Inspire Rehabilitation and Health Center LLC

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observations and staff interviews, for 49 of 49 sampled residents/and or their representatives, the facility staff failed to: 1) post the results of its most recent survey in a place readily accessible to residents, family members, and resident representatives and 2) have reports from the three preceding years, including certification surveys, complaint investigations, and any plan of correction in effect with respect to the facility available upon request for any individual to review.

Inspectors wroteBased on observations and staff interviews, facility staff failed to maintain a safe environment for the residents.

Inspectors wroteBased on observations, record reviews and staff interviews, the facility staff failed to develop effective discharge planning for one (1) of 49 sampled residents whose record showed discharge upon hospitalization. (Resident #188) Resident#188 was admitted on [DATE] 22:28 with diagnosis of fluid overload, hypertension, Skin ulcer of right heel and with Necrosis of muscles, Dementia, Heart failure with reduced ejection fraction, and iron deficiency Anemia. A review of her medical record on 3/6/2026 showed the following progress notes: Date: 01/23/2026 07:24 Type: Nurses Notes: Resident received in bed awake with hypotensive, high fever, altered mental status, lethargy but alert, no SOB or distress noted, V/S- 90/58, HR-102, RR-18, Temp- 101.5, SPO2-97%RA. MD made aware new order given, Transfer to nearest ER [emergency room] for further evaluation. [...]

Inspectors wroteBased on record review and staff interviews for one (1) of 49 sampled residents, the facility staff failed to initiate discharge planning for one resident expressed a desire to return to the community. Resident #30.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on record review and staff interview for one (1) of 49 sampled residents, the facility staff failed to accurately code a Resident as receiving opioids on a quarterly MDS assessment.

Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to ensure a PASARR Level II evaluation was completed for one (1), who had a diagnosis of Bipolar Disorder, of 49 sampled residents. (Resident #50)Findings Include:Resident #50 was admitted to the facility on [DATE] with diagnoses including Bipolar Disorder, Neurosyphilis, Hypothyroidism, Displaced Intertrochanteric Fracture of the Right Femur, Muscle Weakness, Cognitive Communication Deficit, Anemia, Essential Hypertension, Osteoarthritis, and Tobacco Use. A review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] indicated: BIMS score: 15, indicating the resident was cognitively intact and able to participate in care planning. The resident was assessed for mood symptoms, include: [...]

Inspectors wroteBased on record review, observation, and staff interviews, the facility failed to develop and/or implement a comprehensive care plan interventions to address one resident's documented allergies and the application of dentures for another resident in two (2) of 49 sampled residents. (Resident #49 and #199).

Inspectors wroteBased on observation, record review, and staff and resident interviews, the facility staff failed to implement and document individualized one-to-one (1:1) activity sessions for a bed-bound resident in accordance with the resident's care plan and assessed needs for one (1) of 49 sampled residents. (Resident #34).

Inspectors wroteBased on observations, record review and staff interviews for two (2) of 49 sampled residents, it was determined that the facility staff failed to follow physician orders for splint placement for one resident with a contracture and failed to consistently assist one resident with the application of dentures. (Residents #5 and #199)

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure that irregularities identified during the consultant pharmacist's Medication Regimen Review (MRR) were reported, acted upon, and/or implemented in a timely manner for four (4) of 49 sampled residents. (Residents #4, #5, #19 and #7) Resident #4 was admitted to the facility on [DATE] with diagnoses of Chronic Kidney Disease, Hypertension, Diabetes Mellitus, Hyperlipidemia, Osteoarthritis, Dementia with psychotic disturbance, Paranoia Schizophrenia, Depression, and Anxiety. A review of the Physician Medication orders showed Resident #4 is currently taking the following medication. [...]

Inspectors wroteBased on observations and staff interviews, facility staff failed to employ staff with the appropriate competencies.

Inspectors wroteBased on observations and staff interviews, facility staff failed to prepare and distribute food under sanitary conditions, and store food at the appropriate temperatures as evidenced by the following observations.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on record reviews and interviews, for three (4) of 49 sampled residents, the facility staff failed to ensure that residents and or their representatives understood the binding arbitration agreements made between the residents and /or their representatives and the facility. Residents #125, ##27, #33, and #127.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on record reviews and interviews, for three (4) of 49 sampled residents, the facility staff failed to ensure that binding arbitration agreements made between the facility and the resident and or their representative provided for the selection of a neutral arbitrator agreed upon by both parties; and provided for the selection of a venue that is convenient to both parties. Residents # 125, #27, #33, and #127.

Inspectors wroteBased on observations, record review and staff interviews for eight (8) of 49 sampled residents, it was determined that the facility staff failed to: (a.) implement appropriate infection control measures to manage the transmission of a Norovirus outbreak when five (5) residents-four (4) residents on one floor and one (1) resident on another floor-became ill within a five-day period with nausea and vomiting. Subsequently, during this period, one (1) of the five (5) residents became ill after he was allowed to cohort in the same room with his roommate who had exhibited symptoms of the Norovirus (b.) perform hand hygiene when providing services to three (3) residents during meal time; and (c.) conduct an annual review of two (2) infection control policies. Residents' #144, #194, #162, #130, #99, #180, #33, #12.

Inspectors wroteBased on observations and staff interviews, facility staff failed to maintain equipment in safe operating condition.

Inspectors wroteBased on observations, record reviews and staff interviews, facility staff failed to maintain an effective pest control program so that the facility is free of pests.

Inspectors wroteBased on observation, record review and staff interview, for one (1) of 12 sampled residents, facility staff failed to develop a comprehensive care plan with goals and interventions to address one resident's use of a Foley Catheter. Resident #9.

Inspectors wroteBased on record review and staff interviews for one (1) of 12 sampled residents, facility staff failed to ensure that one resident was free of a significant medication error as evidenced by ordering. transcribing and dispensing a medication that included an incorrect route for the Resident's medication.

Inspectors wroteBased on observations, record reviews and staff interviews, for two (2) of 12 sampled residents, facility staff failed to follow infection control policies and procedures for residents on Enhanced Barrier Precautions (EBP).

Inspectors wroteBased on record reviews and staff interviews, for one (1) of five (5) sampled residents, the facility's staff failed to inform a resident's physician about a difficulty with getting a medication for resident. (Resident #1)

Inspectors wroteBased on observation, record review and staff interviews, for one (1) of five (5) sampled residents, the facility failed to ensure a resident was free from Neglect. As evidenced by staff not administering Rifaximin and Lactulose as prescribed. (Resident #1)

Inspectors wroteBased on observation, record review, and staff interviews, for two (2) of five (5) sampled residents, the facility's staff failed to ensure: Resident #1 was administered medications (Rifaximin and Lactulose) as prescribed; and Resident #2's care plan was followed to provide proper body alignment at all times. Consequently, on 11/30/23, the resident nearly fell off his wheelchair. (Residents #1 and #2)

Inspectors wroteBased on record review and staff interview, the facility's staff failed to ensure a resident's Medication Administration Records contained accurate information for one (1) of five sampled residents. (Resident #1)

Inspectors wroteBased on observations, record review and staff interviews, for two (2) of 47 sampled residents, facility staff failed to provide a clean, homelike environment. Residents' #132 and #113.

Inspectors wroteBased on record review and staff interview the facility's staff failed to follow it's Abuse Policy by not thoroughly investigating: an allegation of staff-to-resident sexual abuse (inappropriate touch), an allegation of staff-to-resident verbal abuse,a fall incident, an allegation of a verbal altercation between residents and an unusual occurance for five (5) of 47 sampled residents. (Residents #228, #229, #230, #331, and #332). A review of a policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigation with a revision dated of 06/23 instructed, All allegations are thoroughly investigated. 1. The facility's staff failed to thoroughly investigate Resident #228 allegation of staff-to-resident sexual abuse (inappropriate touch). [...]

Inspectors wroteBased on record review and staff interviews for two (2) of 47 sampled residents, the facility staff failed to report allegations of abuse and an unusual incident to the State Agency. Resident #331 and #332.

Inspectors wroteBased on record review and staff interviews, for three (3) of of 47 sampled residents, facility staff failed to have documented evidence that they took corrective actions to protect and prevent further potential abuse of Resident #103 by Employee #13 (Smoke Aide), the alleged perpetrator, after an allegation of physical abuse; failed to show documented evidence that investigations were conducted into Resident #331's report to a social worker of a verbal altercation with another resident; and Resident #332's abuse allegation and unusual incident. Residents #103, #331 and #332.

Inspectors wroteBased on record reviews and staff interviews, for two (2) of 47 sampled residents, facility staff failed to provide the residents or their representative with bed-hold notice upon transfer to the hospital. Residents' #87 and #278.

Inspectors wroteBased on record reviews and staff interviews for two (2) of 47 sampled residents facility staff failed to accurately code Resident #379's Quarterly Minimum Data Set (MDS) assessments to accurately reflect the resident's history of falls and failed to accurately code Resident #174's admission MDS to reflect the resident's surgical wound.

Inspectors wroteBased on observations, record review and staff interviews for one (1) of 47 sampled residents facility staff failed to implement a Resident's care plan for the use of carrot palm guards to bilateral hands to prevent skin integrity impairment and further immobility/contractures.

Inspectors wroteBased on observations, record review, and staff interviews for one (1) of 47 sampled residents facility staff failed to ensure that a resident with a limited range of motion received the appropriate treatment and services to increase the resident's range of motion or prevent further decrease in range of motion.

Inspectors wroteBased on record review and staff interviews for one (1) of 47 sampled residents, the facility staff failed to adequately supervise Resident #331, while toileting as required by the residents Minimum Data Set (MDS) assessment which staff coded as requiring supervision and a one person staff assist with toileting. (Resident #331.) The Findings Included: A review of the facility's policy titled Fall and Fall Management documents .If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant .Staff will monitor if interventions have been successful in preventing falling .If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions . [...]

Inspectors wroteBased on observation, record review and staff interview, facility staff failed to ensure that the established procedures for the accurate reconciliation of narcotics were followed.

Inspectors wroteBased on record review and staff interviews for one (1) of 47 sampled residents, the facility staff failed to show documented evidence in the medical record that the physician reviewed the pharmacy regimen review for Resident #137.

Inspectors wroteBased on two (2) of ten (10) observations and facility interviews, facility staff failed to store and label biologicals in accordance with currently accepted professional practices.

Inspectors wroteBased on two (2) observations of the dishwashing cycle and staff interview, facility staff failed to ensure that the dishwasher reached the required temperature (150 degrees to 165 degrees Fahrenheit) to clean dishes and utensils under sanitary conditions.

Inspectors wroteBased on record review and staff interview, for three (3) of 47 sampled residents, facility staff failed to ensure resident's records contained accurate information. Residents' #229, #132 and #128.

Inspectors wroteBased on record review and staff interviews, the facility staff failed to ensure that one (1) of 47 sampled residents had a current written hospice care plan that included both the most recent hospice plan of care and a description of the care and services furnished by the long term care facility.

Inspectors wroteBased on record review and staff interview, for one (1) of 50 sampled residents (#146), facility staff failed to provide a resident with services consistent with the professional standards of practice to prevent pressure ulcer/injury development. Subsequently, when the resident's pressure ulcer was first observed, it was at an advanced stage (Unstageable).

Inspectors wroteBased on record review and staff interview, facility staff failed to have a qualified Infection Preventionist (IP) who completed specialized training in infection prevention and control.

Inspectors wroteBased on record review and staff interview, for one (1) of 50 sampled residents, facility staff failed to provide the resident or their representative(s) with information regarding formulating an advanced directive. Resident #97.

Inspectors wroteBased on observations, record reviews, and staff interviews for seven (7) of 50 sampled residents, facility staff failed to implement policies for investigating allegations of abuse and injuries of unknown origin, as evidenced by the failure to: obtain interviews or written statements from potential witnesses; and to adhere to the reporting time to the State Agency. Residents #87, #212, #313, #314, #133, #363, and #51.

Inspectors wrote4. Facility staff failed to conduct a thorough investigation of Resident #313's injury of unknown source/origin that occured on 04/06/22. Resident #313 was admitted to the facility on [DATE] with multiple diagnoses that included: Lack of Coordination, Unspecified Abnormalities of Gait and Balance and Altered Mental Status. Review of a Complaint, DC00010664, received by the State Agency on 04/07/22 documented, .Tonight was the absolute final straw for our family, as we learned that my mother has a fractured leg that seemingly occurred without anyone's knowledge or a report by employees . Review of a Facility Reported Incident (FRI), DC00010667, received by the State Agency on 04/08/22 documented, .Upon assessment, no bruises, no swelling nor any sign of trauma noted. Resident medicated as per PRN (as needed) order. Resident re-assessed later and no complains nor signs of pain noted. [...]

Inspectors wroteBased on record review and staff interview, for five (5) of 50 sampled residents, facility staff failed to provide written information related to the facility's bed hold policy for the resident and/or resident's representative. Residents' #71 #47, #415, #313, and #314.

Inspectors wroteBased on record review and staff interview, for eight (8) of 50 sampled residents, the facility's staff failed to: implement Resident #71's fall care plan; develop a care plan to address Resident #19's hypoglycemia; develop a care plan to address Resident #15's diagnosis of cataracts and refusal to wear glasses; develop a care plan to address Resident #87's dental care; implement Resident #90's elopement care plan; implement Resident #414's wound care plan; implement Resident #84's use of a bed alarm, and develop a care plan to address Resident #314's use of an arm sling. Residents' #71, #19, #15, #87, #90, #414, #84, and #314.

Inspectors wroteBased on observation, record review and staff interviews, for two (2) of 50 sampled residents, the facility staff failed to follow standards of transmission-based precautions to prevent the spread of infection as evidenced by: failure to perform hand hygiene prior to providing direct care for one resident; not following infection control practice after providing wound/dressing care for one resident; not wearing appropriate personal protective equipment (PPE); not reviewing and updating its COVID-19 Testing for residents' staff, visitors and volunteers policy at least annually. Residents' #71 and #110.

Inspectors wroteBased on record review and staff interviews, the facility staff failed to ensure that alleged violations involving abuse and neglect or mistreatment were reported immediately for one (1) of 50 sampled residents. Resident #51.

Inspectors wroteBased on record review and staff interview for one (1) of 50 sampled residents, the facility's staff failed to convey all of the required documents to the receiving health care provider when the resident transferred from the facility. Resident #110.

Inspectors wroteBased on record reviews, and interviews, for two (2) of 50 sampled residents, facility staff failed to notify the resident or their representative(s) of the resident's transfer to the hospital in writing, and failed to send a copy of the notice of transfer to the Office of the State Long-Term Care Ombudsman. Residents #47 and #415.

Inspectors wroteBased on observation, record review, and staff interview, for one (1) of 50 sampled residents, facility staff failed to ensure that Resident #147 had a physician's order to receive continuous supplemental oxygen.

Inspectors wroteBased on record review and staff interview, for one (1) of 50 sampled residents, facility staff failed to develop a baseline care plan (within 48 hours of admission) to address resident #146's sacral wounds. Resident #146.

Inspectors wroteBased on record review and staff interview, for one (1) of 50 sampled residents, facility staff failed to ensure that a resident's care plan was reviewed and revised by the interdisciplinary team. Resident #312.

Inspectors wroteBased on observation, record review, and staff interview, for one (1) of 50 sampled residents, facility staff failed to ensure that Resident #86, who is unable to carry out activities of daily living, received the necessary care and services to maintain good personal hygiene.

Inspectors wroteBased on observation, record review, and resident and staff interview, for one (1) of 50 sampled residents, facility staff failed to provide Resident #84 with individual activities designed to meet the interests of and support the resident's choice.

Inspectors wroteBased on observations, record reviews, and staff interviews, for two (2) of 50 sampled residents, facility staff failed to adequately assess and monitor one resident who eloped from the facility; and failed to ensure one resident's room was free from clutter and hazards. Residents' #90 and #71.

Inspectors wroteBased on observation, record review and staff interview, for one (1) of 26 sampled residents, facility staff failed to ensure Resident #1's flow rate of oxygen was set as directed by the physician.

Inspectors wroteBased on record review and staff interview for one (1) of 50 sampled residents, facility staff failed to ensure that one (1) resident received pain medication treatment and care related to pain management in accordance with professional standards of practice. Resident #98.

Inspectors wroteBased on record review and staff interview, for one (1) of 50 sampled residents, facility staff failed to ensure that a resident who required dialysis, received appropriate care consistent with professional standards of practice for removing the dialysis access site dressing after hemodialysis. Resident #75.

Inspectors wroteBased on record review and staff interview for one (1) of 50 sampled residents, the facility's nursing staff failed to provide nursing and related services to meet the residents' needs and promote the resident's well-being. Subsequently, a resident eloped from the facility. Resident #90.

Inspectors wroteBased on record review and staff interview, for one (1) of 50 sampled residents, facility staff failed to develop and implement an individualized person centered care plan for Resident #84 who has a diagnoses of Non-Alzheimer's Dementia.

Inspectors wroteBased on record review and staff interviews for two (2) of five (5) nursing units, the facility staff failed to ensure that the system used for an acceptable standards of practice to account for the receipt, usage, disposition, and reconciliation of controlled medications was followed.

Inspectors wroteBased on record review and staff interview, for one (1) of 50 sampled residents, pharmacist failed to write a report of the recommendations for Resident #100's monthly drug regimen review.

Inspectors wroteBased on observation and staff interview for one (1) of 50 sampled residents, facility staff failed to properly store expired medications for one resident that was discharged from the facility.

Inspectors wroteBased on observation, record review and staff interview for one (1) of 50 sampled residents, facility staff failed to assist a resident in obtaining routine dental care.

Inspectors wroteBased on observation and resident and staff interviews, facility staff failed to ensure a resident's food was palatable. Resident #67.

Inspectors wroteBased on observations and staff interview, facility staff failed to serve foods under sanitary conditions as evidenced by hot foods temperatures that were below 135 degrees Fahrenheit (F) on one (1) of six (6) observations.

Inspectors wroteBased on record review and staff interview, for one (1) of 50 sampled residents facility staff failed to maintain medical records in accordance with accepted professional standards as evidenced by not accurately documenting the date of birth . Resident #71.

Inspectors wroteBased on observations and staff interview, facility staff failed to maintain essential equipment in safe condition as evidenced two (2) of four (4) gas burners that failed to light up when tested, one (1) of two (2) broken grease fryer, one (1) of two (2) ford warmers with a missing temperature indicator, and damaged strip curtains at the loading dock entrance/exit door.

Inspectors wroteBased on observation, record review and staff interview, for one (1) of 50 sampled residents, facility staff failed to provide a safe and functional environment for Resident #71, as evidenced by there being no doorknob on the interior side of resident's room door.

Inspectors wroteBased on observations and staff interview, it was determined that facility staff failed to maintain resident areas in good condition as evidenced by one (1) of two (2) leaky shower valves, one (1) of two (2) shower valves with a broken shower head holder, two (2) of five (5) harpers that failed to flush when tested, and marred walls in five (5) of five (5) social rooms.

Inspectors wroteBased on record review and staff interview for one (1) of 50 sampled residents facility staff failed to code Minimum Data Set (MDS) in accordance with the specified time frame as evidence by MDS record shown as over 120 days old. Resident #1.

Inspectors wroteBased on record review, resident and staff interview for two (2) of 50 sampled residents facility staff failed to update/revise care plan with resident-centered goals for one (1) resident with hearing loss; and for one (1) resident with Cholecystitis.

Inspectors wroteBased on observations and interview, the facility failed to provide an environment that is free from accident hazards as evidenced by surge protectors that were not mounted in two (2) of 43 resident's rooms.

Inspectors wroteBased on observation, record review and staff interview for one (1) of 50 sampled residents, facility staff failed to ensure the dialysis communication form used to reflect ongoing collaboration between the facility and dialysis staff was included in the medical record for Resident #91.

Inspectors wroteBased on record review and staff interview for one (1) of 50 sampled residents facility staff failed to maintain a complete and accurate medical record for Resident #88.

Inspectors wroteBased on observations and staff interview, the facility failed to maintain the call bell system in good working condition as evidenced by call bells in three (3) of 43 resident's rooms that failed to alarm when tested.

Inspectors wroteBased on observations and interview, the facility failed to maintain handrails in good condition as evidenced by several hand rails and rails with no end caps in resident occupied areas and in common areas.