Inspire Behavioral Health

In the surveyor’s words

From the most serious findings on record at Inspire Behavioral Health, in the surveyor’s own words.

• Immediate jeopardy, patternF689Nov 5, 2025

  Based 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… […]

• Actual harm, isolatedF684Nov 5, 2025

  Based 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: Lying down, sitting up, and standing up) as indicated in the SBAR (Situation, Background, Appearance,… […]

• Actual harm, isolatedF689Mar 21, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF755Nov 5, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Nov 5, 2025

  Based 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. […]