Inspire Rehabilitation and Health Center LLC

In the surveyor’s words

From the most serious findings on record at Inspire Rehabilitation and Health Center LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 9, 2023

  Based on observation, record review, review of video footage, staff interviews, and resident interviews, for one (1) of six (6) sampled residents, the facility staff failed to adequately supervise Resident #1 while the resident sat in the secured courtyard on the evening of 07/27/23. Subsequently, a pizza delivery person who was leaving the facility held open the secured gate to allow Resident #1 to pass through. These failures resulted in an immediate jeopardy situation. The immediate jeopardy was identified on August 4, 2023, at 3:04 PM. The facility provided a plan of action to address the immediacy on August 4, 2023, at 10:02 PM and it was accepted. After the plan was verified the IJ was removed on August 7, 2023, at 2:21 PM while the survey team was onsite. […]

• Actual harm, isolatedF686Aug 5, 2022

  Based 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). The findings included: Resident #146 was admitted to the facility on [DATE] with multiple diagnoses that included: Fluid Overload, Chronic Kidney Disease and Dysphagia. Review of Resident #146's medical record revealed: 04/20/22 at 8:35 PM [Admission/Readmission Screener] . Bilateral dry lower extremities (Skin Not open) . 4/20/2022 at 9:42 PM [Admission Note] .admitted from [Hospital Name] . Head-to-toe assessment was conducted . […]

• No harm, potential for more than minimal, widespreadF882Aug 5, 2022

  Based 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. The findings included: During a face-to-face interview conducted on 08/04/22 at 12:47 PM, Employee #3 (Assistant Director of Nursing/ADON), the facility's designated Infection Preventionist (IP), revealed that she had not completed the specialized training in infection prevention and control. Employee #3 stated, I am working on completing the infection prevention and control course.

• No harm, potential for more than minimal, patternF578Aug 5, 2022

  Based 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. The findings included: Review of the policy Advance Directive revised in February 2022 documented, .Upon admission, Social Services staff will meet with the resident to inquire if there is an existing Advance Directive (AD) . and the right to formulate and to issue Advance Directives . provide written information to the resident . […]

• No harm, potential for more than minimal, patternF607Aug 5, 2022

  Based 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. The findings included: Review of the facility's policy entitled Investigating Incidents Processrevised in March 2022, stated: .Interview and/or obtain a statement from the person reporting allegation or suspicion .Interview and/or obtain statements from potential witnesses as determined by the scope of the investigation . […]