Hope Springs

The facility failed to ensure healthcare referral and follow-up for a resident by failing to book necessary appointments for cardiology and physical therapy. Despite referrals being placed in August 2025, the resident reported waiting over a month for therapy services.

The facility failed to administer medications as ordered by the provider for two sampled residents. Specifically, one resident did not receive prescribed long-acting and sliding scale insulin, and another did not receive prescribed mood stabilizing and antidepressant medications.

The facility failed to administer medications as ordered by the provider for 2 out of 7 sampled residents. Specifically, one resident did not receive ordered long-acting and sliding scale insulin, and another did not receive ordered mood stabilizing and antidepressant medications.

The facility failed to administer medications in accordance with physician orders, specifically regarding the crushing of extended-release medications. During medication passes, staff were observed crushing Potassium Chloride ER, which should not be crushed, and errors were identified in the administration of medications for allergies, swelling, urinary retention, and insulin for multiple residents.

The facility failed to administer medications according to provider orders, specifically failing to follow 'Do Not Crush' instructions for 3 of 4 residents observed. This included crushing extended-release potassium chloride, which can cause irritation and improper drug release. Additionally, a 20% medication error rate was observed during medication passes, including errors in timing and documentation.

The facility failed to maintain hot water temperatures between 100 and 116 degrees Fahrenheit for 18 of 21 fixtures. Specifically, water temperatures at various resident room sinks and shared bathrooms were observed to be as high as 126 degrees Fahrenheit.

The facility failed to maintain hot water temperatures between 100 and 116 degrees Fahrenheit for 18 of 21 identified fixtures. Observations revealed temperatures as high as 126 degrees F in resident rooms and shared bathrooms, posing a safety risk to residents.

The facility failed to ensure proper referral and follow-up for a resident with elevated heart rates and high finger stick blood sugar results. Specifically, there was no documentation of physician notification for pulse rates of 151 and 142, and the facility failed to follow physician-ordered parameters for notifying the doctor regarding blood glucose levels exceeding 451.