Horizons Care Center

Inspectors wroteBased on record review and interviews, the facility failed to report and investigate allegations of abuse involving three (#2, #3 and #7) of six residents reviewed for abuse out of 11 sample residents. Specifically, the facility failed to timely report potential abuse towards Resident #2, Resident #3 and Resident #7.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to: -Implement an effective water management plan; -Appropriately discard Resident #8's medication that was dropped; and, -Provide proper infection control practices while maintaining an indwelling catheter.

Inspectors wroteBased on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to: -Ensure hand hygiene was conducted appropriately; and, -Santitize potentially contaminated surfaces of a food preparation counter.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure the self-administration of medications was clinically appropriate for one (#9) of one out of 20 sample residents. Specifically, the facility failed to appropriately assess Resident #9 for self-administration of medications.

Inspectors wroteBased on record review and interviews, the facility failed to ensure resident choices for one (#18) of five residents reviewed for activities of daily living (ADL) out of 20 sample residents. Specifically, the facility failed to provide bathing assistance for Resident #18 per his preference.

Inspectors wroteBased on observations and interviews, the facility failed to maintain a comfortable homelike environment for residents on one of four units. Specifically, the facility failed to ensure the 400 hallway maintained a temperature of 71 degrees fahrenheit (F) to 81 degrees F.

Inspectors wroteBased on record review and interviews, the facility failed to provide services by qualified persons for two (#14 and #30) of three residents reviewed for falls out of 20 sample residents. Specifically, the facility failed to ensure Resident #14 and Resident #30 were assessed by a registered nurse (RN) after sustaining unwitnessed falls.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#11 and#18) of five residents reviewed for activities of daily living (ADLs) received appropriate treatment and services to maintain or improve his or her abilities out of 20 sample residents. Specifically, the facility failed to provide the necessary assistance and equipment for Resident #11 and Resident #18, who required assistance and encouragement with eating.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#10) of two residents reviewed for pressure injuries out of 20 sample residents received care and services necessary to prevent the development of pressure injuries. Specifically, the facility failed to ensure staff consistently followed the care planned wound prevention interventions for Resident #10, who had a facility-acquired pressure ulcer.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide respiratory care services for one (#8) of two residents reviewed for respiratory care services out of 20 sample residents. Specifically, the facility failed to ensure oxygen was administered as ordered by the physician for Resident #33.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that the medical record was complete and accurate in keeping with accepted standards of practice for one (#9) of two residents reviewed for skin breakdown out of 20 sample residents. Specifically, the facility failed to conduct an accurate and thorough assessment of a resident's skin.

Inspectors wroteBased record review and interviews, the facility failed to ensure adequate supervision and provide assistance devices to prevent falls for one (#1) of three residents reviewed for falls out of three sample residents. Specifically, the facility failed to ensure Resident #1, who was at high risk for falls, had adequate supervision at night. Resident #1 was left alone on 7/7/23 late at night in the living room without a call light available so she could call for help. As a result, Resident #1 sustained a fall on 7/7/23 and had to be airlifted to the hospital for treatment, where she was diagnosed with a subdural hematoma (a collection of blood that forms on the surface of the brain).

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that the residents environment was free from accident hazards and received supervision and assistance to prevent accidents and hazards for two (#9 and #13) of six sample residents out of 26 sample residents. The facility failed to ensure a hot beverage was a safe temperature before it was served to Resident #9. Due to the facility failures, the resident experienced a burn that caused her pain after a hot beverage spilled onto her right lower leg. In addition, Resident #13 was kept free from an accident in a malfunctioning wheelchair.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on three of four units and one of two dining rooms. Specifically, the facility failed to: -Ensure appropriate hand hygiene practices during meals and doffing personal protective equipment (PPE); -Ensure appropriate use of PPE such as masks; -Ensure medical equipment was disinfected after use; and, -Ensure high touch surfaces were disinfected after potentially contaminated items were placed on top of the surfaces.

Inspectors wroteBased on observations, record review and staff interviews the facility failed to provide services three (#23, #27 and #21) out of seven residents reviewed out of 26 sample residents according to professional standards of practice. Specifically, the facility failed to ensure: -Resident #23 and #27's blood pressure was monitored prior to the administration of a blood pressure medication; and, -Resident #21 skin assessment was performed underneath bilateral lower extremity fracture walking boots.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for three (#3, #27 and #21) of four residents reviewed out of 26 sample residents. Specifically, the failed failed to: -Ensure Resident #3 received care to prevent a mat from forming in her hair; and, -Ensure Resident #3, Resident #27 and Resident #21 received bathing according to their preference and plan of care.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure one (#1) of one sample residents received care, consistent with professional standards of practice, to prevent pressure injuries and did not develop pressure injuries unless the individual's clinical condition demonstrated they were unavoidable; and to promote healing, prevent infection and prevent new ulcers from developing. Specifically the facility failed to ensure appropriate interventions were in place and followed related to Resident 16's pressure ulcer.

Inspectors wroteBased on record review and interviews, the facility failed to identify the use of the indwelling catheter in the medical record for one resident (#3) of one resident reviewed for catheter use out of 26 sample residents. Specifically, the facility failed to ensure an assessment of the indwelling catheter that included a comprehensive, interdisciplinary review identifying the underlying factors which support the clinical indication for the initiation and continued need for catheter use, the development of a plan for removal, consideration of complications resulting from the use of an indwelling catheter, insertion, ongoing care that adhered to professional standards of practice and infection prevention and control procedures; and ongoing monitoring for changes related to potential catheter associated urinary tract infections (CAUTIs).

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure each resident received necessary respiratory care and services that is in accordance with professional standards of practice and the resident's care plan for one (#21) of three residents reviewed for oxygen therapy out of 26 sample residents. Specifically, the facility failed to ensure Resident #21 received oxygen therapy in accordance with the physician's order.

Inspectors wroteBased on observations, interviews and record review, the facility failed to manage pain in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents goals and preferences for two (#21 and #3) out of 26 sample residents. Specifically, the facility failed to: -Offer non-pharmacological pain interventions for Resident #21; -Determine an acceptable pain level for Resident #21 and #3; and, -Administer pain medications per physician's order for Resident #3.

Inspectors wroteBased on record review and interviews, the facility failed to allow residents the right to make choices about aspects of his or her life in the facility that were significant to the resident for three (#11, #21 and #40) of five residents reviewed for bathing preferences out of 24 sample residents. Specifically, the facility failed to provide routine bathing consistent with the residents' preferences for Resident #11, #21 and #40.

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure three (#9, #31 and #5) of five residents reviewed out of 24 sample residents were free from abuse by Residents #37, #5, #11 and #31. Specifically, the facility failed to ensure: -Resident #9 was free from verbal abuse by Resident #37; -Resident #31 was free from sexual abuse by Residents #5 and #11; and, -Resident #5 was free from physical abuse by Resident #31. Cross-reference F609 failure to report abuse, F610 failure to thoroughly investigate abuse and F742 mental health and behavioral services.

Inspectors wroteBased on record review and interviews, the facility failed to thoroughly investigate abuse allegations involving five (#9, #37, #31, #5 and #11) of six out of 24 sample residents reviewed. Specifically, the facility failed to thoroughly investigate: -Resident #9's verbal abuse by Resident #37; -Resident #31's sexual abuse by Residents #5 and #11; and -Resident #5's physical abuse by Resident #31. Cross-reference F600 failure to ensure residents were free from abuse, F609 failure to report abuse, and F742 mental health and behavioral services.

Inspectors wroteBased on record review and interviews, the facility failed to identify and report abuse incidents involving two (#37 and #31) of six out of 24 sample residents reviewed to the State Survey and Certification Agency. Specifically, the facility failed to identify as abuse and report: -Resident #37's ongoing incidents of verbal abuse and threatening behavior directed toward other facility residents; and, -Resident #5's physical abuse by Resident #31. Cross-reference F600 failure to ensure residents were free from abuse, and F742 mental health and behavioral services.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents identified with a mental disorder (MD) or intellectual disorder (ID) were evaluated and received care and services in the most integrated setting appropriate to their needs for one (#18) of one resident reviewed for pre admission screening and resident review (PASRR) of 24 sample residents. Specifically, the facility failed to ensure Resident #18 had a follow up PASRR after initial evaluation, dated 4/9/21, determined revaluation was needed within 30 days.

Inspectors wroteBased on record review and interviews, the facility failed to provide mental health care and services for one (#37) of two residents reviewed out of 24 sample residents. Specifically, the facility failed to identify and provide for Resident #37's mental health needs. Resident #37 exhibited anxiety, adjustment difficulty and distress, and exhibited verbally abusive behaviors toward other residents. Resident #37 resided in the memory care neighborhood with 10 other vulnerable residents. Cross-reference F600, failure to protect residents from abuse.