Horizon Health and Rehabilitation Center

Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure a resident's medical record was updated to reflect a physician established medication stop date for a psychotropic medication and a psychotropic medication verbal consent contained two witness signatures for 1 of 43 sampled residents (Resident 109). The deficient practice had the potential to result in continued administration of psychotropic medication beyond the physician established duration and lacked documented verification of informed consent for psychotropic medication use.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure a resident received a shower as scheduled for 1 of 43 sampled residents (Resident 85). This deficient practice had the potential to compromise the resident's hygiene, comfort, dignity, and overall quality of life.

Inspectors wroteBased on interview, record review and document review, the facility failed to ensure prescribed medication was ordered timely, available, and administered, which resulted in a four-day delay in medication administration for 1 of 43 sampled residents (Resident 129). The deficient practice had the potential to result in interruption of prescribed medication therapy and adverse clinical outcomes related to delayed medication administration.

Inspectors wroteBased on observation, interviews, record review, and document review, the facility failed to ensure medication was properly secured for 1 of 43 sampled residents (Resident 11). This deficient practice had the potential to place the resident at risk for medication errors and unintended access to the medication.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure an oxygen concentrator used to administer oxygen to a resident was maintained in sanitary conditions for 1 of 43 sampled residents (Resident #56). This deficient practice had the potential to increase the resident's risk of infection, compromise respiratory hygiene, and reduce the effectiveness of the oxygen delivered.

Inspectors wroteBased on observation, interview, and document review, the facility failed to maintain proper food storage practices in the dry storage area, and temperature control in the refrigerators. The deficient practice had the potential to compromise food safety and increase the risk of foodborne illness among residents.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure residents have a right to make choices about aspects of their life in the facility which are significant to the resident for 1 of 26 sampled residents (Resident 89) and 3 unsampled residents (Residents 29, 32, and 61). The failure to accommodate the residents' preferences and choices had the potential risk to cause psychosocial distress to the residents.

Inspectors wroteBased on record review, document review and interview, the facility failed to ensure a resident was provided information about the right to formulate an advanced directive for 1 of 26 sampled residents (Resident #67). The deficient practice has the potential to deprive the resident of their right to determine their life status.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure a resident's yelling and disruptive behaviors were addressed for 1 of 26 sampled residents (Resident 55). The deficient practice deprived other residents of the right to live in a peaceful environment with comfortable noise levels permitting for a restful night's sleep.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to review and follow up on a Preadmission Screening and Resident Review (PASRR) level 2, following a resident's psychiatric hospitalization for 1 of 26 sampled residents (Resident #57), and failed to ensure referrals for PASRR level 2 screening were completed for 4 of 26 sampled residents (Residents #121, 64, 55, and 67). The deficient practice had the potential to delay necessary specialized services and interventions for the residents, and could have impacted their placement, overall care and well-being.

Inspectors wroteBased on record review, interview, and document review, the facility failed to develop and implement a comprehensive care for post-traumatic stress disorder (PTSD) reflecting a resident's new mental health conditions and following a new Preadmission Screening and Resident Review (PASRR) Level 2 screening determination for 1 of 26 sampled residents (Resident #57). The deficient practice had the potential to compromise the resident's mental health management, leading to inadequate treatment, delayed interventions, and a lack of necessary support services.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure a new skin impairment was communicated to the wound care team in accordance with facility protocol for 1 of 26 sampled residents (Resident 118). This deficiency placed the resident at risk for wound complication.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure interventions were implemented to identify hazards and risks associated with smoking, and residents who smoked were adequately monitored or supervised for 2 of 16 sampled residents (Residents 91 and 99), and 1 unsampled resident (Resident 97), identified as smokers. This deficient practice had the potential to result in fire hazards and compromise the safety and well-being of the residents, staff, and others in the facility.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure the Foley catheter was assessed timely, the physician was notified of foul-smelling urine, the change in condition was documented, and the urinary drainage bag was changed as ordered for 1 of 26 sampled residents (Resident 104). This deficient practice had the potential to contribute to urinary tract infection, compromised skin integrity, and overall health status.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure enteral feeding orders administered through the gastrostomy tube were followed as ordered, and total volume delivered was monitored and documented for 1 of 26 sampled residents (Resident 34). This deficient practice had the potential to result in inadequate nutritional and fluid intake, leading to malnutrition, dehydration, electrolyte imbalances, impaired wound healing and increased susceptibility to infections.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure 1) a resident's yelling and disruptive behaviors were communicated to the psychiatric provider and 2) the resident was referred to the behavioral services provider for psychotherapy services for 1 of 26 sampled residents (Resident 55). The deficient practice potentially had a negative impact on the resident of concern's overall well-being and deprived other residents of the right to live in a peaceful environment free from disruptive noise.

Inspectors wroteBased on observation, interview, document review, and record review, the facility failed to ensure target behaviors were monitored for a resident receiving medication to treat Post Traumatic Stress Disorder (PTSD) for 1 of 26 sampled residents (Resident #26). This deficient practice had the potential to cause the residents to use unnecessary medication, which may result in possible adverse effects.

Inspectors wroteBased on observation, interview, document review, and record review, the facility failed to ensure a medication error rate of less than 5% was obtained during medication pass. There were 31 opportunities observed, which revealed three errors. The medication error rate was 9.68%. Failure to follow physician orders during medication administration had the potential to cause harm or injury to residents.

Inspectors wroteBased on interview and document review, the facility failed to ensure a Quality Assurance Performance Improvement (QAPI) plan was in place. This deficient practice has the potential to negatively affect the outcomes of resident care and the quality of each resident's life.

Inspectors wroteBased on observation, interview, and document review, the facility failed to 1) procure a clean food preparation environment and 2) ensure food products that needed to be refrigerated were kept in a safe temperature range by accurately monitoring the temperature of the walk-in refrigerator. The deficient practice could potentially expose residents to foodborne illnesses.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a walk-in refrigerator was maintained in working condition to keep refrigerated food products in a safe range of temperature. The deficient practice could potentially endanger the safety of the food, exposing residents to foodborne illnesses.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure the signs and symptoms (s/s) of bleeding for a resident on anticoagulants were monitored for 1 of 25 sampled residents (Resident 2). This deficient practice had the potential to result in hemorrhage, an increased risk of severe anemia, and harm to the resident.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to provide care to prevent a stage 4 pressure ulcer for 1 of 25 sampled residents (Resident 72). The deficient practice caused a wound to develop and not be identified until it had progressed into a stage 4 pressure ulcer.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure a physician order for splint application was obtained and implemented to treat a resident's contracture for 2 of 35 sampled residents (Residents 2 and R77), and the care plan was updated following the resident's readmission for 1 of 35 sampled resident (Resident 77). The deficient practice could potentially lead to worsening contractures, decreased mobility, increased pain, and a reduced quality of life for the affected residents.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure: 1) the nutritional assessment for a resident on percutaneous endoscopic gastrostomy (PEG) was completed upon readmission per policy for 1 of 25 sampled residents (Resident 2), and 2) care orders to manage the PEG tube were obtained and transcribed for 1 of 25 sampled residents (Resident 2). The deficient practice could have the potential to compromise resident safety and well-being, leading to inadequate nutritional support and an increased risk of complications related to PEG tube management.

Inspectors wroteBased on observation, interview, and document review the facility failed to post daily staffing information in a place accessible to residents and visitors. The deficient practice had the potential to result in a lack of awareness for residents and visitors regarding the type and number of staff on duty on any given day.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure their medication error rate was below five (5) percent (%) when two errors were identified with 30 opportunities observed, calculating an error rate of 6.67%. Failure to follow physician orders and timely administer medications posed a potential risk of injury or harm to the resident.