Horizon Post Acute

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide adequate supervision to prevent accidents for Resident (R) 71. On 04/27/2026 at 08:00 PM, R71 self-propelled himself into an unlocked shower room, then came out and waved down Certified Nurse Aide (CNA) M to request assistance with shaving. CNA M assisted R71 with shaving and then left the resident alone in the shower to complete his own shower. While staff were out of the shower room, R71 slipped and hit his chin on the shower bar. Approximately two hours later, R71 began to feel nauseous. He vomited, reported a headache, and requested to go to the hospital. R71 went to the emergency department where he was diagnosed with a subdural hematoma and was subsequently placed on a ventilator. The resident returned to the facility on [DATE] on hospice and died in the facility on 05/06/2026. [...]

Inspectors wroteBased on review and interviews, the facility failed to facilitate and ensure the resident council was able to meet regularly.

Inspectors wroteBased on interviews, record reviews, and observation, the facility failed to ensure a safe, clean, comfortable, home like environment. This deficient practice placed the residents at risk for tripping hazards, electrical accidents, respiratory hazards, and decreased comfort.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure Resident (R)5's call light was within his reach to enable him to call for staff assistance. Findings Included:- R5's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), major depressive disorder (major mood disorder that causes persistent feelings of sadness), neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying), and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff secured and protected the privacy and confidentiality of Resident (R) 8's medical record.

Inspectors wroteBased on interviews, observation, and record review the facility failed coordinate care for Resident (R) 22 following a Preadmission Screening and Resident Review (PASSAR-short series of questions designed to determine whether or not a more in-depth assessment for mental health or mental retardation services is required) which indicated a PASSAR II (an in-depth assessment for the purpose of determining whether the individual requires the level of services provided by a nursing facility or the level of services provided in a specialized program for persons with mental illness or developmental disabilities) was needed.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to revise Resident (R) 5's Care Plan to include the care of his catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid). [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure staff assisted Residents (R)5 with bathing, and hygiene as needed. Findings Included:- R5's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), major depressive disorder (major mood disorder that causes persistent feelings of sadness), neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying), and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to implement an activities program to support Resident (R)10's social needs with involvement in both individual and group activities to support his highest psychosocial well-being when staff failed to offer and provide activities of his choice.

Inspectors wroteBased on observation, record reviews, and interviews, the facility failed to provide adequate catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) acre for Resident (R) 5 when staff failed to secure the tubing with an anchoring device to prevent pulling and injury and further failed to provide a dignity bag for the urine collection bag. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide adequate respiratory care and services for Resident(R) 5, who had a respiratory infection, when staff failed to store R5's continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) and his nasal cannula in a sanitary manner when not in use. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that Resident (R) 1 when staff failed to assess the residents dialysis (a procedure where impurities or wastes are removed from the blood) access site within the standards of practice. The facility additionally failed to ensure R2 had an active physician's order that included the time, place, and days of their dialysis clinic treatments.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure pureed food (food has been ground, pressed, and/or strained to a consistency of a soft, smooth, thick paste similar to a thick pudding) had been prepared to conserve the nutritive value, palatable flavor for two residents on a pureed diet.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to post the previous state inspection information in a location accessible to residents and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the daily nurse staffing sheet was posted and failed to retain the required 18 months of daily nurse staff posting.

Inspectors wroteThe facility reported a census of 69 residents. The sample included three residents. Based on observation, record review, and interviews, the facility failed to maintain an effective pest control program. This deficient practice had the potential for decreased psychosocial well-being and impaired safety and comfort for the affected residents.

Inspectors wroteThe facility reported a census of 69 residents. The sample included three residents. Based on observation, record review, and interviews, the facility failed to promote a sanitary, homelike environment. This deficient practice had the potential for decreased psychosocial well-being and impaired safety and comfort for the affected residents.

Inspectors wroteThe facility reported a census of 69 residents. The sample included four residents reviewed for elopement (when a cognitively impaired resident leaves the safe area or premises without supervision). Based on observation, interview, and record review, the facility failed to implement interventions to mitigate the risk of elopement for Resident (R) 1, when the facility failed to update the facility ' s Elopement Risk Book used to alert staff which residents were at risk for elopement. This deficient practice increased the risk of elopement for the affected residents.

Inspectors wroteThe facility had a census of 66 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to implement a water management program for Legionella disease (Legionella is a bacterium spread through mist, such as from air-conditioning units for large buildings. Adults over the age of 50 and people with weak immune systems, chronic lung disease, or heavy tobacco use are most at risk of developing a pneumonia caused by legionella). The facility failed to implement acceptable infection control practices when staff failed to properly store Resident (R) 48 and R60's oxygen tubing and nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a person in need of respiratory help) in a sanitary manner. This deficient practice placed the residents in the facility at risk for infectious diseases. Findings Included: [...]

Inspectors wroteThe facility had a census of 66 residents. The sample included 17 residents. Based on observation, record review, and interview the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents who ate in the main dining room and resided in the 400 hall. This deficient practice placed the residents who ate in the main dining room at risk for impaired health and well-being; and the residents who resided in the 400 hall at risk for falls.

Inspectors wroteThe facility had a census of 66 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety in one kitchen. This deficient practice placed the residents who received their meals from the facility's kitchens at risk for foodborne illness.

Inspectors wroteThe facility had a census of 66 residents. The sample included 17 residents, with five residents reviewed for immunizations, Resident (R) 24, R25, R29, R33, and R37, to include pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) vaccinations. Based on record review and interviews, the facility failed to offer, or obtain an informed declination, or a physician documented contraindication for the pneumococcal PCV20 vaccination per the latest guidance from the Centers for Disease Control and Prevention (CDC). This deficient practice placed the residents at risk for pneumococcal infection and related complications.

Inspectors wroteThe facility had a census of 66 residents. The sample included 17 residents with one resident reviewed for discharge. Based on observation, record review, and interview, the facility failed to provide Resident (R) 18 with written information regarding the facility bed hold policy when she was transferred to the hospital. This deficient practice placed R18 at risk for not being permitted to return and resume residence in the nursing facility.

Inspectors wroteThe facility identified a census of 66 residents. The sample included 17 residents, with one Resident (R) 24 reviewed for trauma-informed care (treatment or care directed to prevent re-experiencing or reducing the effects of traumatic events). Based on observation, record review, and interviews, the facility failed to implement a person-centered care plan with individualized interventions to address R24's post-traumatic stress disorder (PTSD - a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), trauma, triggers, and interventions to prevent re-traumatization. These deficient practices placed R24 at risk for decreased psychosocial well-being and ineffective treatment.

Inspectors wroteThe facility had a census of 66 residents. The sample included 17 residents. Based on observation, record review, and interview the facility failed to promote an environment free of hazards for Resident (R)21 who smoked cigarettes but was assessed for supervised safe smoking practices by the facility, however the resident revoked the assessment, and smoked without supervision. This placed the resident at risk for avoidable injuries and fire related hazards

Inspectors wroteThe facility had a census of 66 residents. The sample included 17 residents, with one reviewed for dialysis. Based on observation, record review, and interview, the facility failed to provide ongoing care plan communication and documentation of Resident (R) 70, who received dialysis (the process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood) treatment, including updated care, and services required for R70. This deficient practice placed R70 at risk for inadequate care, complications, and health decline.

Inspectors wroteThe facility identified a census of 66 residents. The sample included 17 residents, with one Resident (R) 24 reviewed for trauma-informed care (treatment or care directed to prevent re-experiencing or reducing the effects of traumatic events). Based on observation, record review, and interviews, the facility failed to identify trauma-based triggers related to R24's post-traumatic stress disorder (PTSD - a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress). The facility failed to implement individualized interventions to prevent re-traumatization to R24. These deficient practices placed R24 at risk for decreased psychosocial well-being and ineffective treatment.

Inspectors wroteThe facility identified a census of 66 residents. The sample included 17 residents, with five sample residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported when Resident (R) 25's physician ordered insulin (a hormone that lowers the level of glucose in the blood) administration and finger stick blood sugar (a procedure that measures the level of sugar in a small drop of blood from the fingertip) had not been completed as ordered. This deficient practice placed R25 at risk for unnecessary medication administration and related complications.

Inspectors wroteThe facility identified a census of 66 residents. The sample included 17 residents with five sample residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure facility staff administered Resident (R) 25's physician-ordered insulin (a hormone that lowers the level of glucose in the blood) and obtained finger stick blood sugars (a procedure that measures the level of sugar in a small drop of blood from the fingertip) as ordered. This deficient practice placed R25 at risk for unnecessary medication administration and related complications.

Inspectors wroteThe facility identified a census of 66 residents. The sample included 17 residents with five sample residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 25, R38, and R22 had an adequate Centers for Medicare and Medicaid (CMS) approved indication for the use of an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication. This deficient practice placed R25 at risk for unnecessary medication administration and related complications.

Inspectors wroteThe facility had a census of 66 residents. The sample included 17 residents. Based on observation, interview, and record review, the facility failed to discard Resident (R) 10 flex pen, R68 vial of expired insulin (a hormone that lowers the level of glucose in the blood), and further failed to label R36 and R70 insulin flex pens when opened to use and when they expired. This deficient practice placed the affected residents at risk for ineffective medications.

Inspectors wroteThe facility identified a census of 66 residents. The sample included 17 residents, with two sampled residents reviewed for hospice care. Based on observation, record review, and interview, the facility failed to ensure there was a collaboration of care between Resident (R) 38's hospice provider and the facility. This deficient practice placed R38 at risk of inadequate end-of-life care.

Inspectors wroteThe facility reported a census of 68 residents, with five sampled, including three residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, interview, and record review, the facility failed to ensure Resident (R)1, who was totally dependent on staff for cares, had been repositioned timely and his brief changed timely after bowel and/or bladder incontinent episodes. Furthermore, the facility failed to monitor R1's skin weekly, conduct weekly wound assessments, and provide wound treatments as ordered. R1 developed an unstageable pressure ulcer (depth of the wound is unknown due to the wound bed is covered by a thick layer of other tissue and pus) on 05/20/24. [...]

Inspectors wroteThe facility reported a census of 58 residents with five residents selected for review. Based on observation, interview, and record review, the facility failed to revise the care plan for Resident (R)1 for his pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) to his buttocks and placement of a urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag), for R2 for her right foot wound, and for R5 for catheter management. This deficient practice placed these three residents at risk to not receive appropriate cares and treatments.

Inspectors wroteThe facility reported a census of 68 residents with three sampled residents for skin conditions. Based on observation, interview, and record review, the facility failed to ensure the staff provided treatments as ordered to Resident (R)2, who had an ulcer to her right foot, monitor her wound status weekly, and ensure she had pressure relieving boots in place when in bed.

Inspectors wroteThe facility reported a census of 68 residents with five residents reviewed, including three residents reviewed for urinary incontinence management. Based on observation, record review, and interview, the facility failed to provide timely incontinence care to Resident (R)1 and R2.

Inspectors wroteThe facility reported a census of 68 residents with five residents reviewed, with one resident reviewed for pharmacy services, Resident (R)4. Based on observation, interview, and record review, the facility failed to ensure the staff ordered R4's medication timely, resulting in her missing eight doses of her scheduled Norco (narcotic pain medication) and one dose of her scheduled Fentanyl (narcotic pain medication) patch.

Inspectors wroteThe facility reported a census of 68 residents. Based on observation, record review, and interview, the facility failed to maintain an effective prevention and control program with failure to perform appropriate glove removal and hand hygiene during after a disposable brief removal and during a dressing change for Resident (R)3 on 07/29/24, lacked hand hygiene during peri-care for R2, stored R2's pressure reducing boot directly on the floor, and failed to ensure R5's catheter drainage bag positioned appropriately to ensure proper urine flow.

Inspectors wroteThe facility reported a census of 70 residents. The review included 14 facility self-reported incidents with allegations of resident-to-resident abuse, between the dates of 11/10/21 and 04/21/23. Based on observation, interview, and record review the facility failed to provide a safe and secure living environment for the residents of the facility with the failure to accurately investigate, assess, and implement adequate immediate interventions to prevent the continued abuse of resident-to-residents, following these 14 incidents reviewed. This deficient practice put 70 residents in immediate jeopardy and placed 19 residents at risk for continued resident-to-resident abuse.

Inspectors wroteThe facility reported a census of 70 residents. The review included 14 facility self-reported incidents with allegations of resident-to-resident abuse, between the dates of 11/10/21 and 04/21/23. Based on observation, interview, and record review the facility failed to conduct a thorough investigation of the allegations of resident-to-resident abuse and failed to take appropriate corrective actions to protect residents from further abuse. This deficient practice put 70 residents in immediate jeopardy and placed 19 residents at risk for continued resident-to-resident abuse.

Inspectors wroteThe facility reported a census of 70 residents. The review included 14 facility reported incidents with allegations of resident-to-resident abuse, between the dates of 11/10/21 and 04/21/23. Based on observation, interview, and record review, the facility failed to provide a safe and secure living environment for the residents of the facility with the failure to report the incidents in a timely manner as required, following 11 of these 14 incidents reviewed. This deficient practice put 70 residents in immediate jeopardy and placed 19 residents at risk for continued resident-to-resident abuse.

Inspectors wroteThe facility census totaled 70 residents, with 18 in the sample, including one resident reviewed for accident hazards. Based on observation, interview, and record review the facility failed to ensure staff provided adequate supervision and followed the resident's fall prevention interventions to prevent further falls for Resident (R) 18, including one fall which resulted in a fractured (broken bone) right femur (thigh bone) and surgical repair.

Inspectors wroteThe facility reported a census of 70 residents. Based on observation and interview, the facility failed to provide necessary housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior in resident areas including on five of the five resident hallways, the dining room, the beauty shop, and in courtyards, for the residents of the facility.

Inspectors wroteThe facility reported a census of 70 residents on five hallways, one being a locked dementia (progressive mental disorder characterized by failing memory, confusion) unit. Based on observation, interview, and record review, the facility failed to have sufficient nursing staff to provide nursing and related services which included behavioral monitoring and staffing. The facility further failed to ensure adequate nursing staff to monitor medication administration as ordered by a physician, and to perform adequate monitoring of medications administered. Findings Included: - Upon entrance on 04/24/23 at 09:00 AM Administrative staff A informed the survey team the facility Director of Nursing (DON) quit two weeks ago, but the Minimum Data Set (MDS) nurse would be the acting interim DON. [...]

Inspectors wroteThe facility reported a census of 70 residents, with 18 residents sampled. Based on observation, interview, and record review the facility failed on four days to have Registered Nurse (RN) coverage for at least eight hours daily in the last three months.

Inspectors wroteThe facility reported a census of 70 residents. The facility identified three residents that received pureed meals from the main kitchen. Based on observation, interview, and record review, the facility failed to prepare and serve food in a sanitary manner to prevent the spread of food borne illnesses to the residents of the facility.

Inspectors wroteThe facility reported a census of 70 residents. Based on observation, interview, and record review the facility failed to provide administrative services in a manner to effectively and efficiently use resources to attain/maintain each resident's highest physical, mental, and psychosocial well-being, for all 70 residents that resided in the facility.

Inspectors wroteThe facility reported a census of 70 residents. Based on record review and interview, the facility failed to conduct Quality Assurance and Performance Improvement (QAPI) committee meetings with the required members present, which included having the Medical Director present at the meetings. This had the potential to affect all residents.

Inspectors wroteThe facility reported a census of 70 residents. Based on observation, interview and record review, the facility failed to maintain an effective infection control program with the failure of staff to perform hand hygiene when appropriate and failure of the staff to clean equipment between resident use. This deficient practice has the potential to negatively affect every resident in the facility.

Inspectors wroteThe facility reported a census of 70 residents. Based on observation and interviews, the facility failed to maintain an adequate call light system for the residents of the facility, when only two direct care workers had access to pagers to monitor for call lights, on the facility five resident hallways.

Inspectors wroteThe facility had a census of 70 residents. The sample included 18 residents with one resident reviewed for bed side rails. The facility had 11 residents with bed side rails in place. Based on observation, interview, and record review the facility failed to monitor the use of bed side rails for Resident (R) 4. This deficient practice placed R4 and the other 10 residents at risk for potentially serious injury.

Inspectors wroteThe facility census totaled 70 residents, with 18 residents included in the sample. Based on interview and record review the facility failed to ensure sufficient competent staffing to address the behavior health needs of the residents to provide a safe environment.

Inspectors wrote- R57's pertinent diagnoses from the Electronic Health Record (EHR) documented dementia (a progressive mental disorder characterized by failing memory, confusion) with agitation, other frontotemporal neurocognitive disorder (a progressive disease of the brain affecting the frontal and temporal lobes of the brain resulting in behavior outbursts, trouble communicating and base personality changes) and unspecified speech disturbances. R57's admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) by staff assessment indicating memory problems with severely impaired cognition. No abnormal behaviors were documented during the seven-day look back period. The resident received an antipsychotic (class of medications used to treat psychosis and other mental emotional conditions) daily during the seven-day look back period. [...]

Inspectors wroteThe facility reported a census of 70 residents with 18 residents selected for review and included five residents reviewed for unnecessary medications. Based on observation, interview and record review, the facility failed to ensure Resident (R) 50 and R57 were monitored for side effects of extrapyramidal (abnormal involuntary body movements caused by medications) symptoms due to antipsychotic (a class of medication used to treat psychosis and other mental emotional conditions) medication use, failed to monitor R25 and R48 for behaviors related to antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression) medication use and antianxiety (a class of medications that calm and relax people with excessive anxiety, nervousness, or tension).

Inspectors wroteThe facility reported a census of 70 residents with 18 selected for review. Based on interview, observation, and record review, the facility failed to protect the privacy and dignity of Resident R42. This deficient practice led to R42 being able to be around multiple other residents with visibly soiled clothing.

Inspectors wroteThe facility reported a census of 70 residents, with 18 included in the sample. Based on observation, interview, and record review the facility failed to incorporate the recommendations from a Preadmission Screening and Resident Review (PASRR) level II evaluation report into Resident (R) 12's assessment, care plan, and/or a transition of care. Findings Included: - The Electronic Health Record (EHR) for R12 revealed the following diagnoses; [...]

Inspectors wroteThe facility reported a census of 70 residents with 18 sampled, including one for PASRR (Pre-admission Screening and Resident Review). Based on interview and record review the facility failed to inform the state mental health authority in a timely manner of Resident (R) 12's significant change on 10/14/22.

Inspectors wroteThe facility reported a census of 70 residents with 18 residents included in the sample. Based on observation, interview, and record review the facility failed to develop a comprehensive care plan for one resident of 18 residents reviewed for care plans. Resident (R) 216.

Inspectors wroteThe facility census totaled 70 residents with 18 included in the sample. Based on observation, interview, and record review the facility failed to provide timely care to skilled Resident (R) 216, who was in rehabilitation, with plans to return home.

Inspectors wroteThe facility reported a census of 70 residents with 18 selected for review with two reviewed for incontinence. Based on interview, observation, and record review, the facility failed to provide appropriate treatment and services of Resident (R)42 through failure to recognize visibly soiled clothing related to urinary incontinence. This deficient practice had the potential to negatively affect R42.

Inspectors wroteThe facility identified a census of 70 residents, which included 18 residents in the sample. Based on record reviews, the facility failed to ensure timely physician visits for Resident (R) 54, R43, and R25.

Inspectors wroteThe facility reported a census of 70 residents. Based on interview and record review the facility failed to ensure Certified Nurse Aides (CNA) received an annual evaluation for three of five staff reviewed to ensure the care provided to the residents for their highest practicable level of well-being. Findings Include: - Review of five Certified Nurse Aides (CNA) records (with employment for the facility documented as more than one year) revealed lack of documentation of annual evaluations for three of the five CNAs reviewed. (CNA L, CNA V, and CNA W). On 04/27/23 at 02:01 PM Administrative Staff A confirmed the facility was behind on the evaluations of the staff. The October 2017 facility Staffing policy lacked any direction/information/documentation that addressed the CNA annual evaluation. [...]

Inspectors wroteThe facility census reported 70 residents with 18 residents sampled, that included five residents sampled for unnecessary medications. Based on observation, interview, and record review, the facility failed to follow the physician's orders for Resident (R)50, related to physician ordered insulin. This failure placed the resident at risk for adverse effects related to medication use.