Horizon Health & Subacute Center

Inspectors wroteBased on interviews, observations, and record review, the facility failed to follow their Policy and Procedure (P&P) and provide professional standards of care when:1. The facility did not provide behavioral health training for Activity Aides per policy.2. The facility did not review and update 1 of 4 sampled P&Ps at least annually per policy.3. The facility did not create a multidisciplinary plan for ventilator (respiratory ventilator (a machine that helps a person breathe when they cannot breathe well enough on their own) weaning for one of one sampled resident (Resident 1) per policy. This had the potential to result in poor care, unsafe conditions, and injury to residents and staff. 1. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure sufficient nursing staffing to meet residents' needs for 3 of 4 sampled residents (Residents 1, 2, and 3) when: 1. The facility failed to adjust staffing levels to account for a high-acuity resident (Resident 5) who required extensive staff time, further contributing to delays in care for other residents. 2. The facility decided to reduce PM shift staffing in the sub-acute (is a designated area within the facility that provides a higher level of skilled nursing care services than a regular nursing home unit) from two certified nursing assistant (CNA) to one, without conducting an assessment of resident's acuity or monitoring the impact of these changes. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure safe and competent nursing care when:3 of 4 sampled Activity Assistants (AA) (AA 1, 2, and 3) lacked required behavioral health training.7 out of 8 sampled staff members (Certified Nurse Assistant (CNA) 3, CNA 4, CNA 5, CNA 7, Licensed Vocational Nurse (LVN) 2, LVN 3, Respiratory Therapist (RT) 1, Unit Manager (UM) 1, and UM 2 could not locate key policies and procedures. This failure had the potential to result in substandard care and injury to residents and staff.1. During a phone interview on 3/18/26 at 11:02 am with Complainant 1, Complainant 1 reported that AAs were required to entered the Special Treatment Program (STP), the facility's behavioral health unit, to assess residents' activity needs without having the required behavioral health training. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure food equipment was properly cleaned and sanitized for 8 of 8 sampled residents (Resident 1, 2, 3, 4, 5, 6, 7, 8) when the popcorn machine had a piece of popcorn on the kettle lid, black and brown buildup on the lid, rim, and kettle exterior. This failure had the potential risk for residents to consume popcorn prepared using contaminated equipment, which could result in cross-contamination (the transfer of harmful substances or pathogens to food via inadequately cleaned food contact surfaces). During a concurrent observation and interview on 2/26/26 at 1:28 pm with the Activity Assistant (AA) 1 and the Activity Director (AD) in the malt shop, the door was open and a posted sign indicated the malt shop hours were 2pm-3pm daily. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to established and maintain an effective infection prevention and control program to prevent the development and transmission of communicable disease for all residents in the facility when the facility identified cases of scabies (a contagious skin infestation caused by tiny mites) and failed to timely report upon identification of the initial confirmed case of scabies (a contagious skin infection caused by tiny mites) to the Local Public Health Department (LPHD- is a government agency-often at the county or city level-responsible for protecting and promoting the health of the community) and California Department of Public Health (CPDH-public health office oversees a variety of research, response and prevention programs to protect the public's health). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, clean, comfortable and homelike environment for one of five residents (Resident 1) when the supply ventilation duct (an opening which allow cool or warm air to pass through supplied by a HVAC; Heating, Ventilation, and Air Conditioning system) in Resident 1's room was covered with three pieces of rubber material and two pieces of the rubber material were loose (hanging from the ceiling). This failure posed as a fire hazard endangering the lives of Resident 1, other residents and staff members.

Inspectors wroteBased on observation, interview, and record review the facility failed to meet professional standards of quality for one of five residents (Resident 1) when Resident 1 had an appointment on [DATE] for a CT scan (Computed Tomography; a medical imaging procedure used to create detailed pictures of the inside of the body) of the right lower leg due to a history of DVT (Deep Vein Thrombosis; a condition where a blood clot forms in a deep vein, typically in the legs) at [name of outside agency; a facility that provides a certain type of service the facility did not] and the CT scan was canceled because the outside agency was not informed that Resident 1 required a mechanical lift (a mechanical device used by caregivers to safely transfer individuals with limited mobility, such as those who are bedbound or unable to bear their own weight) for transfer. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an effective infection prevention and control program when: 1. When Resident 16's handheld nebulizer (a flexible tube that fits into a small, handheld machine that turns liquid medicine into a mist and resident inhale the mist through the mouthpiece for delivery of medication) tubing was on the floor. 2. The washing machine had a white substance buildup on and below the front-loading door and on the handle of the front-loading door. These failures placed residents at risk for cross-contamination (the process when germs are unintentionally transferred from one substance or object to another, which causes a harmful effect) and infection (an invasion of the body by germs that cause disease). 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person centered care plan for four of 12 residents (Residents 66, 72, 118 and 114) when: 1. Resident 66's divalproex sodium (a medication used to treat involuntary movements and mental disorders) care plan (a detailed document that outlines a patient's individual healthcare needs) had interventions for lithium (mood stabilizing medicine used to treat certain mental illnesses) and not divalproex sodium (an anticonvulsant [anti-seizure] medication also used as a mood stabilizer). This failure had the potential to cause Resident 66's divalproex sodium administration side effects such as weight loss, loose stools, and drowsiness to go unmonitored. 2. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure three of the five sampled Certified Nursing Assistant's (CNA) received nurse aide performance evaluation (a formal assessment of a nurse aide's job performance, covering areas like clinical competence, communication, teamwork, and professionalism, to identify strengths and areas for improvement) every 12 months. This failure resulted in CNAs not getting their performance check and had the potential for weak areas to not be identified and improved.

Inspectors wroteBased on interview, and record review, the facility failed to prevent residents from receiving unnecessary medications for three out of seven sampled residents (Residents 8, 38, and 126) when: 1. Resident 8 and 126's did not have liver function test labs (LFT- blood tests that measure how well your liver is functioning) completed or monitored while taking valproic acid (a medication used to treat seizure disorders [sudden burst of electrical activity in the brain], certain psychiatric conditions [a wide range of conditions that affect a person's thoughts, emotions and behavior]). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent when the facility ' s medication error rate was 14.81 percent. There were 27 opportunities for errors and four medication errors occurred with two of four sampled residents (Residents 25 and 85) when: 1. Resident 25 was administered an fluticasone propionate and salmeterol inhalation (medication that is inhaled and helps reduce swelling in the airways) and did not rinse mouth after use as indicated in the prescriber order. 2. Resident 85 was administered one Bumetanide tablet (medication that can treat fluid retention and high blood pressure [force exerted by blood on the walls of the arteries as it is pumped by the heart throughout the body]) at 9:32 a.m. when it was scheduled to be administered at 8:00 a.m. (over an hour past the administration time). [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to properly store and label medications in two of six medication carts when: 1. Eight of fifteen liquid bottled medications did not have an open date in the long-term wing medication cart. Seven of these nine medications were for Residents 1, 25, 34, 62 and 100. This failure had the potential to decrease medication potency that could compromise the therapeutic effectiveness of stored medications 2. Five of 11 eye drop bottles did not have patient labels for Residents 1, 62, and 94 in the long-term wing medication cart. This failure had the potential to result in misidentification of a medication, patient safety risks, and incorrect dosage. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food was stored, prepared and distributed in accordance with professional standards when: 1. Kitchen staff (KS 3) did not monitor had not recorded the temperature during the cooling process after preparing tuna salad that was at ambient temperature (room temperature) ; 2. Kitchen staff (KS 4) did not wear a beard net while preparing resident juice cups nor did kitchen staff (KS 5) wear a beard net while putting away equipment and wiping down surfaces; 3. Two robot coupes were stored wet with water inside, pooled on bottom and condensation on the lid; 4. A black serving scoop was stored inside a dry storage bin containing thickener; and 5. A box containing hash brown potatoes was on the floor inside the walk-in freezer. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure accurate and complete medical records in accordance with professional standards of practices were maintained for seven of twelve sampled residents (Residents 15, 16, 33, 45, 52, 106, and 126), when the Physician Orders for Life-Sustaining Treatment (POLST- a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) were not accurate and complete. This failure had the potential for Resident 15, 16, 33, 45, 52, 106, and 126's decisions regarding treatment options and end of life wishes to not be honored.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity in an environment that promotes and enhances quality of life for two of six sampled residents (Residents 1 and 74) when Certified Nursing Assistants (CNA's 2 and 3) stood to fed them lunch. This failure violated Residents 1 and 74's right to be offered a dignified dining experience and made Resident 1 feel uncomfortable and disrespected.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of six sampled residents (Resident 53) had the right to make choices about aspects of his life in the facility when his choice to have a shower on a Saturday instead of a Friday was not honored. This failure resulted in Resident 53's skin on his upper cheat and left upper arm becoming red, dry and itchy leading to him scratching himself opening the skin and the potential for an increased risk for infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a comfortable and homelike environment for one of eight residents (Resident 55), when the facility did not respond to Resident 55's complaint of air from the vent in his room blowing on his face. This failure resulted in Resident 55 feeling cold, frustrated, and uncomfortable in his bed.

Inspectors wroteBased on interview and record review the facility failed to notify the Ombudsman (a public official who advocates for residents' rights, health, safety, and well-being, investigating and resolving complaints and concerns), and the resident representative, (RP-person designated to make decisions for a resident), in writing of a resident's transfers to the hospital for one of six sampled residents (Resident 66) when the facility did not inform the ombudsman of Resident 66's transfer to the hospital and the RP was not given written notice of Resident 66's transfer to the hospital. This failure violated Residents 66's right to have his RP and Ombudsman properly informed of his hospitalization on 7/8/24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of practice for two of seven sampled residents (Residents 52 and 113) when: 1. Resident 52's tube feeding bag (TF - a liquid form of nutrition that is carried through your body through a flexible tube) was not labeled with the date it was hung (set up for administration). 2. Resident 113's TF bag was not labeled with the time the TF bag was hung. These failures had the potential to result in Residents 52 and 113 to receive nutrition that was outdated or expired and put them at risk of food borne illness (any illness resulting from eating contaminated/spoiled foods).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain routine dental services to meet the needs each for one of two residents when Resident 76 had treatment recommendations for a bone spur (an abnormal bony growth that forms on or around joints or along the edges of bones) removal and a new full set of dentures (a removable plate or frame holding one or more artificial teeth) and no action taken by the facility since 9/15/23, leaving the resident without dental service intervention for 17 months and three weeks. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two out of twenty-three kitchen staff (KS 1 and 2) had appropriate competencies and skill sets to safely and effectively carry out the functions of food and nutrition services when: 1. KS 1 used a #12 scoop (1/3 cup, 2.67 ounces) to portion chopped meat when the menu did not indicate portion sizes for chopped meat; and 2. KS 2 did not use the correct portion size when preparing tuna and egg salad sandwiches. These failures had the potential to result in residents receiving inadequate protein which could result in frailty (decreased energy), weight loss, delayed wound healing, loss of muscle, and increased risk of fractures (broken bones).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of six sampled residents (Resident 35) area was maintained a safe, functional, sanitary and comfortable environment for residents staff and the public when, Resident 35's room had a bag of adult diapers, multiple t-shirts, sweaters and jackets stacked on top of a walker and wheelchair at the foot of the hospital bed, blocking access to the window. These failures had the potential to cause injuries, falls and a fire safety hazard for Resident 35 and her roommate.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for one of three residents (Resident 1), when Resident 1 required two person assist for turning and repositioning but was turned by Certified Nursing Assistant (CNA) 1 during briefs (adult diaper) change alone (without another person to assist) on [DATE]. This failure resulted in Resident 1 falling out of bed and onto the floor on [DATE] and the potential for Resident 1 to be injured.

Inspectors wroteBased on interview and record review, the facility failed to implement their policy to ensure Injuries of Unknown Origin (any injury without a reason the injury could have or did occur) were reported to all Local and State Officials in the required time frame, as defined by law, for one of three sampled residents (Resident 1) when, the facility discovered Resident 1, a non-verbal and non-mobile resident, had a closed fracture of his left humerus (a brake in the bone of the upper left arm) and did not report it to the Police Department or Ombudsman. This failure resulted in the delay of investigation by outside agencies, assistance in the facility ' s investigation, and had the potential to result in resident abuse not being discovered, putting all residents at risk of abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four residents (Resident 1) was free from abuse, neglect, and exploitation when Licensed Vocational Nurse (LVN) 1 used profane language (language that is considered offensive, vulgar, or irreverent) toward Resident 1 and instructed staff not to assist Resident 1 after an unwitnessed fall (when an individual falls to the ground or a lower surface without anyone seeing it) on 11/17/24. These failures had the potential for Resident 1 to experience agitation, intimidation, disrespect, and fear.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when two boxes containing 48 [brand name] Covid-19 (an infectious disease caused by the SARS-CoV-2 virus) self-test kits were expired on 8/23/24 in the clean utility supply room (a space for storing, preparing, and distributing clean and sterile supplies for patient care). This failure had the potential to produce inaccurate Covid-19 test results.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three residents (Resident 1) was free from physical abuse when one Mental Health Worker (MHW) placed both of his hands on Resident 1's shoulders and shoved him backwards. This failure resulted in Resident 1 stumbling backwards and experiencing mental anguish, including intimidation, feeling threatened, frightened, and increased agitation.

Inspectors wroteBased on interview and record review, the facility failed to check the references of one of three employees (Mental Health Worker, or MHW) prior to employment. This failure resulted in the potential for one unqualified employee (MHW) to provide care to residents [Cross Reference with F600].

Inspectors wroteBased on interview and record review, the facility failed to report the findings of an investigation of an abuse allegation to the Department within five days. This failure had the potential for an allegation of abuse to not be thoroughly investigated and result in further abuse [Cross Reference with F600].

Inspectors wrote2. A review of Resident #105's admission Record, revealed the facility admitted the resident on 04/20/2023 with diagnoses that included type 2 diabetes mellitus, congestive heart failure, morbid obesity, localized edema. Per the admission Record, the resident received a diagnosis of non-pressure chronic ulcer of the left lower leg on 04/28/2023. A review of Resident #105's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/27/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. A review of Resident #105's care plan, revised on 08/30/2023, revealed the resident had a venous/stasis ulcer of the left and right lower leg. Interventions directed staff to administer treatment as ordered by the physician. [...]

Inspectors wrote2. A review of Resident #304's admission Record, revealed the facility admitted the resident on 02/23/2024, with diagnoses that included acute respiratory failure with hypoxia, asthma, and morbid obesity. A review of Resident #304's care plan, initiated on 02/23/2024, revealed the resident was at risk for hypoxemia related to diagnoses of acute respiratory failure with hypoxia and morbid obesity. Interventions directed staff to apply the resident's CPAP device at the prescribed time and setting as indicated by the physician's order. A review of Resident #304's Order Summary Report, revealed an order dated 02/24/2024 for staff apply the resident's CPAP/auto-adjusting positive airway pressure (APAP) device at bedtime and remove in the morning upon awakening. The order did not specify the PEEP setting for the CPAP/APAP. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain complete, accurate, and readily accessible documentation of records for three of three sampled residents (Resident 1, 2, and 3) when Resident 1, 2, and 3 required turning and repositioning every two hours and the facility was unable to obtain documentation of turning and repositioning Resident 1, 2, and 3 every two hours. This failure was not the standard of practice according to the facility's policy and procedure titled, Charting and Documentation.

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of quality when one of three residents (Resident 1) complained of persistent and severe pain following a right hip replacement (a surgical procedure in which the diseased parts of the hip joint; ball and socket of the pelvis is replaced with new, artificial parts) and staff did not notify the Attending Physician (medical doctor assigned to care for a patient) according to the facility ' s policy and procedure titled, Change in a Resident ' s Condition or Status. This failure resulted in delaying the identification of the dislocation (when the ball of the new hip implant comes out of the socket) of Resident 1 ' s right hip.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 62) with known risk for injuries due to the diagnosis of contracture's (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), received adequate supervision and assistance to prevent injuries when Licensed Nurses (LN) failed to provide assistance and monitor Resident 62's body repositioning every two hours as prescribed by the physician. This failure resulted in Resident 62's hospitalization with a diagnoses of a left arm spiral fracture (broken bone [spiral] occurs due to a rotational, or twisting, force) when he received care from one Certified Nursing Assistant (CNA) without assistance by the licensed nursing staff as ordered by the physician.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the food services staff were competent to carry out the functions of food services safely and effective for all residents being provided meals from the kitchen when two of two food service staff were unable to verbalize the cool down process. This failure had the potential for untrained staff to place residents at risk of exposure for foodborne illnesses (food poisoning).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided met professional standards of quality for two of three sampled residents (Resident 136 and Resident 91) when: 1. Licensed Vocational Nurse (LVN) 4 did not follow the facility's policy and procedure on self-medication administration for Resident 136 and left his prepared medications on top of his bedside table unattended; LVN 4 signed the medications as being administered without first verifying Resident 136 took his medications and LVN 2 failed to take the necessary precautions to store Resident 136 medication left at his bed side table by LVN 4. This failure placed Resident 136 at risk for medication error and for unauthorized personnel to access Resident 136's medications. 2a. LVN 1 administered Resident 91's medication without explaining what the medications were being administered for; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate care and services to assure residents received the care to attain and maintain their highest practicable physical, mental, and psychosocial well being for two of two sampled residents (Resident 136 and Resident 22) when: Resident 136 and 22 were not assisted to the bathroom in a timely manner. This failure resulted in Resident 136 and Resident 22 feeling upset and frustrated and the potential for the residents to experience an incontinent episode and a fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely store, prepare and serve food safely when: 1. Multiple open contianers of condiments were stored and available for use without an open date inside the spice rack and walk-in refrigerator. 2. Restorative Nursing Assistant (RNA) 2 her face, hair and mouth while serving plates of food to residents in the dining room. These failures to ensure effective dietetic service operations placed the residents at risk for foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the dialysis record used as a communication tool was documented accurately and completely for two of two sampled residents (Resident 111 and Resident 105). This failure resulted in an incomplete and inaccurate documentation of Resident 111's and 105's clinical records and potentially to disrupt the continuity of care between providers.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective infection control and prevention program for three of three sampled residents (Resident 44, 62 and 141) when: 1. For Resident 44, Resident 62, Resident 141, the Respiratory Therapist (RT) used his stethoscope (a medical instrument for listening to the action of someone's heart or breathing) and did not sanitized the stethoscope's diaphragm (the flat part at the end of the tubing which contains thin plastic used to listen to high pitch sounds such as lung sounds) in between use of residents. 2. The handwashing sink was located on the same counter as the clean plates and lids next to the steam table holding the food. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to send a copy of the resident transfer and discharge notification to a representative of the Office of the State Long-Term Care Ombudsman (an official appointed to represent the elderly and frail residents rights under public authorities) for one of four sampled residents (Resident 98) when Resident 98 was transferred for hospitalization and the local Ombudsman was not notified. This failure had the potential to result in inappropriate resident transfer and discharge practices for Resident 98.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure grooming needs were met for one of two sampled residents (Resident 116) when Certified Nursing Assistants (CNA's) and Licensed Nurses (LN's) failed to provide Resident 116 with nail care to keep nails short and well trimmed as indicated in her plan of care. This failure resulted in Resident 116's self inflicted scratches to her left arm and leg and placed her at risk for a skin infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs were stored safely inside the medication cart (med cart) when Licensed Vocational Nurse (LVN) 1 left an over the counter (OTC) drug on top of the med cart unattended. This failure had the potential for the medication to be left unattended on top of the med cart which could result to unauthorized access by other residents, staff, and visitors in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide timely dental services for one of one sampled residents (Resident 111) when there was no follow up for Resident 111's dentures from the dental office since 2/8/19. This failure delayed Resident 111's acquisition of his full upper and lower dentures that would enable him to eat regular food and enhance his well-being.