Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hope Springs Care Center during CMS and state inspections, most recent first.
Two residents in the facility developed pressure injuries due to inadequate care and delayed interventions. One resident's stage 2 pressure injury worsened to an unstageable injury due to delayed implementation of a low air loss mattress and incorrect firmness settings. Another resident developed an unstageable pressure injury on the heel, with inconsistent use of pressure relieving boots and incomplete documentation of wound care. The facility failed to follow its pressure ulcer prevention policy, leading to the development and worsening of pressure injuries.
Two residents in the facility experienced severe weight loss due to inadequate nutritional interventions and monitoring. One resident lost 38 pounds over three months, primarily consuming sweets and refusing other foods. The facility failed to implement new interventions after significant weight loss. Another resident lost 23.1 pounds, with inconsistent weight documentation and unavailable nutritional supplements. The facility did not provide a timely nutrition care plan or reweigh the resident after significant weight changes, contributing to the continued weight loss.
The facility failed to implement an effective water management plan to prevent Legionella growth, lacking a process flow diagram and documentation of flushing procedures. Staff interviews revealed insufficient training and understanding of CDC guidelines, with the Maintenance Director unaware of the need for weekly flushing and the DON uninformed about the facility's monthly flushing practice.
The facility failed to provide adequate supervision and timely fall interventions for residents, leading to multiple falls and safety hazards. A resident with severe cognitive impairment experienced 18 falls, with no new interventions for 12 of them. Another resident, cognitively intact but with balance issues, had unwitnessed falls without consistent neurological assessments or care plan updates. A third resident, moderately impaired, also lacked proper assessments after a fall. Additionally, a resident with moderate impairment had her call light out of reach, leading to several unwitnessed falls. The facility's inaction in updating care plans and ensuring safety measures contributed to ongoing risks.
The facility failed to maintain the dignity and respect of two residents. One resident, with severe cognitive impairments, was repeatedly observed without a shirt in common areas, and staff did not consistently assist him. Another resident, with communication deficits, experienced distress as her foot was dragged under her wheelchair, and her communication board was not used effectively. These incidents highlight deficiencies in adhering to policies on dignity and resident rights.
A facility failed to honor a resident's advance directive rights by not ensuring the proxy's decision to decline artificial nutrition was supported by required physician certifications. The resident, with multiple medical conditions and cognitive impairment, had a MOST form indicating a DNR status. Staff interviews revealed a lack of understanding of proxy roles and limitations, highlighting systemic issues in staff training on advance directive protocols.
The facility failed to ensure residents were free from physical restraints, as clothing was used to restrain a resident with cognitive impairment, and a wander guard was used without a proper physician's order for another resident with dementia. Staff interviews revealed a lack of awareness regarding the use of restraints, and the facility's policies on restraint management were not followed, leading to deficiencies in care.
A resident over 65 with severe cognitive impairments was not offered influenza and pneumococcal vaccinations as per facility policy. Despite the need for these vaccinations, confirmed by state immunization tracking, the resident had not been offered them until the survey date. The DON admitted the oversight, acknowledging the resident should have been offered the vaccinations earlier.
A resident with an ileostomy developed dermatitis due to the facility's failure to provide timely and appropriate care. The resident's ileostomy bag frequently leaked, and the facility did not obtain timely physician's orders for care. The ileostomy was left open to air without orders, leading to skin irritation and a fungal rash. Staff interviews revealed difficulties in managing the ileostomy, and necessary supplies were not available before discharge.
Failure to Prevent and Treat Pressure Injuries
Penalty
Summary
The facility failed to provide necessary treatment and services to treat and prevent pressure injuries for two residents. One resident, who was at risk for pressure injuries, developed a facility-acquired stage 2 pressure injury on the sacrum, which worsened to an unstageable pressure injury. The facility did not update the resident's care plan to include the new pressure injury and delayed implementing a low air loss pressure relieving mattress for 15 days after the initial injury was identified. Additionally, the mattress was not set to the correct firmness level as per physician's orders, and the pressure injury care plan was not initiated until two weeks after the injury worsened. Another resident, also at risk for pressure injuries, developed a facility-acquired unstageable pressure injury on the left heel. The facility documentation indicated that pressure injury prevention interventions were not initiated until after the injury was identified. Observations revealed that the resident was not consistently wearing pressure relieving heel protector boots, and wound care treatments were not documented as occurring on several occasions. The facility failed to document the resident's refusal of interventions or provide reasons for the lack of documentation. The facility's policy and procedure for pressure ulcer prevention and treatment were not followed, as evidenced by the lack of timely interventions and documentation. Staff interviews revealed inconsistencies in the implementation of care plans and adherence to physician's orders. The facility's failure to implement timely interventions and maintain accurate documentation contributed to the development and worsening of pressure injuries in both residents.
Failure to Address Severe Weight Loss in Residents
Penalty
Summary
The facility failed to ensure that two residents received the necessary care and services to meet their nutritional needs, resulting in severe weight loss. Resident #31, admitted with diagnoses including hypertension and depression, experienced a significant weight loss of 38 pounds (31.5%) over three months. Despite interventions such as encouraging family to bring favorite foods and providing nutritional supplements, the resident's weight continued to decline. Observations revealed that the resident often refused meals, consuming only sweet foods like cookies, and the facility did not implement new or revised interventions after the resident's severe weight loss. Resident #50, diagnosed with dementia and adult failure to thrive, also experienced severe weight loss, losing 23.1 pounds (19.4%) over three months. The resident did not receive a nutrition care plan until after significant weight loss had occurred, and there were inconsistencies in weight documentation. The resident's nutritional supplement, Mighty Shake, was not consistently available, and the resident was observed to eat less than 25% of meals on occasion. The facility failed to reweigh the resident after significant weight changes and did not implement timely person-centered interventions to address the weight loss. The facility's policies and procedures for weight management were not effectively followed, as evidenced by the lack of timely interventions and inaccurate weight documentation. Staff interviews indicated that the facility could have done more to address the residents' weight loss, and there was a lack of consistent oversight in weight management. The facility's failure to implement effective nutritional interventions and accurately monitor residents' weights contributed to the residents' continued weight loss.
Inadequate Water Management Plan for Legionella Prevention
Penalty
Summary
The facility failed to maintain an effective infection control program, specifically in implementing a water management plan to prevent the growth and transmission of Legionella bacteria. The facility's water management plan did not include a process flow diagram of the water systems, and there was no documentation of testing for Legionella bacteria. Instead, the facility relied on visual inspections and hot water flushing. The plan also failed to document when empty resident rooms with low flow piping runs and dead legs were flushed, which is contrary to CDC recommendations that such areas should be flushed at least weekly. Interviews with staff revealed a lack of understanding and training regarding the water management plan. The Maintenance Director (MTD) was not involved in creating the current plan and was unaware of what a process flow diagram was. The MTD also stated that monthly flushing of empty rooms was sufficient, despite CDC guidelines suggesting more frequent flushing. The Director of Nursing (DON), who was also acting as the Infection Preventionist, was not directly involved in the water management plan and was unaware of the facility's practice of monthly flushing, believing instead that daily flushing was necessary to prevent the spread of waterborne pathogens.
Inadequate Supervision and Fall Prevention in LTC Facility
Penalty
Summary
The facility failed to provide adequate supervision and implement timely and effective fall interventions for several residents, leading to multiple falls and safety hazards. Resident #28, who had a severe cognitive impairment and a history of falls, experienced 18 falls over the course of a year. Despite having a fall care plan in place, the facility did not implement new interventions for 12 of these falls. The resident's falls were often attributed to poor cognition and impulse control, yet the facility did not consistently update the care plan with new strategies to prevent further incidents. Resident #13, who was cognitively intact but had balance issues, experienced unwitnessed falls on two occasions. The facility failed to perform consistent neurological assessments after these falls and did not update the resident's care plan with new interventions. Similarly, Resident #32, who was moderately cognitively impaired, experienced an unwitnessed fall, and the facility did not perform the required neurological assessments consistently. The facility's inaction in updating care plans and performing necessary assessments contributed to ongoing safety risks for these residents. Resident #50, who had moderate cognitive impairment and a history of falls, was observed multiple times with her call light out of reach, which compromised her ability to call for assistance. The facility did not ensure the call light was consistently within reach, and the resident experienced several unwitnessed falls. The incident reports and progress notes often lacked documentation on whether the call light was used or within reach at the time of the falls, indicating a failure to address a critical safety measure. These deficiencies highlight the facility's inadequate supervision and failure to implement effective fall prevention strategies for residents at high risk of falls.
Deficiencies in Resident Dignity and Communication
Penalty
Summary
The facility failed to maintain the dignity and respect of two residents, leading to deficiencies in their care. Resident #18, who has severe cognitive impairments and a history of dementia and Alzheimer's disease, was observed multiple times in common areas without a shirt. Despite the resident's visible frustration and repeated attempts to put his shirt back on, staff members frequently passed by without offering assistance. The care plan for Resident #18 noted his tendency to remove his shirt, yet interventions were not consistently applied, and staff resorted to using overalls or multiple shirts to prevent him from undressing, which was not intended as a restraint. Resident #46, who has cognitive communication deficits and relies on a wheelchair, experienced significant communication challenges. The resident was observed yelling and expressing distress as her foot was dragged under her wheelchair, yet staff did not immediately address her needs. Despite having a communication board designed to aid in expressing her needs, it was not consistently used or readily available, leading to further frustration. Interviews revealed a lack of awareness among staff about the communication board and inconsistent communication strategies, contributing to the resident's distress. The facility's policies on dignity and resident rights emphasize treating residents with respect and ensuring their needs are met. However, the observations and interviews indicate a failure to adhere to these policies, resulting in residents experiencing undignified situations and unmet needs. The lack of effective communication and intervention strategies for both residents highlights a gap in the facility's ability to provide individualized care that respects each resident's dignity and autonomy.
Failure to Ensure Resident's Advance Directive Rights
Penalty
Summary
The facility failed to ensure that a resident's right to formulate an advance directive was honored, specifically regarding the selection or refusal of life-saving treatments by a proxy. Resident #8, who was over 65 years old and had multiple medical conditions including stage 3 chronic kidney disease and cognitive impairment, was admitted to the facility. The resident's Medical Orders for Scope of Treatment (MOST) form indicated a do-not-resuscitate (DNR) status and that the proxy declined artificial nutrition. However, the facility did not have the required physician's note signed by both the resident's physician and a neurologist, certifying that artificial nutrition would only prolong the act of dying, as stipulated on the MOST form. Interviews with facility staff revealed a lack of understanding regarding the roles and limitations of a proxy versus a medical durable power of attorney (MDPOA). The Nursing Home Administrator (NHA) and Business Office Manager (BOM) were unaware of the proxy's decision-making capabilities on the MOST form. The Social Services Director (SSD) admitted to not having read the back of the MOST form and was unaware of the proxy's limitations in declining artificial nutrition. The Director of Nursing (DON) also confirmed a lack of awareness regarding the proxy's decision-making capabilities, indicating a systemic issue in staff training and understanding of advance directive protocols.
Deficiencies in Restraint Management for Two Residents
Penalty
Summary
The facility failed to ensure that residents were free from physical restraints, as evidenced by the use of clothing to restrain Resident #18 and the lack of a proper physician's order for a wander guard restraint for Resident #39. Resident #18, who had severe cognitive impairment and a history of removing his shirt in common areas, was observed wearing overalls and multiple shirts to prevent him from undressing. Staff interviews revealed that the use of overalls was intended to make it harder for the resident to remove his shirt, effectively acting as a restraint, which was not documented or consented to in the resident's care plan. Resident #39, diagnosed with frontotemporal neurocognitive disorder and dementia, was using a wander guard device daily. However, the facility did not have a physician's order specifying the medical symptoms the device was intended to address, nor did it document attempts to use less restrictive interventions. Staff interviews indicated a lack of awareness that the wander guard constituted a restraint, and the existing orders were only for the maintenance of the device, not its use as a restraint. The facility's policies on physical restraint management and resident rights emphasize that restraints should only be used for medical symptoms and not for staff convenience or discipline. The failure to adhere to these policies resulted in the inappropriate use of clothing as a restraint for Resident #18 and the improper implementation of a wander guard for Resident #39, highlighting deficiencies in the facility's restraint management practices.
Failure to Offer Required Vaccinations to Resident
Penalty
Summary
The facility failed to implement its policies and procedures regarding the administration of influenza and pneumococcal vaccinations for a resident. According to the facility's immunization policy, each resident should be offered an influenza immunization annually from October 1 through March 31, unless medically contraindicated or already immunized. Additionally, the facility is required to determine the pneumococcal immunization status of residents upon admission and offer vaccinations as indicated by CDC recommendations. However, the facility did not offer these vaccinations to a resident over the age of 65, who was admitted and readmitted to the facility, despite the resident's medical records indicating the need for both vaccinations. The resident, who had severe cognitive impairments and a BIMS score of three out of 15, had not received an influenza vaccine for the current season and was not up to date with pneumococcal vaccinations. The state immunization tracking documentation confirmed that the resident required both vaccinations. Interviews with the DON revealed that the normal process was to begin offering these vaccinations in October, but the resident had not been offered either vaccination until the survey date. The DON acknowledged that the resident should have been offered the vaccinations earlier.
Inadequate Ileostomy Care Leads to Dermatitis
Penalty
Summary
The facility failed to provide appropriate ileostomy care for a resident, leading to the development of dermatitis around the ileostomy site. The resident, who was over 65 and had undergone major surgery requiring skilled nursing care, was admitted with an ileostomy. Despite having supplies, the facility did not manage the ileostomy effectively, resulting in frequent leaks and exposure of fecal matter to the skin. This exposure caused the resident's skin to become red, raw, and develop a fungal rash, as documented by the ostomy clinic. The facility did not obtain timely physician's orders for the resident's ileostomy care, which contributed to the inadequate management of the condition. The resident's ileostomy bag was changed multiple times in a short period, contrary to professional standards that recommend changes every three to five days. The lack of proper sealing and frequent changes led to further skin irritation and dermatitis. Additionally, the facility left the ileostomy open to air without a physician's order, exacerbating the skin condition. Interviews with staff revealed that the facility struggled to fit an appliance for the resident's ileostomy, and the necessary supplies were not available before the resident's discharge. The DON acknowledged that leaving an ileostomy open to air without a physician's order could lead to infection or dermatitis. The resident's condition required intervention from an ostomy clinic, which provided new supplies and instructions for care. However, the facility's failure to manage the ileostomy effectively and obtain timely orders resulted in the resident's skin condition worsening.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Montrose
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Valley Manor Care Center | 0.6 mi | — | 1 | 0 |
| Colorow Care Center | 11.3 mi | — | 2 | 0 |
| Willow Tree Care Center | 19.9 mi | — | 14 | 0 |
| Horizons Care Center | 24.6 mi | — | 1 | 0 |
| Paonia Care And Rehabilitation Center | 30.7 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.