Inspiration Hills Rehabilitation Center

not recall all the details.

She stated that she believed all was taken care of during the care plan

Resident #30 was injured by the facility staff.

She stated that during incontinent care Resident #30

She stated that no grievance or self-report was made about the incident and law enforcement unsubstantiated the allegations as it was not a concern

During an interview on 06/04/2026 at 5:03 p.m., the Social Worker revealed that she was present for the care plan meeting on 05/14/2026.

She stated Resident #30's RP was hard to work with.

She stated she wanted medical records.

She stated the RP received another denial letter about her request for Resident #30's medical records.

She stated she directed Resident #30's RP her to Medical Records staff to submit another request or to request information into the denial reason.

The Social Worker stated that Resident #30's RP informed her that she never received the first denial letter.

She stated she did not know the outcome of Resident #30's RP's concerns regarding delayed medical records request.

She stated this concern was not a grievance and Resident #30's RP never said it was a complaint and because she helped the RP fill out the records request form that this was considered a quick resolution, and no further action was required.

She stated she understood that the facility's legal team was involved with the request, but they have been away from the office for the last two weeks.

She stated she did not have further information and as it was not a grievance she did not track if resolved.

During an interview on 06/04/2026 at 5:39 p.m., the Administrator revealed that she was aware of Resident #30's RP's concerns with the delayed request into medical records.

She stated she was aware of Resident #30's RP's first and second requests made for medical records and due to an invalid address and she believed was an invalid POA in Resident #30's chart the RP was denied access to Resident #30's medical records.

She stated she was not sure of the turnaround time for medical records request but believed it could be up to two weeks at most.

She stated it was only recently that the team found an old POA listing Resident #30's RP as her representative to make all and every health care decision on Resident #30's behalf s that was submitted during Resident #30's admission.

She stated the hardcopy POA was in storage.

Record review of a facility policy titled, Resident admission Agreement, dated March 2021, revealed .Rights of the Elderly. (f) An elderly individual may complain about the individual's care or treatment.

The complaint may be made anonymously or communicated by a person designated by the elderly individual.

The person providing service shall promptly respond to resolve the complaint.

Record review of a facility policy titled, Resident Rights, dated December 2016, revealed, .

Employees shall treat all residents with kindness, respect, and dignity.

These rights include the resident's right to: . u. voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal. v. have the facility respond to his or her grievances.

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what to call into the State Agency.

She would then complete the provider investigation report.

She

these residents as well as the staff.

She stated she was notified by the Director of Nursing about the

that on 5/19/2026 Resident #30 was aggravated, upset, angry and scratched herself while combative with incontinent care.

She stated the RP was notified and she arrived at the facility and she called the police as she felt staff caused Resident #30's injury to her ring finger.

She stated Resident #30's RP alleged that Facility #1's staff abused Resident #30.

She stated the police arrived and investigated the incident and found the allegations unsubstantiated and no further action was taken.

She stated that law enforcement's investigation was sufficient to unsubstantiate the allegations made by Resident #30's RP and she did not believe the incident was reportable.

She stated she did not investigate the incident further.

Record review of a facility policy titled, Abuse Investigation and Reporting dated March 2017, revealed .All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. 1. If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. 3.

The Administrator will keep the resident and his/her representative (sponsor) informed of the progress of the investigation. 1.

All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a.

The State licensing/certification agency responsible for surveying/licensing the facility.

Record review of a facility policy titled, Resident admission Agreement dated March 2021, revealed .Rights of the Elderly. (2) has the right to be free from abuse, neglect, and exploitation. c. An elderly individual has the right to be free from physical and mental abuse.

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During an observation and interview of Resident #34 on 06/01/2026 at 9:28 a.m. he was noted to be lying in bed.

Attempted interview with Resident #34 revealed he had difficulties with speech and could not be understood. He was noted to have his right hand in a splint, foley in privacy bag hung at bedside.

When asked resident was able to locate call light clipped to bedding.

During an interview on 06/04/2026 at 1:24 p.m. the MDS Coordinator stated that care plans required the Interdisciplinary Team to come together and this usually consisted of the Social Worker, Assistant Director of Nursing, Director of Nursing, Therapy Manager, Activity Director, and Dietary Manager and each would make changes pertaining to their department.

She stated she was unsure of the last time she received training on care plans.

She stated care plans gave a picture of the specific care that a resident needs.

She stated a care plan gave specific care instructions for staff to follow, such as a guide.

She stated if the care plan was not updated and depending on what area of the care plan it could range from less serious to possibly something more serious.

The MDS Coordinator stated that immediately following the IDT meeting the care plan should be updated to avoid any delays in care.

During an interview on 06/04/2026 at 3:02 p.m., CNA A stated he reviewed the resident care plans for specific care to provide a resident in his hall. He stated if the care plans not updated there could be a delay in care.

Record review of a facility policy titled, Comprehensive Assessments and the Care Delivery Process, dated December 2025, revealed .

Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions. (1) Gather relevant information from multiple sources, including: (f) consultant reports. a.

Selecting and Implementing interventions, based on the results. a.

Periodically reviewing progress and adjusting treatments. (1) Continue to define or refine objectives of specific treatments as well as overall care and services.

Record review of a facility policy titled, Care Planning - Interdisciplinary Team dated September 2013, revealed .

Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident.

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her hard copy daily activity roster and activity progress notes and stated Resident #26 should have

recall the date, and she was unsure as to why she did not return to Resident #26's room to offer

would do a compassion visit and Resident #34 does not show any interest in playing cards.

She stated she was unsure why Resident #34's electronic medical record only documented two activity progress notes for a 16-week period (02/01/2026 to 06/04/2026).

The Activity Director was observed reviewing her hard copy daily activity roster and activity progress notes and stated Resident #34 should have been documented in the report, but she could not find it.

Record review of a facility policy titled, Activities dated November 2017, revealed .It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences of each resident.

Facility?sponsored group and individual activities and independent activities will be designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, as well as, encourage both independence and interaction within the community. 1.

Each resident's interest and needs will be assessed on a routine basis.

The assessment shall include, but is not limited to: . b.

Activity assessment to include resident's interest, preferences and needed adaptations. 2.

Activities will be designed with the intent to: a.

Enhance the resident's sense of well-being, belonging, and usefulness. b.

Promote or enhance physical activity. c.

Promote or enhance cognition. d.

Promote or enhance emotional health. e.

Promote self-esteem, dignity, pleasure, comfort, education, creativity, success and independence. 4.

Activities may be conducted in different ways: a.

One-to-One Programs. b.

Person Appropriate - activities relevant to the specific needs, interests, culture, background, etc. for the resident they are developed for. c.

Program of Activities - to include a combination of large and small groups, one-to-one, and self-directed as the resident desires to attend. 9.

Special considerations will be made for developing meaningful activities for residents with dementia and/or special needs.

These include, but are not limited to, considerations for: e.

Residents who have withdrawn from previous activity interest/customary routines, and isolates self in room/bed most of the day.

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and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to

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During an interview on 06/04/2026 at 2:47 p.m., CNA K stated that he had worked at the facility for 9 months. He said that he received training in incontinent care at the facility. He said that he was instructed to be sure to wipe top to bottom, pat the skin instead of scrubbing it, change gloves and sanitize his hands between handling of the dirty and clean items, lower bed and place call light within reach after care. He stated that it is important to clean all of the areas during incontinent care or the resident could get sores on the skin or get an infection.

During a joint interview on 6/04/2026 at 3:07 p.m. with the facility DON and ADON, the expectations for CNAs providing incontinent care to the residents include hand hygiene; sanitizing hands before and after care.

Training is offered to CNAs on a yearly basis typically, unless they notice that UTI rates are increasing – then they would offer training sooner than that. DON stated that it is important to keep the residents safe and free from infections.

Record review of the facility's Perineal/Incontinent Care policy, dated December 2025, indicated the following: For a male resident: Continue to wipe the perineal area including the penis, scrotum and inner thighs and Wipe the rectal area thoroughly, including the area under the scrotum, the anus and the buttocks.

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to see something concerning, she would get the nurse to check the Gtube to be sure. If she needs to

stated that he has received training on Gtube care. If he needs to provide care to a resident with a

would not get hurt.During a joint interview with DON and ADON on 6/04/2026 at 3:15 p.m., regarding Gtube care, DON stated that the CNAs are trained to call the nurse for assistance with the feeding tube and pump.

Only the nurses are allowed to handle the Gtubes and the pumps. DON stated that the resident could potentially aspirate if the head of the bed was in the flat position for more than 30 minutes with the tube feeding infusing.

Record review of facility policy titled Enteral Nutrition dated December 2025 revealed: 1.

Staff caring for residents with feeding tubes will be trained on potential adverse effects of tube feeding, such as: Reduced opportunity for socialization;Diminished sensory experience;Restriction of movement; andFeeding-tube associated complications.Staff caring for residents with feeding tubes will be trained on how to recognize and report complications associated with the insertion and/or use of a feeding tube, such as:Aspiration;Leaking and skin breakdown around insertion site;Perforation of the stomach or small intestine leading to peritonitis;Esophageal swelling, strictures, fistulas; andClogging of the tube.Staff caring for residents with feeding tubes will be trained on how to recognize and report complications relating to the administration of enteral nutrition products, such as:Nausea, vomiting, diarrhea and abdominal cramping;Inadequate nutrition;Metabolic abnormalities:Interactions between feeding formula and medications; andAspiration.

Risk of aspiration will be assessed by the Nurse and Physician and addressed in the individual care plan.

Risk of aspiration may be affected by:Diminished level of consciousness;Moderate to severe swallowing difficulties;Improper positioning of the resident during feeding; andFailure to confirm placement of the feeding tube prior to initiating the feeding

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The facility failed to ensure that Resident #7's oxygen tubing was handled properly to prevent contamination. Resident 7's nasal cannula was on the floor in her room and CNA C placed it back on resident.

This failure could put residents receiving supplemental oxygen via nasal cannula at risk for cross-contamination and respiratory infection.The findings included:

Record review of Resident #7's face sheet, dated 06/02/2026, reflected an [AGE] year-old female with current admission date of 05/14/2026.

Diagnosis includes hypertensive heart disease (high blood pressure causes damage to the heart) and atherosclerotic heart disease (hardening of the arteries).

Record review of Resident #7's MDS dated [DATE] revealed resident #7 is rarely/never understood and receives oxygen therapy.

Record review of Resident #7's physician order dated 05/14/2026, indicated Oxygen at 2 lpm via nasal cannula continuously every shift.

Record review of Resident #7's comprehensive care plan dated 06/02/2026 revealed: Impaired Gas Exchange r/t Respiratory Failure.

Oxygen at 2 lpm via nasal cannula to maintain O2Sats > 92%, Date Initiated: 06/02/2026.

Observation on 06/01/2026 at 11:10 am, resident #7 in bed with head of bed elevated approximately 30 degrees, oxygen concentrator located on left side of bed was running and set at 2 L/min with tubing above resident's head and nasal cannula lying on the floor on right side of bed. CNA C came into room and while surveyor was checking the oxygen concentrator filter, CNA C picked up nasal cannula from the floor and placed it back on resident's face with prongs in the nares. LVN A entered the room at this time. LVN A stated the cannula was contaminated and immediately changed it out.

During an interview with CNA C on 06/01/2026 at 11:15am, CNA C stated she put resident 7's nasal cannula back on because she didn't think it had touched the floor. CNA C stated the nasal cannula could be contaminated and cause infection by touching the floor. CNA C stated resident#7 receives oxygen continuously. CNA C stated if she found respiratory equipment on the floor, she should notify the nurse to replace it.

During an interview on 06/01/2026 at 11:20am, LVN A stated he changed out the nasal cannula and tubing for resident #7 because it had touched the floor and was contaminated which can cause infection. LVN A stated resident #7 has been receiving continuous oxygen since recently returning from the hospital. DON interview 06/01/2026 at 3:20pm, DON stated her expectation is that if tubing or nasal cannula were on the floor, they are to be changed out to prevent infection.

Review of policy titled Oxygen Administration dated 12/2025, did not specify preventing or procedure for contamination of oxygen equipment.

06/03/2026 at 5:33PM, the DON stated she spoke to resident #32 hospice provider and the Zyprexa

continue administering the dose of Zyprexa 15mg to resident #32, order dated 06/03/2026 at 5:38pm

Administering Oral Medications, dated 12/2025: Purpose: The purpose of the procedure is to provide guidelines for the safe administration of oral medications. 1.

Verify that there is a physician's medication order for this procedure.

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During an observation of medication administration on 06/02/2026 from 10:36 a.m. to 10:40 a.m., MA A was observed to start preparing Resident #3's medication administration at 10:36 a.m. On MA A's electronic medication administration record screen, Resident #3's Amlodipine, Duloxetine, Gabapentin and Gemtesa were observed to be highlighted red and scheduled for administration at 09:00 a.m. MA A was observed to administer Resident #3's medications at 10:40 a.m.

During an interview on 06/04/2026 at 2:30 p.m., LVN C stated that she was trained about medication administration policies in her new hire training.

She stated that 9am medications can be given from 8am to 10am but if the medication is a scheduled narcotic it cannot be given earlier than the time stated in the order. If a medication is given late, she would need to contact the MD and get a one time order to administer the medication at the later time.

She would also be required to notify the DON as well as the family/RP.

During an interview on 06/04/2026 at 3:07 p.m., LVN B stated that she had received training regarding medication administration, but it's been awhile.

She said that she was instructed about the 5 rights and the need to double check orders. In regard to medication administration times, she stated that the staff is to administer medications no earlier than one hour before or one hour after the ordered/scheduled time. If medications are late, she is supposed to notify the DON, ADON, MD and family.

The purpose of giving medications at the correct time is to prevent complications, as some medications are fast acting.

During a joint interview on 6/4/2026 with facility DON and ADON, DON stated that education is provided to staff regarding medication administration times.

Per DON, medications can be given one hour before or one hour after the scheduled time. If administration time is outside of that, they need to let the provider know why and get clarification on the orders. If medications are given late and more than one dose is ordered for the day, the resident could be either overdosed or underdosed. If a staff member is giving medications outside of the administration times, they should notify DON or ADON, the MD and family. DON stated that there are 3 or 4 staff members available to assist, so staff should ask for help if there is a risk of passing medications outside of the acceptable times.

Record review of facility's policy titled, Administering Oral Medications, dated December 2025, revealed no specific policy regarding medication administration times.

Requested the Administering Medications policy referenced within this policy and the Facility Administrator stated that they do not have this policy.

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serve food in accordance with professional standards.

food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for

freezers were labeled or dated and canned foods were not dented and damaged.

This failure could place residents at risk for health complications, foodborne illnesses, and decreased quality of life.The findings included:During an observation and interview on 06/01/2026 at 9:10 a.m., the initial kitchen tour revealed food items in the commercial refrigerator and freezers were uncovered, unlabeled, and undated and canned foods were dented and damaged.

The 102-ounce canned mangos and canned pineapples contained deep dents, deep enough to lay a finger in, the commercial freezer contained a pot roast partially unwrapped, unlabeled, and undated with freezer burn.

The Dietary Manager stated she was not sure why canned foods were not labeled with date the supplier delivered them.

She stated she was new in this role, for four weeks, and she had been educating dietary staff to understand the importance of labelling foods.

She stated she did not know why dented cans of fruit were on the rack and she was observed removing them during the initial tour.

She stated that the dented cans should have been removed from the rack and put in the trash.

She stated she does not return the cans dented to the supplier as there was a long delay and process to have food replaced and she opted to throw it out completely.

She stated the dietary staff were trained in labelling foods when delivered by the supplier and she planned to continue educating them.

During an interview on 06/03/2026 at 11:44 a.m., the Dietary Aide stated that labeling food helped with food safety and stated dietary staff may have missed some food items.

During an interview on 06/03/2026 at 10:43 a.m. requested policies for Kitchen and Food/Nutrition from the Administrator.

The Administrator stated there were no specific policies for the kitchen.

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