Inspiration Hills Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences in 1 (Resident #7) of 2 residents reviewed receiving supplemental oxygen via nasal cannula. The facility failed to ensure that Resident #7's oxygen tubing was handled properly to prevent contamination. Resident 7's nasal cannula was on the floor in her room and CNA C placed it back on resident. This failure could put residents receiving supplemental oxygen via nasal cannula at risk for cross-contamination and respiratory infection.The findings included: Record review of Resident #7's face sheet, dated 06/02/2026, reflected an [AGE] year-old female with current admission date of 05/14/2026. Diagnosis includes hypertensive heart disease (high blood pressure causes damage to the heart) and atherosclerotic heart disease (hardening…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 1 of 4 resident (Residents #1) reviewed for infection control. The facility failed to ensure CNA A washed her hands before donning gloves and failed to change soiled gloves prior to touching clean brief and linens during an incontinent care observation for Resident #1 on 03/04/2026. This deficient practice could place residents at risk of cross contamination and infections.Findings included:Record review of Resident # 1's electronic face sheet dated 03/04/2026 reflected Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: unspecified cerebral infarction (medical condition occurs when blood flow to a part of the brain is obstructed which leads to the death of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 4 residents (Resident #1) reviewed for care plans: The facility failed to ensure Resident #1's comprehensive care plan was completed in a timely manner and included behaviors she had refusing care or being combative during care. This deficient practice could cause confusion for staff members responsible for providing direct care to the residents and place residents at risk of receiving improper care and services. The findings included:The findings included: Record review of Resident #1's admission record, dated 11/26/25, revealed a [AGE] year-old female resident was admitted to the facility on [DATE] with diagnoses including lack of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 facility reviewed for food service safety. 1. The facility failed to maintain the cleanliness of the facility ice maker. 2. Two open food items were observed in the medication storage fridge, undated and unlabeled. 3. Three open and unrefrigerated containers of fluid drinks intended for residents were observed on two medication carts. This failure could place residents who receive food and/or snacks from the facility at risk for food borne illness. The findings included: 1. Observation on 04/03/2025 at 11:32 AM revealed a black substance build-up within the ice maker. The ice machine was observed to have a sticker on it stating the contracted cleaning company had last cleaned the ice machine in March of 2025, and it would next be cleaned in September of 2025. Observation on 04/03/2025 at 11:45 AM revealed water pitchers with ice in them and an ice chest in the hallway with ice in it for staff to provide to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 5 (Residents #8, #15, #31, #62, and #77) of 18 residents reviewed for care plans. 1. The facility failed to develop care plan interventions for Resident #77's hospice services. 2. The facility failed to develop care planning related to Resident #15's ordered Wanderguard device and known tendencies to wander the facility in attempts to elope. The care planning for this resident also did not include monitoring for the resident's ordered, psychotropic medications. 3. The facility failed to develop care planning related to Resident #62's known tendency to wander the facility in attempts to elope as well as care planning monitoring the resident's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 8 residents (Resident #9, #28, and #40) reviewed for personal hygiene. 1. The facility failed to provide Resident #9, 8 of 13 scheduled showers between 03/04/2025 and 04/03/2025. 2. The facility failed to provide Resident #28, 8 of 13 scheduled showers between 03/04/2025 and 04/03/2025. 3. The facility failed to provide Resident #40, 4 of 14 scheduled showers between 03/04/2025 and 04/03/2025. This failure could place residents who require assistance from staff for personal hygiene at risk of not receiving care and services contributing to overall poor hygiene, risk of experiencing a diminished quality of life, and possible skin infections. The findings included: 1. Record review of Resident #9's admission Record, dated 04/04/2025, reflected a [AGE] year-old resident with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and records review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and each resident receives adequate assistance devices to prevent accidents for 3 of 3 resident halls reviewed for infection control and 1 resident (Resident #64) of 3 residents reviewed for accidents and hazards. 1. The facility failed to store hand sanitizer in a way that prevented residents to access the hazardous substance without supervision. 2.The facility failed to ensure that fall mats were in place for Resident #64. These failures could place resident at risk for injuries due to not having adequate supervision or devices. 1.Observation and interview during the initial facility tour on 4/01/2025 beginning at 09:49 AM, it was observed that hand sanitizer dispensers were not present outside of resident rooms in Hall B or within the PPE cart located in front of room B7. Surveyors on Halls A and C confirmed that dispensers were not present on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to revise the comprehensive care plan after each assessment for 1 (Resident #64) out of 8 residents reviewed for care planning. The facility failed to revise the care plan after investigating a fall sustained by Resident #64. The facility investigation included planned interventions that were not included care plan revision. This failure could result in the resident not receiving planned care or additional falls. The findings included: Review of Resident #64's face sheet, dated 4/04/2025, reflected a [AGE] year-old female with an initial admission date of 8/08/2024. Relevant diagnoses included muscle wasting and atrophy, other lack of coordination, unspecified dementia (a progressive disorder that affects a person's thinking skills), unsteadiness on feet, weakness, and muscle weakness. Review of the quarterly MDS for Resident #64 submitted on 3/11/2025 revealed a BIMS score of 04, indicating severe cognitive impairment . On 2/28/2025, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation , interview and record review, the facility failed to ensure that residents receive proper treatment to maintain vision abilities and assist the resident in making appointments for 1 (Resident #18) of 6 residents reviewed for communication and sensory problems. The facility failed to reschedule an ophthalmology appointment for Resident #18 to evaluate and treat the resident's medical condition affecting her eyesight. This failure could lead to diminished or loss of vision and decreased quality of life. The findings included : Record review of Resident #18's face sheet reflected she was an [AGE] year-old female originally admitted on [DATE]. Relevant diagnoses included type 2 diabetes mellitus without complication (a medical disorder that causes difficulty in regulating blood sugar levels), dementia (a progressive disorder that impairs thought processes such as memory, thinking, and reasoning), and cognitive social or emotional deficit following unspecified cerebrovascular disease. A review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for two of two (Resident #8 & Resident #31) residents reviewed for range of motion. The facility failed to ensure Resident #8's left palm protector (medical device used to treat hand contractures, permanent tightening of the muscles, tendons, skin and surrounding tissues that causes stiffness, placed in the hands to help improve range of motion) was in place to her left hand. The facility failed to identify a medical device for Resident #31's right hand to help improve range of motion. The failures could place residents at increased risk for decrease in mobility and range of motion and contribute to worsening of contractures. Findings included: Record review of Resident #8's face sheet revealed a [AGE] year-old female admitted [DATE] and readmitted [DATE]. Resident #8's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 8.11% based on 3 errors out of 37 opportunities, which involved two residents (Resident #22 and Resident #3) of four reviewed for medication administration. 1. CMA B administered Fingolimod HCl oral capsule 0.5mg 1 capsule for personality disorder to Resident #2 at 09:34 AM that was ordered for administration at 08:00 AM. CMA B administered Sertraline HCl oral tablet 25mg 1 tablet for anxiety to Resident #22 at 09:34 AM that was ordered for administration at 08:00 AM. 2. CMA B documented administration of medication Cholecalciferol Tablet 1000 units 1 tab for vitamin deficiency during medication administration at 09:49 AM. However, this medication was not observed as administered at this time . These failures could place residents at risk of not receiving the intended therapeutic benefits of their medications or not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 8 residents (Resident #24) reviewed for medication administration. The facility provided Resident #24 with the medication Carvedilol outside of physician parameters. This failure could place residents at risk for not receiving the therapeutic effects of their prescribed medications. The findings included: Record review of Resident #24's admission Record, dated 04/04/2025, reflected a [AGE] year-old resident with diagnosis including dysphagia (difficulty swallowing), cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain), and human immunodeficiency virus [HIV] disease (a virus that attacks cells that help the body fight infection). Record review of Resident #24's quarterly MDS assessment, dated signed 03/09/2025, reflected Resident #24 was assessed with a BIMS score of 0, indicating the resident was severely cognitively impaired. Record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanity, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #69) of 4 residents reviewed for medication administration. The facility also failed to handle and transport linens so as to prevent the spread of infections for infection control practices in 1 of 3 resident hallways observed for infection control. 1. The facility failed to ensure CNA A removed soiled gloves prior to exiting a room, as well as securing soiled linen in a bagged or contained method at the point of collection prior to transporting. 2. The facility failed to ensure CMA B sanitized a reusable blood pressure cuff between residents while obtaining vital signs needed for medication administration. These failures could lead to the spread of infection. The findings included: 1. While performing initial tour of the facility on 4/01/2025, CNA A was observed at 09:53 AM exiting a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure residents maintained the right to receive visitors of his or her choosing at the time of his or her choosing for 1 of 1 facility reviewed for resident rights. The facility failed to ensure all residents had the right to receive visitors between 8:00 PM and 8:00 AM. This failure placed residents at risk of isolation, decreased emotional well-being, and diminished quality of life. The findings included: During a confidential interview on 2/22/2024 at 2:30 PM, residents stated that staff members came into their rooms at 8:00 PM and informed the resident and their visitors that it was time for visitors to leave. The residents also stated that if a family member came to the facility after 8:00 PM and called or tried to ring the doorbell the family members were ignored by staff. Interview on 2/23/2024 at 12:10 PM, the Administrator stated there was a policy for visiting hours, and that visiting hours were generally from 8:00 AM until 8:00 PM, but they usually let residents have visitors later if it did not disrupt other…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 8 residents (Residents #17) reviewed for care plans. The facility failed to care plan Resident #17's use of Clopidogrel 75 mg (blood thinner). This failures could have placed residents at risk of not having their needs met. Record review of Resident #17's face sheet dated 2/21/2024 revealed a [AGE] year-old female admitted to the facility on [DATE] with the diagnosis that included: Alzheimer's disease (is a brain disorder that slowly destroys memory and thinking skills). Hepatitis C( is an inflammation of the liver caused by the hepatitis C virus.) Right hemiplegia( indicates paralysis on the right side of the body). Record review of Resident's # 17's Quarterly MDS Assessment , dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure residents are free of any significant medication errors for 1 of 3 residents (Resident #63) reviewed for medication administration, in that: The facility failed to prevent Resident #63 from being provided Midodrine, a medication designed to raise a person's blood pressure, while Resident #63 was assessed with blood pressure higher than the physician recommended parameters for providing the medication. This failure could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings included: Record review of Resident #63's face sheet dated 2/23/2024 reflected a [AGE] year-old resident with an initial admission date of 1/01/2024 and diagnoses including major depressive disorder, and seizures. Record review of Resident #63's most recent MDS assessment, dated 1/08/2024, reflected a resident with a BIMS summary score of 15 , indicative of intact cognition. Record review of Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide or obtain laboratory services, to meet the needs of its residents for 2 of 12 residents (Resident #32 and #60) reviewed for laboratory services, in that: 1.) The facility failed to obtain the ordered labs for Resident #32 on 11/23/2023 in a timely manner. 2.) The facility failed to obtain the ordered lab for Resident #60 on 11/22/2023 in a timely manner. This failure could place residents at risk of not receiving timely diagnosis and treatment, and not receiving appropriate monitoring for health and well-being. Findings included: 1.) Record review of the admission Record printed 2/23/2024, revealed Resident #32 was an [AGE] year-old female originally admitted on [DATE] with an admitting diagnosis of chronic kidney disease, stage 4. Record review of the quarterly MDS assessment dated [DATE], revealed Resident #32 had a BIMS summary score of 6, indicative of severe cognitive impairment. Resident #32 was coded as moderate assistance [helper does…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide or obtain laboratory services ordered by physician assistant, nurse practitioner or clinical nurse specialist in accordance with state law, including scope of practice laws, to meet the needs of its residents for 1 of 12 residents (Resident #32) reviewed for laboratory services, in that: The facility failed to report laboratory results received on 12/08/2023 for Resident #32 in a timely manner to the physician. This failure could place residents at risk of not receiving timely diagnosis and treatment, and not receiving appropriate monitoring for health and well-being. Findings included: 1.) Record review of the admission Record printed 2/23/2024, revealed Resident #32 was an [AGE] year-old female originally admitted on [DATE] with an admitting diagnosis of chronic kidney disease, stage 4. Record review of the quarterly MDS assessment dated [DATE], revealed Resident #32 had a BIMS summary score of 6, indicative of severe cognitive impairment.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 4 residents (Resident #17) reviewed for accuracy of medical records in that: The facility failed to ensure Resident # 17's medication, Clopidogrel 75 mg, was correctly listed on Face sheet , for use for hypertension instead of a blood thinner. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment. The findings included: Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 4 residents (Resident #17) reviewed for accuracy of medical records in that: Resident # 17's medication, Clopidogrel 75 mg, was incorrectly listed for use for hypertension instead of a blood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.