The physician's order requiring those precautions had been written the day before, on June 2, 2026.
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Inspectors pulled the facility's internal schedules and nursing staff census sheets and found that Hope Springs did have adequate coverage on those days.
The error affected one resident out of 26 reviewed for MDS accuracy.
She was wrong, and the facility's own policy said so.
Inspectors watched the whole thing happen.
The inspection of the Hall A cart, conducted at 9:26 a.m.
The nurse worked across all units of the facility.
When a federal inspector stopped to speak with him on June 1, the resident said he was concerned about it too, and that the bag should always be covered.
That's what federal inspectors found when they visited the facility on June 5, 2026.
The finding emerged from a June 4, 2026 inspection at the facility on West Broadway Avenue.
Federal inspectors documented the finding on June 2, 2026.
The facility's therapy contractor had been trying to work something out.