Horizon Health & Subacute Center

In the surveyor’s words

From the most serious findings on record at Horizon Health & Subacute Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Mar 1, 2024

  Based on observations, interviews, record reviews, and facility policy reviews, the facility failed to: 1) ensure staff monitored urinary output in accordance with the physician's order, and the facility policy; 2) immediately address Resident #1's complaint of severe pain; and 3) ensure the resident's stage four pressure ulcers were treated as ordered by the physician. On 02/26/2024 at 11:12 AM, Resident #1 notified Certified Nursing Assistant (CNA) #1 of their pain; however, staff did not intervene and address the resident's complaint of pain until 1:10 PM. Resident #1 experienced severe pain for greater than two hours, suffered bladder distension due to a malfunctioning catheter and had an infected pressure ulcer that was left uncovered. […]

• No harm, potential for more than minimal, widespreadF814Jul 31, 2026

  Based on observation, interview, and record review, the facility failed to ensure garbage was stored and disposed of in a manner that prevented unsanitary conditions when one out of two outdoor dumpsters was observed with one lid open. This failure had the potential to attract pests, create offensive odors and negatively impact food safety and the overall sanitary environment of the facility. During a concurrent observation and interview on 7/28/26 at 8:45 a.m. during the initial tour of the kitchen with Dietary Service Supervisor (DSS), the facility was observed with two dumpsters located behind the building. One dumpster for food waste was observed with one lid open. […]

• No harm, potential for more than minimal, widespreadF880Mar 7, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF656Jul 31, 2026

  Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan (CP - a detailed approach to care customized to an individual resident's needs) to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for four of 15 sampled residents (Residents 132, 12, 31, and 121) when: 1. Resident 132's nutrition care plan for significant unintended weight loss was not developed. […]

• No harm, potential for more than minimal, patternF658Jul 31, 2026

  Based on observation, interview, and record review the facility failed to meet professional standards of practice for 5 of 25 sampled residents (Residents 42, 31, 2, 135, 59) when: 1. The facility did not follow the physician's order to recheck Resident 42's blood glucose (the amount of sugar in the blood) 15 minutes after administering 16 units (a standard measurement used to determine the dose of insulin) of insulin lispro (a rapid-acting insulin medication used to lower blood sugar) for blood glucose results of 451-500 mg/dL (milligrams per deciliter, the unit used to measure the amount of sugar in the blood) and did not establish physician notification parameters for hyperglycemia ( high blood sugar) to guide nursing interventions. […]