A list of the most recent deficiencies for Inspire Behavioral Health. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-22 | 2023-03-12 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-12-14 | 2022-12-15 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-11-05 | 2021-12-10 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-11-05 | 2021-12-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-05 | 2021-12-10 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-11-05 | 2021-12-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-11-05 | 2021-12-10 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-11-05 | 2021-12-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-11-05 | 2021-12-10 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-11-05 | 2021-12-10 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-11-05 | 2021-12-10 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-11-05 | 2021-12-10 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-11-05 | 2021-12-10 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-11-05 | 2021-12-10 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-11-05 | 2021-12-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-05 | 2021-12-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-05 | 2021-12-10 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-11-05 | 2021-12-10 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-11-09 | 2021-11-29 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-11-09 | 2021-11-29 | N |
| Use approved construction type or materials. | Fire Safety | 2021-11-09 | 2021-11-29 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2021-11-09 | 2021-11-29 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-11-09 | 2021-11-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-09 | 2021-11-29 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-11-09 | 2021-11-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-11-09 | 2021-11-29 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-11-09 | 2021-11-29 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-11-09 | 2021-11-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-11-09 | 2021-11-29 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-06-02 | 2021-06-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-02 | 2021-06-22 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-02-05 | 2020-03-30 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2020-02-05 | 2020-03-30 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2020-02-05 | 2020-03-30 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2020-02-05 | 2020-03-30 | N |
| Provide emergency officials' contact information. | Fire Safety | 2020-02-05 | 2020-03-30 | N |
| Establish staff and initial training requirements. | Fire Safety | 2020-02-05 | 2020-03-30 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-02-05 | 2020-03-30 | N |
| Implement emergency and standby power systems. | Fire Safety | 2020-02-05 | 2020-03-30 | N |
| Use approved construction type or materials. | Fire Safety | 2020-02-05 | 2020-03-30 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2020-02-05 | 2020-03-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-02-05 | 2020-03-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-02-05 | 2020-03-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-05 | 2020-03-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-02-05 | 2020-03-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-02-05 | 2020-03-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-02-05 | 2020-03-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-02-05 | 2020-03-30 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-02-05 | 2020-03-30 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-02-05 | 2020-03-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-05 | 2020-03-30 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2020-01-09 | 2020-01-30 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-01-09 | 2020-01-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-09 | 2020-01-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-01-09 | 2020-01-30 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-01-09 | 2020-01-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-09 | 2020-01-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-09 | 2020-01-30 | N |
| Keep all essential equipment working safely. | Health | 2020-01-09 | 2020-01-30 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-02-07 | 2019-03-21 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-02-07 | 2019-03-21 | N |
| Use approved construction type or materials. | Fire Safety | 2019-02-07 | 2019-03-21 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-02-07 | 2019-03-21 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-02-07 | 2019-03-21 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-02-07 | 2019-03-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-02-07 | 2019-03-21 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-02-07 | 2019-03-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-02-07 | 2019-03-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-02-07 | 2019-03-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-02-07 | 2019-03-21 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-12-06 | 2019-01-07 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-12-06 | 2019-01-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-12-06 | 2019-01-07 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2018-12-06 | 2019-01-07 | N |
| Provide appropriate foot care. | Health | 2018-12-06 | 2019-01-07 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-12-06 | 2019-01-07 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-12-06 | 2019-01-07 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-12-06 | 2019-01-07 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2018-12-06 | 2019-01-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-12-06 | 2019-01-07 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2018-12-06 | 2019-01-07 | N |
