Inglis House

In the surveyor’s words

From the most serious findings on record at Inglis House, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 1, 2025

  Based on observations, review of clinical record, facility policies, facility documentation, and interviews with staff, it was determined the facility failed to adequately supervise one of five residents reviewed (Resident R1). This failure resulted in Resident R1 wandering in the hallways of the facility on an electric wheelchair, and accessing the fire stairway entrance door, falling down a flight of stairs while strapped to the wheelchair. Resident R1 was missing for a period of approximately four hours after the fall. Resident R1 required transfer to the hospital and diagnosed with rib fractures, a fracture of the right clavicle, a subdural hematoma and closed dislocation of left finger and five stiches to the right top of the head. […]

• Immediate jeopardy, isolatedF689Nov 1, 2021

  Based on the review of facility policies, clinical records, observations, review of facility documentation, review of surveillance video footages, and resident and staff interviews, it was determined the facility failed to supervise one Resident R1 who punched Resident R4 on the head and ran his wheelchair over Resident R4's foot. This failure resulted in actual harm to Resident R4 who sustained a fractured right foot. Further, the facility failed to provide appropriate staff supervision to Resident R1 who allegedly sexually assaulted two female residents and with a history of physically aggressive behavior. […]

• Actual harm, isolatedF689Apr 3, 2025

  Based on the review of facility documentation, clinical records, hospital records, and interviews with resident and staff, it was determined the facility failed to provide appropriate staff supervision for Resident R1. This failure resulted in actual harm to Resident R1 who was found with a vertical laceration beginning at the midline of the forehead extending towards the scalp for one of 7 residents reviewed. (Resident R1) Findings include: Review of the facility policy titled Resident Safety revised on September 22, 2016, revealed nurse aides will make safety/hygiene rounds on all resident to ensure that the environment is safe and that resident hygiene needs are met. It is recommended that rounds be made every 2-3 hours. […]

• Actual harm, isolatedF689Mar 20, 2025

  Based on a review of facility policy, clinical records, staff training records, information submitted by the facility, and staff and resident interviews, it was determined the facility failed to ensure the resident environment remained free of accident hazards resulting in actual harm to Resident R127 who sustained a second degree burn on the left knee when an employee's personal hot beverage spilled on the resident for one of 35 residents reviewed (Resident R127). This deficiency is cited as past non-compliance. Findings include: Review of facility policy Hours of Work revised October 24, 2020, revealed employees are not permitted to leave the facility's campus during break periods. Breaks must be taken in the cafeteria; employees lounge, or in similarly designated non-work areas. […]

• Actual harm, isolatedF689Feb 22, 2022

  Based on review of clinical record, review of facility documentation and interviews with residents and staff, it was determined that the facility failed to test the temperature of a hot water beverage provided to one of five residents reviewed (Resident R1). This failure resulted in actual harm to Resident R1 who spilled the hot water beverage on her chin and chest resulting in second degree thermal [CONDITION(S)]. This deficiency was identified as past non-compliance. Findings include: Review of Resident R1's significant change MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated November 26, 2021, revealed that the resident was admitted to the facility January 15, 2015 with the diagnoses of [CONDITION(S)] (paralysis of all four limbs), [CONDITION(S)] (damage to… […]