Inspire Behavioral Health
Inspection Findings
F-Tag F0684
F 0684 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Resident 124's care plan included the intervention made by the IDT Staff will encourage the resident to wait
in her room for her meal tray. The DON also confirmed that there was no documented evidence that this intervention was implemented from the time it was included in the care plan on 2/17/25 until the time of Resident 124's second fall on 3/7/25.Review of facility P&P titled Falls and Fall Risk, Managing, revised December 2007, indicated .The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls.If falling occurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. Review of facility P&P further indicated .The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling.3.Review of Resident 124's clinical record indicated Resident 124 was transferred out of the facility to a GACH on 3/8/25, because of the fall that occurred on 3/7/25. Review of Resident 124's clinical record document titled SBAR Post Fall, dated 3/7/25, indicated in section R. Response to Xray of left hip and left leg, Neurocheck [a quick examination to evaluate brain function after a potential brain injury] per facility protocol, Orthostatic BP x72 hours. Further review of Resident 124's clinical record indicated there were no orthostatic blood pressure measurements recorded for five eight-hour shifts between 3/7/25 at 8:30 AM and 3/8/25 at 7:46 PM (the day the resident was transferred to a GACH). Further review also indicated in the SBAR Post Fall, completed on 2/17/25, Question 7 SYSTOLIC BLOOD PRESSURE was marked for the response No noted drop between lying and standing.During a concurrent interview and record review with the DON on 11/5/25 at 10:54 AM, the DON confirmed that there were no recorded orthostatic vital signs for Resident 124 between 3/7/25 and 3/8/25, and that the response for Question 7 on the SBAR Post Fall completed on 3/7/25 was not accurate.
The DON also said The nurses will sometimes check the orthostatic vitals on the spot but will not record them unless there was a concern.Review of facility P&P titled Blood Pressure, Measuring, revised September 2010, indicated .Documentation. The following information should be recorded in the resident's medical record.The date and time the blood pressure was measured.The name and title of the individual(s) who measured the blood pressure.The blood pressure reading.If the resident refused the treatment, the reason(s) why and the intervention taken.The signature and title of the person recording the data.
Event ID:
Facility ID:
05A277
If continuation sheet
INSPIRE BEHAVIORAL HEALTH in SAN JOSE, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SAN JOSE, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from INSPIRE BEHAVIORAL HEALTH or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.