Inspection Reports for
Horizon Health & Subacute Center
3034 Herndon Ave, Fresno, CA 93720, CA, 93720
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
9.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
145% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Routine
Deficiencies: 2
Date: Mar 26, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident safety, quality of care, and facility environment at Horizon Health & Subacute Center.
Findings
The facility failed to maintain a safe, clean, and homelike environment by covering a supply ventilation duct in a resident's room with loose rubber material posing a fire hazard. Additionally, the facility failed to meet professional standards by not properly communicating the need for a mechanical lift to an outside agency, resulting in a canceled CT scan and delayed care for a resident with deep vein thrombosis.
Deficiencies (2)
F 0584: The facility failed to provide a safe, clean, and homelike environment when a supply ventilation duct in Resident 1's room was covered with loose rubber material, posing a fire hazard.
F 0658: The facility failed to meet professional standards when Resident 1's CT scan was canceled due to the outside agency not being informed that a mechanical lift was required for transfer, delaying care.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Assistant | Interviewed regarding the rubber material covering the supply ventilation duct. | |
| Director of Maintenance | Stated the rubber material was a fire hazard and unacceptable. | |
| Administrator | Stated the rubber material was a fire hazard and unacceptable. | |
| Unit Manager 1 | Discussed the failed communication with the outside agency regarding mechanical lift requirements. | |
| Director of Social Services | Discussed referral procedures and communication with outside agencies. | |
| Director of Nursing | Stated it was required to inform the outside agency about the mechanical lift requirement. |
Inspection Report
Routine
Deficiencies: 14
Date: Mar 7, 2025
Visit Reason
Routine state inspection survey of Horizon Health & Subacute Center to assess compliance with healthcare regulations and resident care standards.
Findings
The facility had multiple deficiencies including failure to ensure dignified dining experiences, honoring resident choices, maintaining a safe environment, proper medication management, infection control, accurate medical records, and food service standards.
Deficiencies (14)
F 0550: Facility failed to ensure residents were treated with dignity during mealtime when CNAs stood while feeding residents, causing discomfort and potential choking risk.
F 0561: Facility failed to honor resident's choice for shower days, resulting in skin irritation and increased infection risk.
F 0584: Facility failed to address resident complaint of air vent blowing on face, causing discomfort and cold sensation.
F 0623: Facility failed to notify resident representative and ombudsman in writing of resident's hospital transfer.
F 0656: Facility failed to develop and implement complete care plans for residents on certain medications, missing monitoring for side effects and behaviors.
F 0730: Facility failed to provide annual performance evaluations and training for several CNAs, risking inadequate care.
F 0757: Facility failed to monitor liver function labs for residents on valproic acid and administered pain medication inconsistently with orders.
F 0761: Facility failed to label tube feeding bags with date/time and improperly administered medications, risking infection and medication errors.
F 0790: Facility failed to maintain routine dental services for a resident needing bone spur removal and new dentures for over 17 months.
F 0802: Facility failed to ensure kitchen staff followed proper portion sizes and lacked competency evaluations.
F 0812: Facility failed to ensure food was stored, prepared, and distributed in accordance with professional standards, including temperature monitoring, hair restraints, and proper labeling.
F 0842: Facility failed to maintain accurate and complete Physician Orders for Life-Sustaining Treatment (POLST) forms for multiple residents.
F 0880: Facility failed to maintain an effective infection prevention and control program including improper storage of nebulizer tubing, dirty washing machines, and inadequate glucometer disinfection.
F 0921: Facility failed to maintain a safe, clean, and comfortable environment for a resident when personal items cluttered the room, blocking access and creating hazards.
Report Facts
Medication error rate: 14.81
BIMS score: 3
BIMS score: 15
BIMS score: 0
BIMS score: 10
BIMS score: 12
BIMS score: 13
BIMS score: 99
Tube feeding portion: 2.67
Tube feeding portion: 3.25
Tube feeding portion: 4
Tube feeding temperature: 47.1
Tube feeding temperature: 43.6
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 20, 2025
Visit Reason
The inspection was conducted following a complaint regarding inadequate supervision that led to a resident falling out of bed during care.
Complaint Details
The complaint was substantiated. Resident 1 fell out of bed due to inadequate supervision when only one staff member provided care instead of the required two. The resident was at moderate risk for falls and required total care.
Findings
The facility failed to ensure adequate supervision for Resident 1 who required two staff members for turning and repositioning but was cared for by one staff member alone, resulting in a fall. The resident was in a persistent vegetative state and required total care, and the facility's policies require two staff members for such care.
Deficiencies (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and provide adequate supervision to prevent accidents. Resident 1, requiring two-person assist for turning, was turned by one staff member alone and fell out of bed.
Report Facts
Fall Risk Evaluation Score: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Named in the finding for providing care alone to Resident 1 leading to the fall. |
| CNA 2 | Certified Nursing Assistant | Interviewed regarding care requirements for Resident 1. |
| Unit Manager | Unit Manager | Provided statements about care requirements and incident. |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided statements about care plan requirements for Resident 1. |
| Administrator | Administrator | Provided statements about care requirements and resident safety. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 7, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report injuries of unknown origin, specifically a closed fracture of Resident 1's left humerus, to the appropriate authorities including the Police Department and Ombudsman.
Complaint Details
The complaint investigation focused on Resident 1, a non-verbal and non-mobile resident with a closed fracture of the left humerus. The facility did not notify the Ombudsman or police because they ruled out abuse based on Resident 1's inconsistent communication and denial of abuse. The Ombudsman was not informed of the injury. The facility's policy required reporting all suspected abuse causing serious injury within two hours, which was not followed.
Findings
The facility failed to implement its policy to ensure injuries of unknown origin were reported to all required local and state officials within the mandated timeframe. This failure delayed outside investigation and assistance, potentially putting all residents at risk of abuse.
Deficiencies (1)
F 0609: The facility failed to timely report suspected abuse, neglect, or theft and the results of the investigation to proper authorities for Resident 1, who had a closed fracture of the left humerus that was not reported to the Police Department or Ombudsman.
Report Facts
Residents sampled: 3
Date of injury discovery: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Interviewed regarding Resident 1's condition and communication |
| CNA 1 | Certified Nursing Assistant | Interviewed about care for Resident 1 and knowledge of abuse reporting policy |
| DON | Director of Nursing | Interviewed about reporting procedures and Resident 1's injury |
| ADM | Administrator | Interviewed about facility's decision not to report injury to police or Ombudsman |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 22, 2024
Visit Reason
The inspection was conducted to investigate an allegation of abuse involving Licensed Vocational Nurse (LVN) 1 and Resident 1 after an unwitnessed fall on 11/17/2024.
Complaint Details
The complaint was substantiated. The allegation involved LVN 1 using vulgar language toward Resident 1 and instructing staff not to document or assist Resident 1 after a fall. Multiple staff interviews and document reviews confirmed the abuse.
Findings
The facility failed to ensure Resident 1 was free from abuse, neglect, and exploitation when LVN 1 used profane language toward Resident 1 and instructed staff not to assist him after a fall. The allegation of abuse against LVN 1 was substantiated following investigation and interviews.
Deficiencies (1)
F 0600: The facility failed to protect Resident 1 from abuse, neglect, and exploitation when LVN 1 used profane language and refused to provide care after an unwitnessed fall on 11/17/24.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Named in abuse allegation involving use of profane language and refusal to assist Resident 1 after fall. |
| LVN 2 | Licensed Vocational Nurse | Resident 1's assigned nurse who was informed of the incident by LVN 1. |
| Mental Health Worker | Witnessed and reported LVN 1's use of vulgar language toward Resident 1. | |
| CNA 1 | Certified Nursing Assistant | Assisted Resident 1 after fall; did not witness LVN 1 using foul language. |
| CNA 2 | Certified Nursing Assistant | Assisted Resident 1 after fall and reported interactions with LVN 1. |
| CNA 3 | Certified Nursing Assistant | Assisted Resident 1 after fall and commented on LVN 1's behavior. |
| Program Director | Program Director | Stated staff must behave professionally and not use profanity. |
| Director of Nursing | Director of Nursing | Stated staff are expected to treat residents with respect and dignity. |
| Administrator | Administrator | Stated staff are expected to treat residents with respect and not deprive care. |
Inspection Report
Routine
Deficiencies: 1
Date: Oct 4, 2024
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically regarding the management and expiration of Covid-19 self-test kits.
Findings
The facility failed to ensure that Covid-19 self-test kits stored in the clean utility supply room were not expired, which could lead to inaccurate test results. The Infection Preventionist and Central Supply staff did not adequately monitor expiration dates, risking potential harm to residents.
Deficiencies (1)
F 0880: The facility failed to provide and implement an infection prevention and control program by storing two boxes of Covid-19 self-test kits that were expired as of 8/23/24 in the clean utility supply room. This failure had the potential to produce inaccurate Covid-19 test results.
Report Facts
Covid-19 self-test kits: 48
Expiration date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Stated that the Infection Preventionist was responsible to ensure Covid-19 self-test kits were not expired. |
| Infection Preventionist | Infection Preventionist | Interviewed regarding expired Covid-19 self-test kits and infection control responsibilities. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jul 9, 2024
Visit Reason
The inspection was conducted following a complaint regarding physical abuse by a Mental Health Worker (MHW) against a resident, as well as concerns about employee reference checks and timely reporting of abuse investigations.
Complaint Details
The complaint involved an incident on 6/24/24 where a Mental Health Worker pushed Resident 1 after the resident pushed him first. The incident was witnessed by staff and resulted in the termination of the MHW. The complaint also included failure to conduct employment reference checks and failure to timely report the abuse investigation findings.
Findings
The facility failed to prevent physical abuse when a Mental Health Worker pushed a resident causing him to stumble and experience mental anguish. The facility also failed to check employment references for the MHW prior to hiring and failed to timely report the findings of the abuse investigation to the Department within five days.
Deficiencies (3)
F 0600: The facility failed to protect a resident from physical abuse when a Mental Health Worker pushed the resident causing him to stumble and experience mental anguish including intimidation and increased agitation.
F 0607: The facility failed to check the references of a Mental Health Worker prior to employment, resulting in the potential for an unqualified employee to provide care to residents.
F 0609: The facility failed to report the findings of an abuse investigation to the Department within five days, risking inadequate investigation and further abuse.
Report Facts
Date of incident: Jun 24, 2024
Date of survey completion: Jul 9, 2024
Number of references missing: 2
Days for reporting abuse findings: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mental Health Worker (MHW) | Employee who pushed the resident and whose employment was terminated | |
| Administrator | Interviewed regarding the incident and termination of MHW | |
| Program Director (PD) | Supervisor of MHW who commented on the incident | |
| Licensed Vocational Nurse (LVN 1) | Witnessed the incident and reported on resident behavior | |
| Certified Nursing Assistant (CNA 1) | Witnessed the incident and assessed resident after the event | |
| Director of Staff Development (DSD) | Reviewed MHW employee file and confirmed missing references | |
| Staffing Coordinator (SC) | Reviewed MHW employee file and confirmed missing references |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 1, 2024
Visit Reason
The inspection was conducted due to complaints and concerns regarding failure to provide appropriate care to residents, including failure to monitor urinary output, failure to address severe pain promptly, failure to follow physician orders for wound care, and failure to change dressings as ordered.
Complaint Details
The complaint investigation found substantiated issues including failure to monitor urinary catheter output leading to bladder distention and severe pain, failure to promptly address pain complaints, failure to follow wound care orders for pressure ulcers, and incomplete physician orders for respiratory care devices. Immediate Jeopardy was identified on 02/26/2024 and removed on 03/01/2024 after implementation of a Removal Plan.
Findings
The facility failed to ensure proper care for residents, including failure to monitor urinary catheter output, delayed response to severe pain, failure to follow physician orders for wound care and dressing changes, and incomplete physician orders for CPAP device settings. Immediate Jeopardy was identified but later removed after corrective actions were implemented.
Deficiencies (2)
F684: The facility failed to provide appropriate treatment and care according to physician orders, including failure to monitor urinary output, address severe pain promptly, and follow wound care orders for pressure ulcers and non-pressure skin concerns.
F695: The facility failed to provide safe and appropriate respiratory care by not verifying complete physician orders for CPAP/APAP PEEP settings before applying the device to a resident.
Report Facts
Residents affected: 6
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Urinary output documented: 400
Urinary output documented: 300
Removal Plan acceptance date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN #8 | Licensed Vocational Nurse | Confirmed Resident #105's dressings were not changed as ordered |
| Wound Care Nurse | Failed to change dressings as ordered and did not report to floor nurses | |
| Director of Nursing | Director of Nursing | Stated nurses should follow physician's orders for dressing changes and addressed staff education |
| Administrator | Administrator | Expected nurses to follow physician orders and address resident pain promptly |
| LVN #2 | Licensed Vocational Nurse | Acknowledged delay in addressing Resident #1's pain and catheter issues |
| CNA #1 | Certified Nursing Assistant | Notified LVN #2 of Resident #1's pain and assisted with care |
| Medical Director | Medical Director | Informed about Resident #1's catheter obstruction and bladder distention |
| LVN #7 | Licensed Vocational Nurse | Acknowledged incomplete physician orders for Resident #304's CPAP device |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 2, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to maintain complete, accurate, and readily accessible documentation of turning and repositioning residents every two hours as required by facility policy and professional standards.
Complaint Details
The complaint investigation found that documentation of turning and repositioning was incomplete and inaccurate, with the facility only able to provide records of turning every shift rather than every two hours as required. The complaint was substantiated with findings of deficient documentation.
Findings
The facility failed to document turning and repositioning of three sampled residents every two hours, instead only documenting every shift. This failure was not consistent with the facility's policy and professional standards, potentially risking worsening pressure ulcers and inadequate care documentation.
Deficiencies (1)
F 0842: The facility failed to maintain complete, accurate, and readily accessible documentation of turning and repositioning for three residents every two hours as required. Documentation showed turning and repositioning only every shift, not every two hours as required to prevent pressure ulcers.
Report Facts
Residents affected: Many residents were affected by the documentation failure.
BIMS scores: 0
Pressure ulcer stage: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse (LVN) 1 | Interviewed regarding Resident 1's condition and care. | |
| Medical Doctor (MD), Wound Specialist | Interviewed regarding Resident 1's wound care and expectations. | |
| Certified Nursing Assistant (CNA) 1 | Interviewed regarding turning and repositioning practices for Resident 1. | |
| Certified Nursing Assistant (CNA) 2 | Interviewed regarding turning and repositioning practices for Resident 1. | |
| Certified Nursing Assistant (CNA) 3 | Interviewed regarding documentation of turning and repositioning in electronic health records. | |
| Director of Nursing (DON) | Interviewed regarding facility policy and documentation practices. | |
| Administrator (ADM) | Interviewed regarding facility documentation and care practices. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 8, 2023
Visit Reason
The inspection was conducted following a complaint regarding the facility's failure to notify the attending physician about a resident's persistent and severe pain after a right hip replacement, which delayed the identification of a hip dislocation.
Complaint Details
The investigation was complaint-driven based on Resident 1's son's report of persistent pain and delayed X-ray and diagnosis. The complaint was substantiated as the facility failed to notify the physician timely, resulting in delayed treatment of the hip dislocation.
Findings
The facility failed to notify the attending physician about Resident 1's persistent and severe right hip pain, resulting in delayed diagnosis of a dislocated hip prosthesis. Staff did not follow the facility's policy for reporting significant changes in a resident's condition.
Deficiencies (1)
F 0658: The facility failed to notify the attending physician of Resident 1's persistent and severe right hip pain, delaying the identification of a dislocated right hip prosthesis. Staff did not follow the policy requiring notification within 24 hours of a significant change in condition.
Report Facts
Pain level: 9
Medication dosage: 325
Medication dosage: 5
BIMS score: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 3 | LVN | Assigned to Resident 1 and reported Resident 1's pain was related to constipation and did not notify physician |
| Registered Nurse Supervisor | RNS | Assessed Resident 1's right hip on 10/12/23 and stated physician should have been contacted |
| Physical Therapist Assistant | PTA | Notified nurse of Resident 1's severe hip pain during therapy and stated nurse should have notified physician |
| Director of Nursing | DON | Stated staff left message for physician on 10/13/23 and should have followed up |
| Licensed Vocational Nurse 1 | LVN | Texted attending physician on 10/13/23 regarding X-ray request and acknowledged failure to follow up |
| Attending Physician | AP | Stated he did not recall receiving message and staff should have contacted him or medical director |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 17, 2023
Visit Reason
The inspection was conducted following a complaint regarding a missed medication dose for a resident (R1) at the facility.
Complaint Details
The complaint was substantiated. The missed medication dose was confirmed through interviews with the resident's daughter, nursing staff, and the Director of Nursing. The physician was notified and ordered a replacement dose.
Findings
The facility failed to ensure timely administration of medication to one resident when a nurse did not open the clamp on the IV tubing, delaying the antibiotic infusion. The missed dose was the last dose for the resident and had the potential to delay recovery.
Deficiencies (1)
F 0755: The facility failed to provide pharmaceutical services to meet the needs of each resident by not ensuring timely medication administration when a nurse did not open the clamp on the IV tubing for the pump. This failure had the potential to delay recovery for one resident receiving antibiotics for osteomyelitis.
Report Facts
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN1 | Registered Nurse | Named in medication error finding for not opening the clamp on the IV tubing. |
| LVN1 | Licensed Vocational Nurse | Notified the Director of Nursing and physician about the missed medication. |
| Director of Nursing | Received notification of missed medication and coordinated physician notification. |
Inspection Report
Routine
Deficiencies: 11
Date: Jun 21, 2019
Visit Reason
Routine inspection of Horizon Health & Subacute Center to assess compliance with regulatory standards including resident care, medication administration, infection control, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to notify the Ombudsman on resident transfers, medication administration errors, inadequate resident care such as failure to assist with toileting and grooming, improper medication storage, incomplete dialysis documentation, food safety violations, and infection control lapses.
Deficiencies (11)
F 0623: Facility failed to notify the Office of the State Long-Term Care Ombudsman of resident transfer for hospitalization for one of four sampled residents.
F 0658: Facility failed to meet professional standards of quality in medication administration and treatment for two residents, including leaving medications unattended and failure to notify physician of treatment non-compliance.
F 0676: Facility failed to provide nail care to keep nails short and well trimmed for one resident, resulting in self-inflicted scratches and risk of skin infection.
F 0684: Facility failed to provide timely assistance to two residents to use the bathroom, resulting in resident distress and risk of falls and incontinence.
F 0689: Facility failed to provide adequate supervision and assistance for repositioning a resident with contractures, resulting in a left arm spiral fracture and hospitalization.
F 0761: Facility failed to ensure drugs and biologicals were stored securely; an over-the-counter medication was left unattended on top of the medication cart.
F 0790: Facility failed to provide timely dental services for a resident; dentures were delayed and not followed up after dental office visit.
F 0802: Facility failed to ensure food service staff were competent in food safety; staff unable to verbalize proper food cool down process, risking foodborne illness.
F 0812: Facility failed to safely store and serve food; multiple open condiments lacked open dates and staff served food after touching face without hand hygiene.
F 0842: Facility failed to ensure dialysis records were accurately and completely documented for two residents, risking disruption of continuity of care.
F 0880: Facility failed to maintain effective infection control; respiratory therapist did not sanitize stethoscope between residents, handwashing sink was improperly located near clean plates, and staff did not wear hair nets or follow hand hygiene in food service area.
Report Facts
Deficiencies cited: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Named in medication administration and medication storage deficiencies |
| LVN 4 | Licensed Vocational Nurse | Named in medication administration and self-medication supervision deficiencies |
| CNA 4 | Certified Nursing Assistant | Named in repositioning and injury to Resident 62 |
| RT | Respiratory Therapist | Named in infection control deficiency for failure to sanitize stethoscope |
| DSD 1 | Director of Staff Development | Interviewed regarding medication administration and repositioning deficiencies |
| DSD 2 | Director of Staff Development | Interviewed regarding dialysis documentation and infection control deficiencies |
| UM 1 | Unit Manager | Interviewed regarding repositioning and dialysis documentation deficiencies |
| UM 2 | Unit Manager | Interviewed regarding dialysis documentation deficiencies |
| CDM | Certified Dietary Manager | Interviewed regarding food safety and infection control deficiencies |
| RNA 2 | Restorative Nursing Assistant | Named in food service hygiene deficiency |
| RNA 3 | Restorative Nursing Assistant | Named in infection control deficiency |
| HR 1 | Human Resources | Observed in food service area without hair net |
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