Inspiration Hills Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Inspiration Hills Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Apr 4, 2025

  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. […]

• No harm, potential for more than minimal, widespreadF563Feb 23, 2024

  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. […]

• No harm, potential for more than minimal, patternF689Jun 4, 2026

  Based on observations, interviews and record reviews, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident #41) reviewed for accident hazards and supervision.The facility failed to ensure Resident #41's floor mat was in place.This failure could place residents at risk for falls with the possibility of injury.Findings included:Record review of resident #41's face sheet, dated 06/02/2026 reflected a [AGE] year-old female admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, patternF755Jun 4, 2026

  Number of residents sampled: Number of residents cited: Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administration of all drugs and biologicals) for 1 of 1 resident (Resident #32) to meet the needs of the resident, in that: The facility failed to discontinue Resident #32's order for Zyprexa 10mg when order was changed to 5mg daily resulting in resident #32 receiving the wrong dose x11 days.This failure could place residents at risk of injury by not receiving medications as ordered by the physician. […]

• No harm, potential for more than minimal, patternF759Jun 4, 2026

  Based on observation, interview, and record review, the facility failed to ensure that its medication error rates are not 5 percent (%) or greater. The facility had a medication error rate of 32% based on 8 out of 25 opportunities which involved two (2) of five (5) residents (Resident #2 and Resident #3), and one (1) of three (3) staff (MA A) observed for medication administration errors. 1. MA A administered medications to Resident #2 on 06/02/2026 at 10:30 a.m., 30 minutes after the scheduled administration window of 08:00 a.m. to 10:00 a.m. 2. MA A administered medications to Resident #3 on 06/02/2026 at 10:40 a.m., 40 minutes after the scheduled administration window of 08:00 a.m. to 10:00 a.m. […]