Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
HOPE SPRINGS CARE CENTER
MONTROSE, CO · 74 certified beds · Last Life Safety survey December 10, 2024
CMS Certification Number 065195 · first certified September 1984
Ownership
Operated by RECOVER-CARE HEALTHCARE · For profit - Corporation
- Ownership changed March 1, 2022 (change of ownership)to ELK RIDGE HEALTH AND REHABILITATION CENTER from SSC MONTROSE SAN JUAN OPERATING COMPANY LLC
Position within CO
37 citations — more than 95% of the 210 certified nursing homes in CO. Compared within CO rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 14 citations; the earlier surveys in the window averaged 11.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: May 2026 to December 2026. This facility’s last Life Safety survey was December 2024. Facilities in CO are typically surveyed 17–24 months after the last one (median 19), measured over 177 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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8 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
6 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 37 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
How that compares
Compared with the median facility in CO, and nationally. Surveyors differ markedly between states, so the CO figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 37 |
| Median facility in CO | 16 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| March 24, 2022 | 8 |
| May 25, 2023 | 15 |
| December 10, 2024 | 14 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 3 | 2024-12-10 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 3 | 2024-12-10 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 3 | 2024-12-10 |
| K-0324 | Provide properly protected cooking facilities. | 3 | 2024-12-10 |
| K-0222 | 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. | 3 | 2024-12-10 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2024-12-10 |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | 2 | 2024-12-10 |
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2024-12-10 |
What the citations cover
- Smoke Deficiencies 18
- Gas, Vacuum, and Electrical Systems Deficiencies 7
- Egress Deficiencies 7
- Miscellaneous Deficiencies 3
- Other 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 18 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 7 |
| Egress Deficiencies | 7 |
| Miscellaneous Deficiencies | 3 |
| Services Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
December 10, 2024 — 14 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | 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. | Deficient, Provider has date of correction (April 7, 2025) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (January 9, 2025) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (April 7, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (April 7, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (April 7, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (April 7, 2025) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (February 28, 2025) |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Deficient, Provider has date of correction (April 7, 2025) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (April 7, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (January 17, 2025) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (April 7, 2025) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (April 7, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (January 17, 2025) |
| K-0927 | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Deficient, Provider has date of correction (April 7, 2025) |
May 25, 2023 — 15 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | 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. | Deficient, Provider has date of correction (August 1, 2023) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (August 1, 2023) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (August 1, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (August 1, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (August 1, 2023) |
| K-0347 | Properly provide smoke detection systems in areas open to corridors. | Deficient, Provider has date of correction (July 14, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Waiver has been granted (October 31, 2023) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (August 1, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (August 1, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (August 1, 2023) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (August 1, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (July 3, 2023) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (August 1, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Waiver has been granted (January 15, 2024) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (August 1, 2023) |
March 24, 2022 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (May 15, 2022) |
| K-0222 | 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. | Deficient, Provider has date of correction (April 25, 2022) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (May 15, 2022) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (May 15, 2022) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (May 5, 2022) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (April 29, 2022) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (April 12, 2022) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (May 15, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.