Hope Springs Care Center

Inspectors wroteBased 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 [DATE]. 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. [...]

Inspectors wroteBased 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 [DATE], 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. [...]

Inspectors wroteBased 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.

Inspectors wroteC. Resident #13 1. Resident Status Resident #13, age greater than 65, was admitted on [DATE]. According to the December 2024 CPO, diagnoses included end stage renal disease, bipolar disorder and anemia. The 10/18/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required supervision or touching assistance when bathing, set-up or clean-up assistance with personal hygiene, and was independent with all other activities of daily living (ADL). 2. Record review The fall risk care plan, initiated 4/23/24 and revised 6/21/24, documented that Resident #13 was at risk for falling because of problems with her balance. Interventions included ensuring the resident's call light was within reach, anticipating the resident's needs and that the resident should use a shower bench when in the shower. [...]

Inspectors wroteBased 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 facility failed to: -Ensure Resident #18 did not remove his clothing in the common areas of the facility; -Identify communication techniques for Resident #46 to decrease the resident's frustration and allow her to effectively and consistently express her needs and wants; and, -Ensure the staff stopped and listened to Resident #46 when the resident yelled no, hurt and enough as she was pushed with her wheelchair and her foot was dragged under her wheelchair.

Inspectors wroteBased 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.

Inspectors wroteBased 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 guard restraint.

Inspectors wroteBased 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 surrounding his ileostomy; and, -Failed to obtain physician's orders timely for Resident 48's ileostomy care.

Inspectors wroteBased 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.

Inspectors wroteBased on observations, record review and interviews the facility failed to store, prepare, distribute and serve food in a sanitary manner. Specifically, the facility failed to ensure: -The dishwashing machine temperature and sanitizer levels were consistently addressed when not in range; and, -Resident water cups were consistently cleaned and sanitized.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide appropriate treatment and services to maintain or improve residents' ability to perform activities of daily living (ADLs) for three (#1, #2 and #3) of five residents reviewed for ADLs out of 11 sample residents. Specifically, the facility failed to ensure: -Resident #3's catheter bag was emptied regularly; -Resident #3 was provided incontinence care and repositioning consistently; -Resident #2 was offered and provided timely bathing and oral care; and, -Resident #1 was offered and provided bathing at least twice a week or as preferred.

Inspectors wroteBased on observations, record review, and interviews the facility failed to effectively follow an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection for two out of six halls. Specifically, the facility failed to ensure staff wore the appropriate personal protective equipment (PPE) when providing care to the residents in rooms #15, #16, #17 and #43 who were on isolation protocol.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#2) resident out of 11 sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to: -Thoroughly assess Resident #2 after the resident reported a new or worsening condition; and, -Ensure the Resident #2 had a timely physician appointment scheduled as requested by the physician.

Inspectors wroteBased on record review and interviews, the facility failed to ensure proper medication administration without significant medication errors for one (#1) resident of three residents reviewed for medications. Specifically, the facility failed to: -Properly transcribe hospital physician discharge orders for digoxin to ensure Resident #1 received his correct dosage as ordered; -Ensure Resident #1 was administered the correct dose of digoxin; and, -Ensure all nursing staff were thoroughly trained on the facility expectations of the 24-hour double-check process, triggered warnings in the electronic medication administration record (EMAR), and the apical pulse monitoring to prevent potential future medication errors.

Inspectors wroteBased on observations, interviews and record review the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen and in the activities room. Specifically, the facility failed to: -Ensure food was labeled and dated in the walk-in refrigerators, dry storage and reach-in refrigerator in the main kitchen and in the activities room refrigerator; -Ensure expired food was disposed of in a timely manner; -Ensure cooked food items were monitored and cooled properly; -Ensure artificial nails with policy were not worn by a food worker; -Ensure appropriate use of gloves when handling ready-to-eat foods; and, -Ensure food was stored off the floor in the main kitchen/walk-in freezer.

Inspectors wroteBased on interviews and record review, the facility failed to take timely action to identify, investigate, address and resolve grievances of the resident group. Specifically, the facility failed to take action regarding ongoing resident concerns about food quality and lack of sufficient transportation for outings because the second facility van was not operational.

Inspectors wroteBased on interviews, observations, and record review, the facility failed to take steps to protect three (#145, #22 and #32) of 10 residents reviewed for abuse out of 33 sample residents. Specifically, the facility failed to: -Ensure Resident #145 was free from physical abuse from Resident #21; -Ensure Resident #22 was free from physical abuse from Resident #35; and, -Ensure Resident #32 was free from physical abuse from Resident #16.

Inspectors wroteBased on record review and interviews, the facility failed to provide adequate dementia care and services to ensure the highest practicable psychosocial well-being for three (#22, #32 and #16) of 10 residents reviewed for dementia care out of 33 sample residents. Specifically, the facility failed to provide dementia care and services to ensure Residents #22, #32 and #16 were free from abuse from their peers. Cross-reference F600, free from resident-to-resident abuse

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure menus were followed to meet the resident's nutritional needs. Specifically, the facility failed to: -Ensure residents were served the correct diets; and, -Follow the correct portion sizes to ensure adequate nutrition was provided to the residents.

Inspectors wroteBased on interviews, observations and record review, the facility failed to consistently serve food that was palatable and attractive. Specifically, the facility failed to ensure resident food was palatable in taste, texture and appearance.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide each resident with a nourishing, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident for four (#34, #1, #250 and #5) of seven residents out of 33 sample residents. Specifically, the facility failed to: -Ensure Resident #28's requests and preferences for gluten free and lactose free foods were served to her; -Obtain, document and honor Resident #42, #1 and #250 food preferences; -Ensure Resident #5 received his preferred breakfast prior to going to dialysis; and, -Provide a balanced meal per resident's choices from the alternative menu.

Inspectors wroteBased on interviews and record review, the facility failed to ensure its quality assurance and process improvement (QAPI) committee prioritized its improvement activities, developed and implemented action plans, measured the success of those actions, tracked performance, regularly reviewed and analyzed and acted on data collected. Specifically, the facility failed to identify and implement effective action plans to address repeat deficiencies and resident quality of life issues related to abuse prevention and palatable foods in keeping with residents' preferences.

Inspectors wroteBased on observations, staff interviews and record review, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, the facility failed to: -Keep the biohazard room locked, with chemicals and broken glass accessible to residents; -Keep the maintenance office locked, with tools accessible to residents; -Keep the facility's wing under construction locked, with chemicals and power tools accessible to residents; -Keep a storage closet locked, with hand sanitizer cases accessible to residents; and, -Keep keys that unlock biohazardous rooms out of reach of ambulating residents.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one (#5) out of 33 sample residents were provided prompt efforts by the facility to resolve grievances. Specifically, the facility failed to document and provide resolutions to Resident #5's missing items.

Inspectors wroteBased on record review and interviews, the facility failed to coordinate assessments with the preadmission screening resident review (PASRR) program for (#14) of two reviewed for PASRR out of 33 sample residents. Specifically, the facility failed to: -Maintain PASRR level II form on the medical record; and, -Incorporate the PASRR level II recommendations into the resident's care plan.

Inspectors wroteBased on record review and staff interviews, the facility failed to document resuscitation choices accurately in the medical record for two (#37 and #16) of 10 residents reviewed for advance directives out of 33 sample residents. Specifically, the facility failed to ensure the medical orders for scope and treatment (MOST) forms matched the resident's electronic medical record (EMR) physician orders for their resuscitation choices.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure one (#250) of three residents reviewed for activities of 33 sample residents received an ongoing program of activities designed to meet needs and interests and promote physical, mental and psychosocial well-being. Specifically, the facility failed to offer and provide personalized activity programs for Resident #250.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents were treated with respect and dignity. Residents reports that staff did not consistently: -Respond to their call lights in a timely manner; -Treat them and speak to them in a dignified manner; and, -Respond appropriately and timely when concerns were brought to their attention. Residents said it was wrong the way they were sometimes disrespected by staff and treated like children. As a result, residents used the words angry, aggravated, ridiculous and hurt to describe how they felt.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure two out of six residents reviewed for abuse out of 24 residents were kept free from abuse. Resident #32 and #3 expressed fear and anxiety about a situation that occurred with Resident #4 on 1/11/22. Resident #4 entered their room while they were inside, blocked the door, and began to yell at them. She told them she was going to shoot them and they were afraid she was going to start throwing items at them that were near the sink. Residents #32 and #3 both turned on their call lights for help but they were unable to get staff assistance during the situation and felt like they were being held hostage. They were scared and did not feel safe. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure one (#1) of six residents reviewed was free from significant medication errors out of 24 sample residents. Resident #1 was symptomatic and diagnosed with a urinary tract infection (UTI) and prescribed an antibiotic on 3/17/22. However, she did not receive the first dose of her antibiotic until seven days later on 3/23/22. The resident experienced discomfort, burning and delayed treatment of her UTI. The resident expressed right now I have a UTI and the infection feels like it's eating my skin, and said she felt discomfort, burning, and if I sit in a wet diaper for very long my skin starts burning and I punch the light immediately.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure residents received adequate supervision and assistance, and were free from accident hazards and risks in their environment for one (#27) of six residents reviewed out of 24 sample residents, and in two of two resident shower areas. Resident #27, who had recent bilateral below-the-knee amputations, fell to the floor during a transfer and experienced severe pain during the incident and for several days afterward. The facility failed to provide timely standby assistance and failed to ensure the resident's bedside commode and wheelchair were sturdy and adapted for safety. The facility further failed to ensure both resident shower areas had grab bars for resident safety, that the floors were free from standing water, and that the shower walls and floors were free from toxic mold.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide palatable food to the residents in two of two dining rooms and for resident room trays. Specifically, the residents complained of cold, poorly seasoned food, monotonous menus and lack of certain foods being available to them consistently.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain an infection control program designed to prevent the spread of infection during medication administration observation for two of three nurses. Specifically, the facility: -Failed to implement appropriate hand hygiene practices and glove use during medication administration, and -Failed to discard spilled medication rather than administer it to Resident #25.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one (#22) of one resident reviewed for the care planning process out of 24 sample residents had the right to participate in the development and implementation of their person-centered plan of care. Specifically, the facility failed to schedule and invite Resident #22 to routine care conferences.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide treatment and devices to maintain hearing in a timely manner for one (#27) of one resident reviewed out of 24 sample residents. Specifically, the facility had knowledge that Resident #27 had hearing loss and needed hearing aids. A physician ordered hearing aids on 12/27/21, but as of 3/24/22, three months later, the hearing aids had not been provided for Resident #27.