Hope Springs Care Center

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Smoke Deficiencies

Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Miscellaneous Deficiencies

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Egress Deficiencies

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.

Smoke Deficiencies

Provide properly protected cooking facilities.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Egress Deficiencies

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.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Nutrition and Dietary Deficiencies

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Resident Rights Deficiencies

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.

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Quality of Life and Care Deficiencies

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Properly provide smoke detection systems in areas open to corridors.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Resident Rights Deficiencies

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

Egress Deficiencies

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.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

*** CITATION TEXT NOT FOUND *** A document revisit was completed with all deficiencies being corrected. No other deficiencies were cited and no response is needed.

A survey prompted by #CO38711 was completed on 1/28/25 to 1/29/25. One deficiency was cited. Based on interviews and record review, the facility failed to protect and keep residents safe from physical abuse for one (#300) of five residents reviewed for physical abuse out of five sample residents.Specifically, the facility failed to:-Protect Resident #300 from physical abuse by Resident #301; and,-Assess Resident #300 timely for injuries.Findings include:I. Resident to resident incident on 12/8/24 at 10:45 p.m.The incident investigation, dated 12/8/24, was provided by the nursing home administrator (NHA) on 1/28/25 at 10:37 a.m. According to the investigation, Resident #300 reported that a male resident entered her room. She reported that he was naked and picked up her walker and threw it at her. She reported that she was fearful. The investigation documented no injury was noted. Resident #301 was interviewed and said he did not remember entering someone else' s room or throwing a walker at anyone. Registered nurse (RN) #2 was interviewed during the investigation and reported she heard a female resident calling out for help. When the nurse entered the hallway she saw a naked male resident walking away from the room and back towards his room. When the nurse entered Resident #300' s room, the resident was sitting in her recliner with her walker on top of her. Resident #300 told the nurse someone entered her room naked and threw her walker at her. The incident of abuse was substantiated by the facility because Resident #301 entered Resident #300' s bedroom naked and uninvited, and Resident #300 was found with her walker on top of her. -However, the facility failed to document that the resident was assessed immediately following the incident. II. Resident #300 - victimA. Resident statusResident #300, age greater than 65, was admitted on 12/7/24 and discharged on 1/8/25. According to the January 2025 computerized physician orders (CPO), diagnoses included multiple fractures of the ribs, stage three chronic kidney disease, muscle weakness and cognitive communication deficit.The 1/10/25 facility assessment revealed Resident #3..

1) beauty shop locked, unable to inspect The Colorado Department of Public Safety conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a).The initial comments (ID Prefix Tag #K000) are informational only and represent the facility' s general c.. Through document review and observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and 25. This was evidenced by:1) Weekly/Monthly: Not provid.. Through document review during the survey, it was determined that the facility failed to maintain the electrical systems in accordance with NFPA 99. This was evidenced by:1) Receptacle Testing (99 6.3.4.1): Provided Multiple def.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and 10. This was evidenced by:1) Portable Fire Extinguishers (Monthly/An.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and 72. This was evidenced by:1) Annual: 12.24.24 Black Canyon Fire &a.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 99, and 110. This was evidenced by:1) Load bank test (Monthly)(110 8.4... Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by: 1) Fire Doors (annually)(80 5.2): Not Provided2) l.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:1) Emergency Lighting (Monthly & Annual)(10.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:1) Fire Drills (101 4.7.6 & 19.7) (1 hour apart.. Through observation during the survey, it was determined that the facility failed to maintain hazardous areas in accordance with NFPA 101. This was evidenced by:1) PCU storage rooms 11 and 14 converted from resident room to s.. Through observation during the survey, it was determined that the facility failed to maintain hazardous areas in accordance with NFPA 101. This was evidenced by:1) The dumb waiter lobby needs drywall repair2) The basement mi.. Through observation during the survey, it was determined that the facility failed to meet the healthcare facilities code requirements in accordance with NFPA 101 and 54. This was evidenced by:1) kitchen appliances missing caster .. Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 99 and NFPA 55. This was evidenced by:1) The Oxygen Trans-filling room is not up to code, .. Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and NFPA 54. This was evidenced by:1) Gas valves on the dryer(s) not rated for more th.. Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:1) Hall one delayed egress door not working.NFPA 101 19.2.2.2...

A recertification survey with complaint #CO36893 and #CO38513 was completed on 12/4/24 to 12/10/24. Nine deficiencies were cited. An Emergency Preparedness survey was conducted from 12/4/24 to 12/10/24. No deficiencies were cited. Based on observation and interviews, the facility failed to ensure residents received professional standards of care for one (#48) resident reviewed for ileostomy care out of 28 sample residents.Specifically, the facility failed to:-Provide appropriate ileostomy care in a timely manner, which caused Resident #48 to develop dermatitis to the skin surround.. Based on observation, record review and interviews, the facility failed to ensure two (#31 and #50) of four residents reviewed for nutrition out of 28 sample residents received the care and services necessary to meet their nutritional needs and maintain their highest level practicable physical well-being.Resident #31 was admitted to the facility for l.. Based on observations, record review and interviews, the facility failed to ensure care for residents in a manner and in an environment that maintains or enhances each resident' s dignity and respect, in full recognition of his or her individuality for two (#18 and #46) of 28 sample residents reviewed for respect and dignity. Specifically, the fa.. Based on observations, record review and interviews, the facility failed to ensure residents were free from physical restraints for two (#18 and #39) of four residents out of 28 sample residents.Specifically, the facility failed to:-Identify the staff were using clothing to restrain Resident #18; and,-Ensure Resident #39 had a physician' s order for a wander .. Based on observations, record review and interviews, the facility failed to provide the necessary treatment and services to treat and prevent pressure injuries for two (#46 and #50) of six residents reviewed for pressure ulcers out of 28 sample residents.Resident #46, who was known to be at risk for pressure injuries, was admitted on 5/29/24. Th.. Based on record review and interviews, the facility failed to ensure each resident had the right to formulate an advanced directive for one (#8) of four residents out of 28 sample residents.Specifically, the facility failed to ensure Resident #8' s proxy selected or refused life-saving treatments within the power of a proxy.Findings include:I. Medical.. Based on record review and interviews, the facility failed to implement policies and procedures related to pneumococcal and influenza vaccinations for one (#29) of five residents out of 28 sample residents.Specifically, the facility failed to offer the influenza and pneumococcal vaccinations to Resident #29.Findings include:I. Facility policy.. Based on record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases.Specifically, the facility failed to implement an effective water management plan.Findings include:I. Profes.. This Citation text meets this visualizations limit for 32,000 characters, please reach out to CDPHE HFEMSD Records Team for the full citation text at cdphe_hfemsd_records@state.co.us. Within your email, please include Facility Name, Inspection ID and Citation Code.

A licensure survey was completed on 12/4/24 to 12/10/24. Two deficiencies were cited. Based on observation, record review and interviews, the facility failed to ensure two (#31 and #50) of four residents reviewed for nutrition out of 28 sample residents received the care and services necessary to meet their nutritional needs and maintain their highest level practicable physical well-being.Resident #31 was admitted to the facility for long-term care on 8/12/24 with diagnoses of hypertension (high blood pressure), depression and atrial fibrillation. Upon admission on 8/12/24, the resident weighed 120.8 lbs. On 10/17/24, Resident #31 weighed 94 pounds. Resident #31 lost 26.8 lbs (22.1%) in less than three months, which was considered severe. The facility implemented several nutritional interventions on 10/17/24 which included encouraging her family to bring in her favorite food items, that Resident #31 preferred sweet foods, and to provide assistance and cueing as needed, which did not assist Resident #31 to increase her weight. The facility implemented nutritional supplements on 11/1/24 which were occasionally accepted by Resident #31 and also did not increase Resident #31' s weight.On 11/20/24, the resident weighed 82.8 pounds. Resident #31 lost 11.2 lbs (11.9%) in less than three months which was considered severe. Due to the facility' s failure to effectively implement nutrition interventions timely, Resident #31' s weight continued to decline. Additiona.. Based on observations, record review and interviews, the facility failed to provide the necessary treatment and services to treat and prevent pressure injuries for two (#46 and #50) of six residents reviewed for pressure ulcers out of 28 sample residents.Resident #46, who was known to be at risk for pressure injuries, was admitted on 5/29/24. The resident had diagnoses of dementia, cognitive communication deficit, chronic pain, and generalized muscle weakness.On 11/11/24, Resident #46 developed a facility-acquired stage 2 pressure injury to her sacrum, however, the facility did not initiate further pressure ulcer interventions on the resident' s pressure ulcer prevention care plan once the stage 2 pressure injury was identified and did not update the care plan to include the new pressure injury.On 11/19/24, physician documentation indicated Resident #46' s pressure wound had worsened to an unstageable pressure injury. Despite the worsening of the pressure injury, the facility failed to implement a low air loss pressure relieving mattress until 11/26/24, 15 days after the initial pressure ulcer was identified. Despite the worsening of the resident' s pressure injury, the facility did not initiate Resident #46' s pressure injury care plan, which identified the resident had an actual pressure injury, until 12/4/24, two weeks later.Furthermore, observations during the survey revealed the f..