The November attack was just the latest incident involving Resident #1 at Inspiration Hills Rehabilitation Center, where administrators admitted they had failed to update the woman's care plan for two weeks after she hit herself in the face during nail trimming.
Treatment Nurse B told inspectors the resident "was sometimes not calm during care and would fight staff." During the documented incident, the resident "scratched, hit and bit this nurse, and was hitting CNA" while two staff members attempted to change her dressing.
The facility's own policy requires comprehensive care plans that incorporate "identified problem areas" and "risk factors associated with identified problems." Staff must revise plans "as information about the residents and the residents' conditions change."
But administrators acknowledged they only added a focus area for "resident resistance to care and behaviors" on November 26 — the day of the inspection — despite knowing about the resident's combative episodes for weeks.
The social worker and MDS coordinator told inspectors during a joint interview that they "should have" updated the care plan earlier. The social worker explained she "was busy working between two buildings and just had not had a chance to add the focus area."
Resident #1's representative described her as "a difficult patient because she will scratch and lash out at staff." The representative explained the woman "experienced trauma in the past, had anxiety, and would pick at herself or lash out."
During the inspection, observers watched the resident lying in bed "scratching her arm, constantly rubbing her arms together, and picking under her nails." Her representative said she "does a lot of self-inflicting scratches due to her long nails and behaviors."
The November 12 incident involved the resident becoming combative and hitting herself in the face while staff trimmed her nails. Yet no care plan updates followed.
Staff had developed some informal strategies. When the resident refused care like showers, aides would "call the nurse to come talk to the resident" and "if she became combative they would stop care and return at a later time to try again."
The resident's representative said they would "redirect Resident #1 and ask her to rub her hands to warm them up instead" of picking at herself.
The director of nursing confirmed the resident "was known to be combative with staff during care." Psychiatry had visited and prescribed anti-anxiety medication for about a week, but the care plan remained unchanged.
"The care plan should have been updated after the incident on 11/12/25," the director told inspectors. She emphasized "it was important to update the care plan so the interdisciplinary team would all be on the same page of how to care for the resident."
The facility's December 2020 policy on comprehensive care plans states they must include "measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs." The policy requires ongoing assessments and plan revisions as conditions change.
But for two weeks after the nail-trimming incident where the resident injured herself, no formal updates occurred. Staff continued approaching her care without written guidance on managing her combative behaviors or trauma-related anxiety.
The treatment nurse's bruised forearm served as physical evidence of what happens when care plans lag behind resident needs. During wound care, she and a certified nursing assistant faced scratching, hitting, and biting from a resident whose behavioral interventions existed only in staff memory, not in official documentation.
Administrators finally updated the care plan on November 26 — not because they recognized the gap, but because federal inspectors were asking questions about it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Inspiration Hills Rehabilitation Center from 2025-11-26 including all violations, facility responses, and corrective action plans.
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