Inspire Behavioral Health

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the safety for three of 12 residents (Resident 36, Resident 48, & Resident 98) who were at risk for elopement (the unauthorized, unsupervised departure of a patient/resident from a healthcare facility when their condition puts them at risk of injury or death) and eloped from the facility when:1. The facility failed to provide appropriate and sufficient supervision to Resident 48, when Resident 48 who is deemed gravely disabled (legal term to describe a condition where a person, due to a mental health or substance use disorder, is unable to provide for their basic needs like food, clothing, or shelter) eloped from the locked facility on 10/27/25, when Houskeeper A (HA) failed to follow protocol of ensuring the location of her keys at all times. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the needed care and services that are resident centered for one of four residents (Resident 124) when:1. The facility did not accurately assess Resident 124's risk for falls prior to the two fall events Resident 124 had within one month on 2/16/25 and 3/7/25.2. The facility failed to implement an intervention that was included in Resident 124's care plan after her previous fall incident on 2/16/25.3. The facility did not follow their policy and procedure (P&P) when they failed to complete Resident 124's orthostatic blood pressure measurements (blood pressure measurements that are taken in three different positions: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the provision for safe and effective medication administration when:1. The facility allowed the preparation of medications 1 to 2 hours ahead of administration (or pre-pouring) for all residents at the same time without establishing safeguards and policy and procedures for staff to consistently carry out and to avoid mix-ups or medication errors during the preparation and administration. Consequently, four out of six nursing staff observed during medication administration did not label the medication cup for each resident during the preparation; and did not verify the pre-poured medications against the Medication Administration Record (MAR) for correctness, as a final check, at the time of administration. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards, and facility policy for food service safety in the kitchen and dining room, potentially affecting all the 116 residents when:1. The facility failed to label opened eggs in the walk in fridge with open and use by date. Failed to label 9 trays of prepared desserts with the date, or type of dessert in the walk in fridge.2. The facility failed to ensure kitchen staff performed hand hygiene after touching trash on the floor and after operating dirty equipment prior to returning to food preparation.3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its medication error rate was below 5%. The facility had the medication error rate of 13.11% when 8 medication errors occurred out of 61 opportunities observed during the medication administration observation for 4 out of 12 sampled residents (Residents 39, 65, 75, and 87). Residents 75 and 87 received their medications 4 hours before scheduled time, which had the potential for adverse effects such as medications being given too close together from the previous dose or medications not given as intended (such as before bedtime to help sleep). Resident 39 received the incorrect priming (a required safety check to ensure the pen and needle work properly) of the insulin pen (a pre-filled pen containing insulin - medication to lower blood sugar). [...]

Inspectors wroteBased on observation and interview, the facility failed equip the corridors with firmly secured handrails when the handrail in the hallway across from a resident room (Hallway B). This failure had the potential to adversely affect the health and safety of the residents in the area that use the handrail. During an observation on 10/27/25 at 12:19 PM, the handrail in Hallway B was observed to be loose. An indent in the dry wall was seen where the handrail is supposed to be attached to the wall. During a second observation on 10/29/25 at 12:19 PM, the handrail in Hallway B was observed still to be loose. During an interview with the maintenance person (MAIN) on 10/29/25 at 1:13 PM, the MAIN confirmed the handrail in Hallway B was not supposed to be loose. The MAIN also said he would repair the handrail right away.

Inspectors wroteBased on interview and record review the facility failed to timely notify a representative of the Office of the State Long-Term Care Ombudsman (an entity that serves as an impartial advocate for individuals or groups who have concerns or complaints about a particular organization) regarding discharges for one of one sampled resident (Resident 121). The facility faxed discharge notices on the day of discharge. This failure resulted in missed opportunities for an ombudsman to advocate if residents had concerns about their discharge.

Inspectors wroteBased on observation, interview and record review, the facility failed assess for the need of a transfer pole for two out of two residents (Residents 9 & 81). These failures had the potential to put the residents at risk for entrapment and serious injury. Review of Resident 9's clinical record indicated Resident 9 was admitted to the facility on [DATE] with diagnoses of schizoaffective disorder (a mental disorder that causes individuals to hear and see things that are not there), conversion disorder with seizures or convulsions (a mental disorder that causes medical symptoms in individuals with no explanation), neuroleptic induced Parkinsonism (a disorder of the musculoskeletal system caused by certain medications), and history of falling. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three residents (Resident 52, Resident 83, & Resident 95) received their therapeutic diet (specialized meal plan designed to treat or manage specific medical conditions) as ordered by the Registered Dietician and Physician when Resident 52, Resident 83, & Resident 95 did not receive their fortified item during lunch tray line. This failure had the potential for Resident 52, Resident 83, & Resident 95 to not receive their total calories as ordered in their diet, which could contribute to weight loss overtime. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain equipment and environment in safe operating and sanitary condition when a toilet paper holder was left open in one resident bathroom (Resident Bathroom A). This failure had the potential to adversely affect the health and safety of the residents in Resident Bathroom A.During an observation on 10/27/25 at 8:59 AM, the toilet paper holder in Resident Bathroom A was seen open, with the toilet paper exposed. During a second observation on 10/29/25 at 10:58 AM, the toilet paper holder in Resident Bathroom A was still seen open as during the first observation. During an interview with the maintenance person (MAIN) on 10/29/25 at 1:13 PM, the MAIN confirmed the toilet paper holder in Resident Bathroom A was open and supposed to be closed.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure infection control practices were implemented when the maintenance director (MD) did not wash his hands when entering the kitchen. This failure had the potential to spread infection to residents and staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement effective safety measures in place to prevent elopement (the act of leaving without supervision and authorization) or absence without leave (AWOL, leaving the facility without permission) for one of four sampled residents ( Resident 1) who was at high-risk for elopement due to the fact that: 1. Staff had prior knowledge and awareness of Resident 1's desire and motivation to elope when Resident 1 had expressed a desire to go home prior to the visitation by a friend on 1/15/25, 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately code the elopement risk assessment (an assessment tool to evaluate whether an individual that need additional safety measures is at risk of leaving the facility unsupervised) for one of two residents (Resident 1). This failure had the potential to place the resident's health and safety at risk for not receiving appropriate care.

Inspectors wroteBased on interview and record review, the facility failed to prevent two of three residents (1 and 2) from elopement when the staff and visitors did not look around to make sure Resident 1 and Resident 2 were not close by in the area when they opened the locked exit door to prevent the residents from exiting the locked door immediately when the door was opened. This failure placed the residents at risk for accident and injury.

Inspectors wroteBased on interview and record review, the facility failed to conduct performance review at least once every 12 months for three of three certified nursing assistants (CNA A, CNA B, and CNA C). This failure resulted in unidentified the needed training for the CNAs to improve their skills in resident care every year.

Inspectors wroteBased on interview and record review, the facility failed to provide supervision to prevent one out of three sampled residents (Resident 1) from leaving the facility without staff's knowledge and permission. This failure had a potential risk to compromise Resident 1's health and safety, as she was found walking toward the parking lot outside the facility on 8/11/24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their policies and procedures to report a sexual allegation within the required two hours timeframe to the local law enforcement, the California Department of Public Health (CDPH) and Ombudsman as required for one of three sampled residents (Resident 1); and prevent the recurrence of sexual allegation for of three sampled residents (Resident 2) when: 1. Resident 1 claimed Resident 2 held her breast on 6/18/24. 2. Resident 2 had two sexual assault incidents involving two female residents in a period of one week. The failure to report the sexual allegation within two hours to reporting entities could compromise the welfare, health and safety of Resident 1 and other vulnerable residents; and the failure to prevent recurrence of sexual assaults could potentially put all vulnerable residents at risk.

Inspectors wroteBased on interview, record review, and facility policy, the facility failed to notify the Ombudsman when a resident transferred or discharged from the facility for 3 (Residents #75, #78, and #118) of 3 sampled residents reviewed for hospitalization.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to staff washed their hands before they applied gloves during the preparation of food. This deficient practice had the potential to affect all residents who received food from the kitchen.

Inspectors wroteBased on observation, resident interview, staff interview, and facility policy review, the facility ensure 1 (Station 2 dining room) of 2 dining room provided sufficient space to accommodate all the residents who wished to eat their meals in the dining room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for 1 (Resident #33) of 1 sampled resident reviewed for respiratory care.

Inspectors wroteBased on interview and record review, the facility failed to provide trauma-informed care to 1 (Resident #67) of 1 sampled resident reviewed for behavior-emotional, with a diagnosis of post-traumatic stress disorder.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure staff documented the administration of medications for 1 (Resident #35) of 5 residents observed for medication administration.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to soak soiled linen in a machine or sink as directed by their policy for 1 of 116 residents who resided in the facility.

Inspectors wroteBased on observations, interviews, and facility document review, the facility failed to ensure the registered dietitian comprehensively carried out the functions and evaluated the effectiveness of Food and Nutrition Services as evidenced by: 1. Lapses in the delivery of services associated with: staff competency (cross-reference F802), following the menu (cross-reference F803), accommodating resident food preferences (cross-reference F806), food safety and sanitation (cross-reference F812), providing physician prescribed nutrition supplements (cross reference F692), 2. A lack of a full-time supervisor in the kitchen in August 2021 and September 2021, 3. Resident 85 's Nutritional Assessments were not completed. 4. Resident 3's and Resident 9's Nutritional Assessments were not completed. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety when: 1. An ice machine was not kept in a sanitary condition, 2. The handwashing sink in the kitchen did not have hot water, 3. Multiple food service pans and equipment were stored wet, 4. One staff washed hands in the dishwashing sink on the dirty side of the dish machine, 5. Multiple expired items were stored in the kitchen refrigerators, 6. The meat slicer was stored dirty, and 7. The plates of hot food for the lunch meal were not covered during delivery. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure accurate medication administration in accordance with standards of practice, when registered nurses prepared medications ahead of the scheduled time. This failure had the potential to resultin an increased risk of medication error.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of unnecessary drugs for four residents reviewed, when: 1. There was a duplicate of Resident 32's target behavior symptoms indicated for use of Haldol (antipsychotic), which was prescribed in two different routes of administration. 2. For Resident 266, there was no monitoring for adverse consequences for the use of Risperidone (antipsychotic) and Lorazepam (anti-anxiety). 3. There was no target behavior for Resident 267's use of Invega (antipsychotic). 4. For Resident 46, there was no specific target behavior indicated for use of chlorpromazine hydrochloride (antipsychotic medication) and thiothixene (antipsychotic medication). These posed the risk to negatively impact the residents due to the medication adverse reactions.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility failed to ensure the planned menu was followed for 16 out of 16 residents (Residents: 48, 75, 73, 39, 9, 76, 80, 57, 68, 11, 109, 35, 104, 36, 92, 81) on Regular Mechanical Soft texture diets. This failure had the potential to result in not meeting the nutritional needs thus further compromising the nutritional status of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the food preferences for five (Residents 48, 62, 81, 113, and 10) of 32 residents were followed, when these five residents did not receive their choice of foods they liked, or received food they did not like. This failure infringed on residents' choices and had the potential to adversely affect the psychosocial well-being of the residents. 1. During an observation on 11/01/2021 at 12:46 p.m. in Resident 48's room of her lunch tray, there was beef on her lunch tray which she did not eat. During an interview on 11/01/21 at 12:48 p.m. with certified nursing assistant H (CNA H), CNA H stated Resident 48 does not like beef. She received beef, and was not eating it. Resident 48's meal ticket hd beef as her dislike. During an interview on 11/01/21 at 12:56 p.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain effective infection control practices, when: 1. For six of 12 residents observed during the medication pass administration, the facility staff did not sanitize the surface area in the nursing station with disinfecting wipes, after each resident had received their medication. 2. For Resident 72, the licensed nurse did not replace the two medications that dropped on to the unsanitized counter surface area. Resident 72 took it by his mouth after he picked it up with his bare hand. 3. The meal cart was left open in the hallway while delivering meals, and 4. Two CNA T and CNA U did not perform hand hygiene between each meal tray delivered to residents' rooms. These failures had the potential to place residents at increased risk of healthcare-associated infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to offer to one of 23 sampled residents (Resident 83) a bedside table to use during meals. This failure prevented Resident 83 from eating her meals safely and properly.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean, safe, and sanitary homelike environment for two of 23 sampled residents (Resident 81 and, Resident 113) when the facility shower rooms drainage was not working properly and clogged. This failure had the potential to place the residents in an unsafe and unsanitary environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to keep corrosive cleaning supplies out of the reach of two of ten ambulatory residents (Residents 47 and 72). This failure had the potential to place residents at a safety risk.

Inspectors wroteBased on interview and record review, the facility failed to follow the policy and procedure for incontinence management for two sampled residents (Resident 85 and Resident 17) when the residents bowel and bladder (B&B, to manage urinary incontinence, restore, improve, and maintain the normal bladder function) program was not implemented. This deficient practice had the potential to cause a decline in B&B control.

Inspectors wroteBased on interview and facility document review, the facility failed to provide physician ordered nutrition supplements (products that are used to complement a resident's dietary needs, a high calorie drink in this case) for one resident (Resident 62) with a history of weight loss. This failure had the potential to cause further weight loss and decline in health status.

Inspectors wroteBased on observation, interview and record review, the facility failed to evaluate level of pain numeric scale for one (Resident 5) of three residents reviewed for pain, prior to giving pain medication as needed. This failure had the potential for residents to not receive effective treatment for their pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store all drugs and biologicals appropriately, when: 1. There was an expired emergency kit found in the medication room, which had the potential to result in ineffective drug regimen, when administered to residents. 2. A box of dulcolax (laxative to treat constipation) suppository (inserted into the rectum, vagina, or urethra) was found mixed with oral over-the-counter medications, These failure had the potential to result in an increased risk of medication errors.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure two kitchen staff had appropriate competencies when: 1. One kitchen staff did not follow recipes for the puree diet (a diet for people who have difficulty chewing and/or swallowing), and did not know the correct cool down procedure for cooling hot Time/Temperature Control for Safety Food (TCS foods that require time/temperature control for safety to limit pathogen growth or toxin formation), and 2. One kitchen staff did not properly sanitize dishware. These failures had the potential to place the 113 residents who received food prepared in the kitchen at risk for food borne illness or to not meet their nutritional needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate use of antibiotic (medication for the infection) were properly documented based on the facility policy for one sampled resident and two non-sampled residents (Resident 10, 25 and 87). This failure had the potential for the residents to take unnecessary antibiotics which could lead to resistance to the antibiotics.