
In an interview on 11/30/2023 at 8:05 AM, the Administrator stated that all dual occupancy rooms in the
facility do only have one partial center divide curtain. The Administrator stated that staff were instructed to
always knock before entering a residents' room but stated that the partial curtain did not allow for full
privacy for either resident in the dually occupied room. The Administrator stated that the building was forty
years old and that the partial curtain has never been an issue. The Administrator stated that they do not
have a policy that directly relates to privacy curtains.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676316
If continuation sheet
Page 5 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676316
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/30/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
High Hope Care Center of Brenham
401 East Blue Bell Road
Brenham, TX 77833
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0914
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
In an interview on 11/30/2023 at 10:50 AM, CNA A was asked about the partial privacy curtains in the dual
occupancy rooms. CNA A stated that they always knock before entering a room. CNA A stated that the
partial curtain did not provide full privacy for either resident in the room. CNA A stated that residents not
assigned to the room could also enter without knocking, which would pose a privacy issue for residents.
In an interview on 11/30/2023 at 2:10 PM, the MS was asked if the facility had a policy in reference to the
privacy curtains for their dual occupancy rooms. The MS stated that they did not, and that staff will tell him if
they were dirty or need repair. The MS stated that the current partial center divide curtain did not provide
full privacy for either resident in their dual occupancy rooms.
Record Review of the facility's Quality of Life - Dignity policy with a revision date of August 2009 revealed a
policy statement which read, Each Resident shall be cared for in a manner that promotes and enhances
quality of life, dignity, respect and individuality. Policy Interpretation and Implementation indicated: 6.
Residents' private space and property shall be respected at all times. 10. Staff shall promote, maintain and
protect resident privacy, including bodily privacy during assistance with personal care and during treatment
procedures.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676316
If continuation sheet
Page 6 of 6
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Back to topCitations
4 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F688 - Mobility
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.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F914 - Be designed or equipped to assure full visual privacy for each
Provide bedrooms that don't allow residents to see each other when privacy is needed.
- 0351GeneralS&S Epotential for harm
Install an approved automatic sprinkler system.
FAQ · About this visit
Common questions about this visit
What happened during the November 30, 2023 survey of HIGH HOPE CARE CENTER OF BRENHAM?
This was a inspection survey of HIGH HOPE CARE CENTER OF BRENHAM on November 30, 2023. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at HIGH HOPE CARE CENTER OF BRENHAM on November 30, 2023?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, u..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.