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Inspection visit

complaint

HORIZON ASSISTED LIVING FACILITYLicense 1976097663 citations on this visit
3 citations recorded

Inspector’s narrative

What the inspector wrote

The review of the records revealed the following: R1 was hospitalized on 03/23/2021. Upon admission, R1 was diagnosed with septic shock and acute organ dysfunction and diagnosed with unstageable pressure injury on coccyx, an unstageable pressure injury on left and right heels, deep tissue pressure injury on ischium, a stage III pressure injury (vs trauma) on the leg, deep tissue pressure injuries on the left and right hips, and a deep tissue pressure injury on the left lateral posterior back. Hospital records also documented that R1 was bed bound since sustaining a hip fracture 02/17/2021. Interviews conducted by Investigator Real revealed the following: Administrator and staff were not aware of R1 having pressure injuries prior to hospitalization; however, when interviewed the administrator recalled seeing some “bedsores” on R1’s back. According to the administrator, the pressure injuries were initially open but improved over time and closed. Administrator did not provide approximate time the pressure injuries were observed, or documentation related to the care of the pressure injuries. Additionally, Staff 1 (S1) recalled seeing an injury on R1’s buttocks but did not recall if it was open or closed. R1 received home health services from 02/26/2021 to 03/08/2021 however the services did not include wound care. Home health care staff did not identify pressure injuries. Information obtained during the course of the investigation revealed that R1 developed pressure injuries on or after 03/08/2021. R1 did not receive care for the pressure injuries from a physician or skilled medical professional until being hospitalized on 03/23/2021, therefore the allegation of neglect/lack of care and supervision is substantiated. Per California Code of Regulations (CCR), Title 22, see LIC 9099-D for deficiencies cited. An immediate civil penalty of $500 is also assessed. The licensee was informed that a civil penalty might be assessed based on the Health and Safety Code 1569,49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f). Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.

Citations

5 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87207Type A

    No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.This Requirement was not met as evidenced by: Based on the information obtained by LPA during the visit the licensee/administrator and staff did not comply with he cited section by providing false/misleading statements to LPA regarding Staff/volunteer which posed an immediate personal rights violation to residents in care.

  • 87355(e)(1)Type A

    Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility (1) Obtain a California clearance or a criminal record exemption as required by the Department . This requirement is not met as evidenced byBased on observation and interview the licensee/administrator did not comply with the section cited by allowing S2 to work at the facility prior to obtaining criminal record clearance which poses an immediate health and safety risk to residents in care.

  • 87464(f)Type A

    Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).This requirement was not met as evidenced by: Based on IB investigation record review and interview, the licensee/administrator failed to provide proper care and supervision by not having knowledge of R1's various pressure injuries, which due to neglect were diagnosed as prohibited health conditions upon hospitalization posed an immediate health and safety and personal rights risk to R1

  • 87466Type A

    The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's RP This requirement was not met as evidenced by: Based on IB investigation record review and interview, the licensee/administrator did not comply with the cited section by not having knowledge of R1’s pressure injuries prior to hospitalization which posed an immediate health and safety and personal rights risk to R1

  • 87631(a)(3)(A)Type A

    the licensee shall be permitted to accept or retain a resident who has a healing wound under the following circumstances:(3)Residents with a stage 1or2 pressure injury must have the condition diagnosed by a physician/appropriately skilled professional. (A)The resident shall receive care for the pressure injury from a physician/appropriately skilled professional. This requirement was not met as evidenced by: Based on IB investigation record review & interview, the licensee/admin did not comply with the cited section by not having R1's pressure injuries diagnosed & treated by a physician/appropriately skilled prof. Which posed an immediate health and safety risk to R1

FAQ · About this visit

Common questions about this visit

What happened during the April 7, 2022 inspection of HORIZON ASSISTED LIVING FACILITY?

This was a complaint inspection of HORIZON ASSISTED LIVING FACILITY on April 7, 2022. 3 citations were issued: 3 Type A (serious).

Were any citations issued to HORIZON ASSISTED LIVING FACILITY on April 7, 2022?

Yes, 3 citations were issued (3 Type A, 0 Type B). The first citation was for: "No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the..."

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.