Horizon Post Acute and Rehabilitation Center

In the surveyor’s words

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

• Actual harm, isolatedF600Oct 31, 2025

  The facility failed to ensure residents do not abuse other residents.Based on observations, interviews, record review, the facility failed to protect the resident's right (#1) to be free from physical abuse by another resident (#2). The deficient practice could result in further abuse of residents and appropriate action not taken.Findings include:Regarding Resident #1 (alleged victim) :Resident #1 was admitted to the facility on [DATE] with diagnoses that included hemiplegia, seizures, hypothyroidism, major depressive disorder, schizophrenia, anxiety disorder and muscle weakness.Review of Resident #1's quarterly minimum data set (MDS) assessment dated [DATE] revealed that the Brief Interview for Mental Status (BIMS) score was 15, indicating the resident is cognitively intact.Review of… […]

• No harm, potential for more than minimal, patternF759May 16, 2025

  Based on observations, staff interviews, record review, and policy review, the facility failed to ensure the medication error rate was not 5% or greater, by failing to administer medications as ordered for three of four residents (#58, #25, #103). The deficient practice could result in adverse effects and further medication errors. Findings Include: Six medication administration errors were identified out of 38 opportunities during medication administration observation. The medication error rate was 15.79% -Regarding Resident #58 Resident #58 was admitted to the facility on [DATE] with diagnoses that included viral hepatitis, anxiety disorder, depression, and schizophrenia A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score… […]

• No harm, potential for more than minimal, patternF880May 16, 2025

  -Resident #545 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included urinary tract infection, adult failure to thrive, gastrostomy status, chronic kidney disease stage 3, obstructive and reflux uropathy and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominate side. An admission Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident #545 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated severe cognitive impairment. […]

• No harm, potential for more than minimal, patternF880Apr 1, 2022

  Based on observation, clinical record review, staff interviews, and facility policy and procedure, the facility failed to ensure infection control measures were implemented as required for one resident #105, and failed to ensure one staff wore the face mask appropriately. The deficient practice could result in spread of infection to staff and residents. Findings include: Regarding the face mask On March 28, 2022 at 2:50 p.m., two female staff and one male staff (A) wearing their face masks were observed walking together from the reception area to the kitchen/dining room. At the end of the hallway just before the kitchen/dining room, another male staff (B) wearing a white shirt and tan pants was observed standing and holding a folded box carton. […]

• No harm, potential for more than minimal, patternF600Mar 24, 2021

  Based on clinical record review, resident, family and staff interviews and facility documentation, policy and procedure review, the facility failed to ensure one resident (#1) was free from sexual abuse. The deficient practice could result in further incidents of resident abuse. Findings include: Resident (#1) was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The daily skilled note dated February 24, 2021 included the resident was alert, oriented x 3 with no active symptoms or treatment affecting level of consciousness, cognition, mood and behavior. It also included the resident required extensive assistance with one-person physical assist with bed mobility, transfer and toilet use. A late entry physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . […]