Horizon Post Acute

In the surveyor’s words

From the most serious findings on record at Horizon Post Acute, in the surveyor’s own words.

• Immediate jeopardy, widespreadF600May 2, 2023

  The 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. […]

• Immediate jeopardy, widespreadF610May 2, 2023

  The 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. Findings included: - During the onsite health resurvey, the following 14 facility reported incidents regarding allegations of resident-to-resident abuse, occurring between 11/10/21 and 04/21/23, were reviewed. […]

• Immediate jeopardy, patternF609May 2, 2023

  The 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. […]

• Immediate jeopardy, patternF689Jul 22, 2021

  The facility census total 61 residents with three of the ten residents who reside on the Memory Care Unit sampled for wandering and the potential for elopement. Based on observation, interview, and record review the facility failed to properly secure and alarm an exit door in the dining room of the Memory Care Unit which exited to a courtyard with a six-foot wooden privacy fence in which cognitively impaired, independently mobile Resident (R) 5 exited the unalarmed door and climbed over the privacy fence without the staff's knowledge sometime after 08:45 PM on 07/16/21, a Friday night. […]

• Immediate jeopardy, isolatedF689Jun 3, 2026

  Based on observation, record review, and interview, the facility failed to provide adequate supervision to prevent accidents for Resident (R) 71, who required assistance with bathing. 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. […]