Horizon Post Acute and Rehabilitation Center

Inspectors wroteBased on a review of records, observation, interviews, and a review of facility policies and procedures, the facility failed to ensure that one of 3 sampled residents (Resident #12), property was not misappropriated. The Universe was 145. The deficient practice could lead to resident's property to be misplaced or lost.

Inspectors wroteBased on staff interviews, review of clinical record, and review of policy and procedure, the facility failed to ensure a resident's (#2) rights were honored regarding emergent transfer to the hospital. The deficient practice could result in a resident being unable to make choices about their health, and could cause physical or psychosocial harm to a resident.-

Inspectors wroteThe facility failed to ensure residents do not abuse other residents. Based on observations, interviews, record review, the facility failed to protect the resident's right (#1) to be free from physical abuse by another resident (#2). The deficient practice could result in further abuse of residents and appropriate action not taken.

Inspectors wroteThe facility failed to ensure one resident was free from abuse from another resident,Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#100) was free from physical abuse from other residents (resident #200). The deficient practice could result in further incidents of resident to resident abuse.

Inspectors wroteThe facility failed to ensure a credible allegation of abuse was investigated. Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that their policy on abuse was followed. The deficient practice could result in more cases of resident to resident abuse not being investigated.

Inspectors wroteThe facility failed to ensure a credible incident of abuse was reported timely and accurately. Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that an incident of abuse was reported timely and accurately. The deficient practice could result in further incidents of resident to resident abuse.

Inspectors wroteBased on observation, interviews, review of records, and review of facility policy and procedure, the facility failed to protect the rights of one resident (#22) to be free from abuse by another resident (#16). The deficient practice could lead to physical and psychosocial harm to residents. Findings Include: -Resident #22 was admitted to the facility on [DATE] with diagnoses that included: Human Immunodeficiency Virus Disease, hemiplegia, bipolar disorder, generalized anxiety disorder, unspecified dementia, schizoaffective disorder, major depressive disorder, and general muscle weakness. A quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 9, indicating a moderate cognitive impairment. [...]

Inspectors wroteBased on observations, staff interviews, record review, and policy review, the facility failed to ensure the medication error rate was not 5% or greater, by failing to administer medications as ordered for three of four residents (#58, #25, #103). The deficient practice could result in adverse effects and further medication errors. Findings Include: Six medication administration errors were identified out of 38 opportunities during medication administration observation. The medication error rate was 15.79% -Regarding Resident #58 Resident #58 was admitted to the facility on [DATE] with diagnoses that included viral hepatitis, anxiety disorder, depression, and schizophrenia A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. [...]

Inspectors wrote-Resident #545 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included urinary tract infection, adult failure to thrive, gastrostomy status, chronic kidney disease stage 3, obstructive and reflux uropathy and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominate side. An admission Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident #545 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated severe cognitive impairment. The MDS assessment further revealed that the resident had a Foley catheter and an intravenous catheter (IV). A Nursing Care Plan, dated May 10, 2025, indicated Resident #545 had an indwelling catheter, a Peripherally Placed Central Catheter (PICC) and a feeding tube. Physician orders, dated May 10, 2025, revealed the following: [...]

Inspectors wroteBased on resident and staff interviews, review of the clinical record, facility documentation and policy, the facility failed to ensure that a code status was accurate and consistent in the medical record for one (Resident #28) of twenty-seven residents. The deficient practice could result in residents not receiving care consistent with the signed advanced directive.

Inspectors wrote-Regarding Resident #37: Resident #37 was originally admitted to the facility on [DATE] and most recently re-admitted on [DATE], with diagnoses that included, other psychotic disorder due to a substance or known physiological condition, chronic pain, depression and anxiety. A Pre-admission Screening and Resident Review (PASRR) Level I Screening dated September 12, 2024 completed prior to admission, revealed that it was left mostly blank. A care plan initiated on September 12, 2024 included the following focus: -Psychotropic medications use related to schizoaffective disorder -Ineffective coping related to substance abuse -Potential for a psychosocial well-being problem with interventions that included to consult with psych services and social services. [...]

Inspectors wroteBased on observations, staff interviews and policy review, the facility failed to ensure that medications were not left at the bedside for one resident (#448). The deficient practice could result in harm to the residents, and/or visitors who have access to medications. Findings Include: Resident #448 was admitted on [DATE], diagnosis included displaced fracture of surgical neck of left Humorous, anemia, retention of urine, hypokalemia, chronic pain syndrome, alcohol abuse, and anxiety disorder. The Admissions Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that resident was cognitively intact. Review of care plan revealed no evidence that Resident #448 was able to self-administer medication. Review of the physician's orders revealed no orders to self-administer medications. [...]

Inspectors wroteBased on observation, clinical record review, staff interviews, and facility policy and procedure, the facility failed to ensure infection control measures were implemented as required for one resident #105, and failed to ensure one staff wore the face mask appropriately. The deficient practice could result in spread of infection to staff and residents.

Inspectors wroteBased on clinical record review, staff interviews, facility documents, and policy review, the facility failed to ensure one resident (#425) and/or their representative were informed of the risks and benefits of a psychotropic medication prior to receiving the medication. The sample size was 6. The deficient practice could result in residents and/or their representatives not being aware of the risks and benefits of psychoactive medications.

Inspectors wroteBased on observation, clinical record review, resident and staff interviews, and policy and procedures, the facility failed to ensure one resident (#34) had the right to self-determination by failing to honor the resident request to eat breakfast in the dining room. The sample size was 26. The deficient practice could result in residents being denied their right to make their own decisions.

Inspectors wroteBased on observations, clinical record review, resident and staff interviews, and policy and procedures, the facility failed to ensure [NAME] Hose were applied to one of two sampled residents (#113) as per the physician order. The deficient practice could impact the health and wellbeing of residents.

Inspectors wroteBased on observation, clinical record review, resident and staff interviews, and policy and procedures, the facility failed to ensure a physician order was in place prior to administering oxygen to one of two sampled residents (#113). The deficient practice could result in residents receiving unnecessary oxygen treatment.

Inspectors wroteBased on observations, clinical record reviews, staff interviews, review of facility documents, and review of policies and procedures, the facility failed to ensure the medication error rate was not 5% or greater, by failing to administer medications as ordered to two residents (#27 and #183). The error rate was 10.71%. The deficient practice could result in further medication errors.

Inspectors wroteBased on observations, clinical record review, staff interviews, and policy review, the facility failed to ensure a dish for assistive eating was provided for one sampled resident (#49) as ordered. The deficient practice could result in residents not receiving eating equipment needed when consuming meals.