Horizons Living and Rehab Center

Inspectors wroteBased on record review and interview, the facility failed to notify the resident, family and/or the resident's representative in writing of the transfers/discharge to an acute care hospital for 5 of 6 residents sampled for hospitalizations (Residents #7, #108, #31, #28 and #35).

Inspectors wroteBased on record review and interview, the facility failed to issue a bed hold notice which included the daily bed hold cost, to a resident, known family member and/or legal representative for 5 of 6 sampled residents who had been transferred to the hospital ((Residents #7, #108, #31, #28 and #35).

Inspectors wroteBased on interviews and record reviews the facility failed to ensure all facility staff maintain training in cardiopulmonary resuscitation (CPR) for Healthcare Providers, resulting in staff who are responsible for providing CPR without an active CPR certificate for 8 of 27 days reviewed. This has the potential to effect all of the residents.

Inspectors wroteBased on review of annual evaluations and interviews, the facility failed to complete a annual performance evaluation for Certified Nursing Assistants (CNA) at least every 12 months, for 5 of 5 CNA's reviewed with employment greater than 1 year (CNA #12, CNA #13, CNA #14, CNA #15, CNA #16).

Inspectors wroteBased on the cumulative effect of deficiencies cited during the recertification survey from 8/26/24 through 8/28/24, the facility was not administered in a manner that enabled residents to attain or maintain their highest practicable well-being as evidenced by Federal findings listed under 483.10- Resident rights (F558, F585); 483.15- Resident Notification (F623, F625); 483.24- Quality of Life (F678); 483.25- Quality of Care (F684); 483.35- Nursing Services (F726, F730, T206); 483.60- Food Safety (F812) and 483.95- Training Requirements (F940, F947). These failures to assure a process was in place to monitor staff development and resident care resulted in the facility failing to assist residents to maintain their highest functional and practicable well-being and has the potential to affect all 56 residents. [...]

Inspectors wroteBased on interview and employee personnel record reviews, the facility failed to implement and maintain effective training programs for nursing staff in the areas of cardiopulmonary resuscitation (CPR), nursing competencies, dementia care, resident rights and the required 12 hours of annual in-service education training for Certified Nurses Aid (CNA) for 11 of 12 newly hired nursing staff reviewed and 4 of 5 randomly selected CNAs employed greater than 1 year.

Inspectors wroteBased on Certified Nursing Assistant (CNA) employee education record review and interview, the facility failed to monitor and ensure that the CNA attended the required 12 hours of annual in-service education training and the mandatory yearly trainings for dementia care and resident rights for 4 of 5 randomly selected CNAs employed greater than 1 year (CNA #13, CNA #14, CNA #15, CNA #16). Findings On 8/28/24, a surveyor reviewed the following employee education files: 1. CNA #13 was hired 8/4/21. Review of CNA #13 Employee In-service/attendance Records lacked evidence of dementia and resident rights training. In addition, she has 7.5 of the 12 hours required for continuing education for the year of 2023. 2. CNA #14 was hired 8/10/22. Review of CNA #14 Employee In-service/attendance Records lacked evidence of dementia training. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure accommodations were made for a resident, to include the facility's bathing schedule and resident preferences for 1 of 1 resident reviewed for activities of daily living (Resident #24). Findings On 8/26/24 at 8:20 a.m. and again on 8/27/24 at 7:55 a.m. during interviews, Resident #24 stated he/she had not received a shower in seven days and prefers to be bathed in the morning two times a week. Resident #24 stated he/she has informed the Certified Nurses Aide (CNA), a Registered Nurse, and the Nurse Practitioner of his/her preferences on multiple occasions. On 8/26/24 at 12:46 p.m., observation of the Stowes Unit weekly shower schedule dated 5/2/24 indicated Resident #24 was to receive a shower Wednesday evenings. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to provide follow up care for 1 of 1 resident reviewed with a pacemaker. (Resident #11)

Inspectors wroteBased on observations and interviews, the facility failed to serve and store food in a sanitary manner during 1 of 1 observations of the refrigerator in the main dining room.

Inspectors wroteBased on interviews and record review the facility failed to develop and implement a grievance policy which includes the resident's rights to a grievance, how to file and/or access grievance forms including anonymously and the response or resolution to grievances.

Inspectors wroteBased on record review, observation and interviews, the facility failed to date biological's after opened and according to manufacturer specifications and failed to ensure expired medications were removed from the supply available for use in 1 of 2 medication rooms, 3 out of 3 medication carts and 1 of 3 treatment carts. In addition, the facility failed to adequately store controlled substances in a permanently affixed compartment and double locked in 1 of 2 medication rooms observed.

Inspectors wroteBased on observations and interview, the facility failed to adequately ensure maintenance services necessary to maintain resident's wheelchairs in good repair and sanitary condition and failed to maintain a clean homelike environment on 2 of 3 units ([NAME] and [NAME]).

Inspectors wroteBased on record review and interview, the facility failed to ensure that a care plan included a care area for diabetes management for 1 of 36 sampled residents with care plans developed electronically (#25)

Inspectors wroteBased on record review and interview, the facility failed to establish a system of records for disposition for all controlled drugs to enable accurate reconciliation for the use of Fentanyl (controlled substance, schedule II) transdermal patch for 2 of 3 residents reviewed for Fentanyl transdermal patch use (#37 and #51).

Inspectors wroteBased on electronic medical records review and interviews, the facility failed to ensure that a Minimum Data Set, version 3.0 (MDS) was accurately coded in the area of restraints for 12 of 12 residents reviewed for restraints. In addition, the facility failed to ensure that an MDS was accurately coded in the area of Active diagnosis for 1 of 36 sampled residents. (#8, #11, #18, #25, #26, #29, #30, #33, #35, #36, #37, #44).

Inspectors wroteBased on observation and interview, the facility failed to post the current daily nurse staffing information that includes the facility name, day of the month, a breakdown of the number of registered and licensed nursing staff responsible for direct resident care and indicate which shifts the numbers corresponded to, for 2 of 3 survey days.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the confidentiality of protected health information for 3 of 62 residents 2 of 4 days of survey (Residents #2, #25 and #37).

Inspectors wroteBased on performance evaluation reviews and interview, the facility failed to complete a performance evaluation at least every twelve months for 4 of 4 Certified Nurse Assistant (C.N.A.) performance evaluations reviewed (C.N.A.#1, 2, 3 and 4).

Inspectors wroteBased on review of the facility's Staff Attendance records and interview, the facility failed to monitor and ensure Certified Nursing Assistants (CNAs) attended the required 12 hours of annual in-service education which included Abuse, Resident Rights and Dementia in-services for 2 of 4 randomly selected CNAs employed greater than 1 year (CNA #3 and #4).