Horizons Care Center

In the surveyor’s words

From the most serious findings on record at Horizons Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Sep 5, 2023

  Based 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). Findings include: I. […]

• Actual harm, isolatedF689Apr 13, 2023

  Based 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. Findings include: I. Professional reference According to the U.S. Consumer Product Safety Commission (CPSC) regarding Tap Water Scalds. […]

• Actual harm, isolatedF760Oct 12, 2021

  Based on record review and interviews, the facility failed to ensure one (#1) of three residents reviewed for medication errors out of seven sample residents received treatment and care in accordance with professional standards of practice. The facility failed to administer long term use medication for Resident #1 as ordered, resulting in severe withdrawal symptoms contributing to her hospitalization . Resident #1 experienced confusion, anxiety, pain and hallucinations. The facility failed to have a system in place to ensure the resident's order for the controlled substance medication [MEDICATION(S)] could be filled, when the medication did not arrive with her other medications. […]

• Actual harm, isolatedF689Sep 28, 2021

  Based on observations, record review and interviews, the facility failed to provide an environment as free from accident hazards as possible for one (#7) of five residents reviewed for falls out of 19 sample residents. The facility failed to ensure Resident #7's care plan was followed, and failed to continuously monitor the effectiveness of interventions and update the care plan accurately. The facility failed to implement new, effective, person-centered interventions timely after each of three falls on 8/6/21, 8/30/21 and 9/15/21. The falls resulted in Resident #7 hitting his head and sustaining injuries each time. […]

• No harm, potential for more than minimal, widespreadF880Nov 7, 2024

  Based 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. Findings include: I. Failure to have an effective water plan A. […]