Horizons Care Center

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Miscellaneous Deficiencies

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Resident Assessment and Care Planning Deficiencies

Provide care by qualified persons according to each resident's written plan of care.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Smoke Deficiencies

Construct fire resistant interior walls.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Egress Deficiencies

Meet other general requirements that are deficient.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

*** CITATION TEXT NOT FOUND *** A document revisit was completed with all deficiencies being corrected with the exception of any waived deficiency or deficiencies. All waived deficiencies will be corrected at a later date as per the approved waiver. A plan of correction is not required.

A portable space heater was found in the office; the heating element was measured above 800* and only allowed to be 212* max, removed during the survey. No POC required INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).The f.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and 80. This was evidenced by: 1) Fire Doors (annually)(80 5.2): Not adeq.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 80, 90A, and 105. This was evidenced by:1) Fire Dampers (4-6 years)(101.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 99, and 110. This was evidenced by:1) Emergency Power (101 9.1.3.1 &a.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, and 25. This was evidenced by:1) Fire Sprinkler Annual report missing mu.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:1) The battery-powered egress light for the gener.. Through observation during the survey, it was determined that the facility failed to maintain doors in accordance with NFPA 101. This was evidenced by:1) The hotel rehab corridor is obstructed from rehabilitation gym equipment2) rem.. Through observation during the survey, it was determined that the facility failed to maintain hazardous areas in accordance with NFPA 101. This was evidenced by:1) The storage room in Grand Mesa Way is deemed hazardous and .. Through observation during the survey, it was determined that the facility failed to maintain interior wall and ceiling finishes in accordance with NFPA 101. This was evidenced by:1) remove wood shingles that are a class C finish in the .. Through observation during the survey, it was determined that the facility failed to meet the healthcare facilities code requirements in accordance with NFPA 101 and 54. This was evidenced by:1) need caster blocks added to kitche.. Through observation during the survey, it was determined that the facility failed to meet the means of egress requirements in accordance with NFPA 101. This was evidenced by:1) remove exit signage for the hotel rehab wing. .. Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:1) remove the deadbolt lock on the therapy wing fire doorNFPA .. Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:1) The hotel rehab gym is open to the corridor and needs to re..

A recertification survey with Incident #35938 was completed on 11/4/24 to 11/7/24. Ten deficiencies were cited. An Emergency Preparedness survey was conducted from 11/4/24 to 11/7/24. No deficiencies were cited. Based on observations and interviews, the facility failed to maintain a comfortable homelike environment for residents on one of four units.Specifically, the facility failed to ensure the 400 hallway maintained a temperature of 71 degrees fahrenheit (F) to 81 degrees F.Findings include:I. Facility policy and procedureThe Safe Physical Environment policy, .. Based on observations, interviews and record review, the facility failed to ensure the self-administration of medications was clinically appropriate for one (#9) of one out of 20 sample residents.Specifically, the facility failed to appropriately assess Resident #9 for self-administration of medications.Findings include:I. Professional referenceAcco.. Based on observations, record review and interviews, the facility failed to ensure one (#10) of two residents reviewed for pressure injuries out of 20 sample residents received care and services necessary to prevent the development of pressure injuries.Specifically, the facility failed to ensure staff consistently followed the care planned wound preven.. Based on observations, record review and interviews, the facility failed to ensure two (#11 and#18) of five residents reviewed for activities of daily living (ADLs) received appropriate treatment and services to maintain or improve his or her abilities out of 20 sample residents. Specifically, the facility failed to provide the necessary assistance and equip.. Based on observations, record review and interviews, the facility failed to provide respiratory care services for one (#8) of two residents reviewed for respiratory care services out of 20 sample residents.Specifically, the facility failed to ensure oxygen was administered as ordered by the physician for Resident #33.Findings include:I. Facility policy an.. Based on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to:-Ensure hand hygiene was conducted appropriately; and,-Santitize potentially contaminated surfaces of a food preparation counter. Findings include:I. Pr.. 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 pla.. Based on record review and interviews, the facility failed to ensure resident choices for one (#18) of five residents reviewed for activities of daily living (ADL) out of 20 sample residents. Specifically, the facility failed to provide bathing assistance for Resident #18 per his preference.Findings include: I. Facility policy and procedureThe Showers, .. Based on record review and interviews, the facility failed to ensure that the medical record was complete and accurate in keeping with accepted standards of practice for one (#9) of two residents reviewed for skin breakdown out of 20 sample residents.Specifically, the facility failed to conduct an accurate and thorough assessment of a resident' s.. Based on record review and interviews, the facility failed to provide services by qualified persons for two (#14 and #30) of three residents reviewed for falls out of 20 sample residents. Specifically, the facility failed to ensure Resident #14 and Resident #30 were assessed by a registered nurse (RN) after sustaining unwitnessed falls.Findings in..