Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Horizons Care Center during CMS and state inspections, most recent first.
The facility failed to timely report and investigate multiple allegations and indications of abuse or rough treatment involving three residents. One resident with cognitive and physical impairments told staff he was scared of a CNA who was reportedly rough and left marks on his arm; a CNA and an LPN verbally reported concerns to leadership, but there was no documented abuse report, investigation, or State Agency notification. A second resident with severe dementia repeatedly screamed and showed fear during care, while a staff member observed a CNA using needlessly rough techniques and reported this only informally to an LPN, who acknowledged the CNA could be rough but did not document or report it. A third, cognitively intact quadriplegic resident reported that a CNA pushed his leg off a Hoyer lift, causing his foot to strike the wheelchair, described the conduct as unsafe and abusive, and asked other staff to check for injury, yet there was no EMR documentation or timely reporting to the State Agency until the issue surfaced during the survey. Leadership and staff interviews confirmed that these events were not escalated in accordance with facility policy requiring immediate reporting and investigation of potential abuse.
The facility failed to maintain an effective infection control program, with deficiencies in water management, medication handling, and catheter care. The MTD did not document flushing of empty rooms to prevent Legionella growth. An LPN administered a dropped medication without discarding it, contrary to policy. A resident's catheter bag was observed touching the floor, increasing infection risk. The care plan lacked directives to keep the catheter bag off the floor and covered.
The facility failed to maintain sanitary conditions in the kitchen and dining areas due to inadequate hand hygiene and surface sanitation. A cook and a CNA were observed handling food and utensils without washing their hands after touching potentially contaminated surfaces, despite the facility's policy and training emphasizing the importance of hand hygiene.
A resident in a LTC facility was found with medication left at their bedside without a physician's order for self-administration. Despite the resident's cognitive intactness, the IDT deemed it unsafe for self-administration due to the resident's sleep patterns and potential for untimely medication intake. Staff interviews revealed that a nurse left medication unattended, contrary to facility policy and professional guidelines.
A resident with brain cancer and dementia expressed a preference for two showers per week, but the facility only provided three baths in a 30-day period. Staff interviews confirmed that residents should receive two baths per week or according to their preference, and that baths should be re-offered if refused. The DON acknowledged the deficiency, noting the lack of documentation for refusals and re-offers in the EMR.
The facility failed to maintain a comfortable environment on the 400 hallway, where temperatures were below the acceptable range. Observations showed temperatures as low as 56.8°F, and residents reported discomfort. Staff interviews revealed that uncovered ceiling vents caused the cold draft, and the maintenance director confirmed the oversight. The DON was unaware of the issue and agreed that the temperature was too cold.
Two residents experienced unwitnessed falls, and the facility failed to ensure RN assessments were conducted as required by policy. One resident, who was legally blind and had multiple impairments, was assessed by LPNs after a fall, leading to a delayed diagnosis of a T-2 compression fracture. Another resident with severe cardiac issues was also assessed by an LPN, with a RN assessment delayed by over four hours. Staff interviews confirmed the facility's policy requires RN assessments, but the lack of a RN on duty at all times led to this deficiency.
Two residents in an LTC facility did not receive necessary meal assistance and adaptive equipment as per their care plans. One resident, who was severely cognitively impaired, was left without assistance during meals and not offered alternative options after eating less than 25% of his meal. Another resident did not receive a lipped plate and was not offered an alternative meal after consuming a minimal portion. Staff interviews confirmed the facility's failure to adhere to policies requiring meal assistance and adaptive equipment.
A resident at risk for pressure ulcers did not receive consistent care to prevent their development. Despite having a care plan that included heel protective boots and an offloading device, these interventions were not consistently followed. Observations showed the offloading device was often not in place, and the resident's feet skimmed the floor during wheelchair transport. Staff interviews confirmed the resident's pressure ulcer was considered unavoidable due to declining circulation, but necessary interventions were not consistently implemented.
A resident with chronic respiratory failure was not provided with oxygen as ordered by the physician, with the concentrator set at 3 LPM instead of 2 LPM. The nasal cannula frequently dislodged, and the water level in the concentrator was often low, affecting the resident's breathing. Staff interviews revealed non-compliance with physician orders and facility policies.
A resident with a history of multiple health conditions and at high risk for skin breakdown was observed with a large bruise on the forearm, which was not documented in the medical records. Despite the bruise being visible, nursing staff failed to record it in the weekly skin checks or progress notes, indicating a lapse in maintaining accurate medical records.
Failure to Timely Report and Investigate Allegations of Abuse and Rough Treatment
Penalty
Summary
The deficiency involves the facility’s failure to timely report and investigate multiple allegations and indications of abuse or rough treatment toward three residents, despite a written policy requiring immediate reporting of alleged abuse or neglect to supervisory staff, the NHA, and the State Agency within specified timeframes. The facility’s policy states that all employees must immediately report alleged abuse or neglect to a supervisor or building supervisor, that the executive director or designee and DON must be contacted immediately, and that suspected abuse must be reported to the state within two hours if it involves abuse or bodily injury, or within 24 hours if it does not. Surveyors found that these procedures were not followed for allegations and concerns involving three residents, and that there was no timely documentation, reporting, or formal abuse investigation for these events. For one resident with moderate cognitive impairment, hemiplegia, aphasia, Parkinson’s disease, and dependence on staff for all ADLs, staff reported that a CNA was rough with the resident and that the resident expressed fear of this CNA. A CNA stated that the resident told her he was scared, that the CNA in question pushed and grabbed his arm too hard, and that he had marks on his arm; she reported this to the former DON and human resources but was later told there was no investigation and that the concerns were attributed to the resident’s dementia. An LPN reported that several months earlier the same resident told her a CNA was verbally mean and that he felt scared; she believed she completed a grievance form and gave it to leadership, but later acknowledged she may have only verbally reported it to the former DON and did not document it in a progress note. The NHA reported she never received a grievance form or report of this allegation, and record review showed no abuse report, investigation, or grievance documentation related to these concerns. For a second resident with severe dementia, behavioral challenges, and total dependence on staff for care, documentation showed repeated episodes of screaming, yelling, pushing staff away during care, and fearfulness during repositioning and movement over several months. A staff member reported that a CNA was needlessly rough with this resident, including ripping the resident’s hands off the bed or equipment during ADLs, and described the CNA as preferring a more physical approach and skipping a gentle approach for speed. The staff member stated she mentioned these concerns to an LPN and another nurse but did not file an abuse report because she did not feel the incidents were serious enough. The LPN acknowledged that the CNA could be “a little rough,” that the resident became scared when moved suddenly and would grab the bed, and that he did not report or document what he observed or offer alternative care approaches. Review of State Agency reports showed no abuse allegations reported for this resident. For a third resident who was cognitively intact, quadriplegic, and fully dependent on staff for transfers and positioning, the resident reported that during a Hoyer lift transfer, a CNA pushed his leg off the lift rather than holding and lowering it, causing his foot to hit the wheelchair foot pedal. The resident stated he told the CNA this was unsafe and asked for his leg to be adjusted, but the CNA responded dismissively and referenced her upcoming retirement. The resident asked another CNA and night shift staff to assess his foot for injury and expressed that he felt the CNA’s actions were inappropriate, dangerous, neglectful, and abusive, and that he did not want to work with her. Another staff member reported having seen the same CNA be rough with this resident during transfers, not being careful with his feet so that they slipped off the lift and became caught on equipment, and described the CNA as mean and forceful. Record review showed no documentation of the Hoyer lift incident or assessment of the resident’s foot in the EMR, and the allegation was not reported to the State Agency until it was brought forward during the survey. Additional interviews with leadership and staff confirmed that the NHA and current DON were not made aware of the earlier concerns involving the first and second residents, and that no abuse reports had been submitted to the State Agency for those situations. Staff, including the ADON and human resources director, stated they were not aware of prior concerns related to the CNAs involved. The DON acknowledged that statements of feeling scared, reports of staff being too rough, or reports of disrespect or demeaning speech should trigger an abuse investigation, and the NHA acknowledged that the resident’s statements of fear would have met the definition to prompt an investigation and immediate protective actions if they had been reported. Despite existing policies and staff education on abuse recognition and reporting, multiple staff members either did not recognize these events as potential abuse or did not escalate them beyond informal verbal reports, resulting in the facility’s failure to timely report and investigate allegations of abuse and rough treatment for three residents.
Infection Control Deficiencies in Water Management, Medication Handling, and Catheter Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by several deficiencies observed during the survey. Firstly, the facility did not implement an effective water management plan to prevent the growth and spread of Legionella bacteria. The maintenance director (MTD) admitted to not having a complete understanding of the facility's water system and acknowledged the possibility of stagnant water in old pipes. Although the MTD claimed to flush empty rooms on a rotating basis, there was no documentation to verify that all rooms empty for seven days or more were flushed to prevent Legionella growth. Additionally, the facility did not adhere to proper medication administration protocols. During a medication administration observation, an LPN dropped a Zyrtec pill twice onto the medication cart's surface and proceeded to administer it to a resident without discarding it, contrary to the facility's policy. The LPN believed it was acceptable to recover the medication from the cart's surface, while the DON and another RN confirmed that any dropped medication should be discarded to prevent contamination. Furthermore, the facility failed to maintain proper infection control practices for a resident with an indwelling catheter. The resident's catheter bag was observed touching the floor multiple times, and it was not covered, increasing the risk of contamination. The care plan did not include directives to keep the catheter bag off the floor and covered, which is essential to prevent catheter-associated urinary tract infections (CAUTIs). The DON acknowledged the infection control concern and noted that the staff needed re-education on proper catheter care.
Deficiency in Hand Hygiene and Surface Sanitation
Penalty
Summary
The facility failed to maintain sanitary conditions in the main kitchen, specifically in hand hygiene and surface sanitation. During a lunch meal service, a cook dropped a food thermometer on the floor, picked it up, and placed it on a food preparation counter without sanitizing the counter or performing hand hygiene. The cook continued to handle food and kitchen equipment without washing her hands after touching potentially contaminated surfaces, such as the floor and high-touch areas like the ice scoop and the lid of the ice machine. Additionally, a certified nurse aide (CNA) was observed touching her face multiple times without performing hand hygiene before serving meals to residents. The CNA handled residents' utensils and assisted them with eating without washing her hands after touching her face or other potentially contaminated surfaces. This lack of hand hygiene was observed throughout the meal service, despite the facility's policy and training emphasizing the importance of hand hygiene to prevent cross-contamination and infection. Interviews with staff, including the dietary manager, confirmed that hand hygiene should be performed after touching potentially contaminated surfaces and before serving food. The facility's policy and training materials also highlighted the importance of hand hygiene in preventing healthcare-associated infections. However, the observations during the survey indicated a failure to adhere to these standards, leading to the deficiency in maintaining sanitary conditions in the kitchen and dining areas.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure the self-administration of medications was clinically appropriate for a resident. The resident, who was cognitively intact and had a history of various medical conditions including gastroesophageal reflux disease and dysphagia, was observed with a medication tablet left at his bedside. The resident expressed that the nurse would leave his medication for him to take at his convenience, which was against the facility's policy and professional guidelines that prohibit leaving medications unattended. The facility's care plan for the resident did not include instructions for self-administration of medications, nor did it address the resident's preference not to be woken up for medication administration. Despite the resident's desire to self-administer, the interdisciplinary team (IDT) determined it was unsafe due to the resident's tendency to fall asleep and not take medications timely. The resident's electronic medical record lacked a self-administration assessment prior to the survey, and there was no physician's order permitting self-administration. Interviews with staff revealed that a registered nurse had left medication in the resident's room without a physician's order for self-administration, acknowledging that the resident did not want to be disturbed for medication. The Director of Nursing confirmed that medications should not be left unattended and that the resident did not have an order to self-administer. The facility conducted on-the-spot training to address the issue during the survey period.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor a resident's preference for bathing frequency, which is a violation of the resident's right to self-determination. Resident #18, who is over 65 years old and has diagnoses including brain cancer, chronic respiratory failure, and unspecified dementia, expressed a preference for receiving two showers per week. However, the facility's records showed that the resident only received three baths out of eight opportunities over a 30-day period. The resident reported feeling ignored as he often received only one shower per week and sometimes went a week without being offered a shower. The facility's policy requires that residents receive necessary care and services to maintain their abilities in activities of daily living, including bathing. Interviews with staff, including a CNA and RN, confirmed that residents should receive two baths per week or according to their preference, and that baths should be re-offered if initially refused. The Director of Nursing acknowledged that Resident #18 did not receive the appropriate number of baths and emphasized the importance of investigating reasons for refusals and re-offering baths at a preferred time. Despite these policies, the electronic medical record did not document reasons for bathing refusals or attempts to re-offer baths to Resident #18.
Facility Fails to Maintain Comfortable Temperature in Hallway
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment for residents on one of its units, specifically the 400 hallway, where temperatures were consistently below the acceptable range of 71 to 81 degrees Fahrenheit. Observations revealed that the temperature outside a resident's room was as low as 56.8 degrees Fahrenheit, which was confirmed over three consecutive days. Interviews with residents indicated discomfort due to the cold temperatures, with one resident expressing frustration over having to frequently adjust the thermostat to maintain a comfortable room temperature. Staff interviews revealed that the cold draft in the hallway was due to uncovered ceiling vents, which were supposed to be covered during the winter months. The maintenance director acknowledged the oversight and confirmed that the vents were not covered until the survey was conducted. The director of nursing was unaware of the issue and did not know the appropriate temperature range for the facility, although she agreed that 56 degrees Fahrenheit was too cold for residents.
Failure to Provide RN Assessment After Resident Falls
Penalty
Summary
The facility failed to provide services by qualified persons for two residents who experienced unwitnessed falls. Resident #14, who was legally blind and had multiple physical impairments, fell and was found with a head injury. Despite the severity of the situation, the assessments were conducted by LPNs rather than a RN, which is against the facility's policy. The resident later developed additional pain and was diagnosed with a T-2 compression fracture after being sent to the emergency room. Resident #30, who had a history of severe cardiac issues, also experienced an unwitnessed fall. The initial assessment was conducted by an LPN, and a RN did not assess the resident until over four hours later. The resident was found attempting to walk to the bathroom and was not injured from the fall, but the delay in RN assessment was a significant oversight given the resident's medical history. Interviews with staff, including LPNs, CNAs, and the DON, confirmed that the facility's policy requires a RN to perform post-fall assessments. However, due to the lack of a RN on duty at all times, this policy was not adhered to, leading to inadequate assessments and documentation for both residents. The DON acknowledged the deficiency and the lack of immediate RN assessments following the falls.
Failure to Provide Adequate Meal Assistance and Equipment
Penalty
Summary
The facility failed to provide necessary assistance and equipment for two residents who required help with eating, leading to deficiencies in their care. Resident #11, who was severely cognitively impaired and dependent on staff for all activities of daily living, was not consistently assisted during meals. Observations revealed that Resident #11 was left without assistance for significant periods, was not offered alternative meal options after consuming less than 25% of his meal, and experienced delays in receiving his meal. These actions were contrary to his nutritional plan of care, which required extra time for eating and offering food alternatives. Resident #18, also severely cognitively impaired and dependent on staff, was observed eating less than 25% of his meal without being offered a lipped plate as specified in his nutritional care plan. The resident was not provided with an alternative food option after consuming a minimal portion of the meal. The care plan for Resident #18 included the use of adaptive equipment to aid in eating, which was not adhered to during the observed meal service. Interviews with staff, including CNAs and the DON, confirmed that the facility's policies and procedures were not followed. Staff acknowledged the need to offer alternative meal options and to provide adaptive equipment as per the residents' care plans. The registered dietitian and DON highlighted the importance of allowing residents extra time to eat and ensuring they receive appropriate meal assistance, which was not consistently provided to Residents #11 and #18.
Failure to Prevent Pressure Ulcers in Resident
Penalty
Summary
The facility failed to ensure that a resident received the necessary care and services to prevent the development of pressure injuries. The resident, who was over 65 years old and admitted with conditions including chronic systolic heart failure and type two diabetes mellitus, was at risk for developing pressure ulcers. Despite being cognitively intact, the resident was unable to confirm if he had wounds on his feet or if he was comfortable with the heel protective boots and offloading device. Observations revealed that the heel offloading device was not consistently used, as it was often found on the floor instead of under the resident's legs to offload pressure from his heels. The care plan for the resident, revised in November 2024, documented that the resident was at risk for skin breakdown on his heels due to poor nutrition, impaired mobility, and a preference to stay in bed. Interventions included the use of heel protective boots and a heel offloading device, which the resident occasionally declined. However, staff observations showed that these interventions were not consistently followed. The resident was seen without the heel offloading device in place, and his heels were not offloaded as required. Additionally, the resident's wheelchair foot pedals were not used during transport, causing his feet to skim the floor, increasing the risk of skin breakdown. Interviews with staff, including an LPN and the DON, confirmed that the resident's pressure ulcer was considered unavoidable due to declining circulation, but the necessary interventions to prevent further injury were not consistently implemented. The LPN noted that the resident's pressure ulcer might have been caused by his footboard, as he would slide down in bed and prop his feet against it. Despite the presence of protective interventions, such as heel protective boots and a bolster wedge, these were not always used correctly. The DON acknowledged confusion regarding the placement of the bolster wedge, which was incorrectly positioned at the foot of the bed instead of the head, potentially contributing to the resident's pressure injuries.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to provide appropriate respiratory care services for a resident, specifically in the administration of oxygen as ordered by the physician. The resident, who was over 65 years old and had a history of chronic respiratory failure with hypoxia, was observed with her oxygen concentrator set at 3 liters per minute (LPM) instead of the prescribed 2 LPM. Additionally, her nasal cannula was frequently dislodged, and the water container on her oxygen concentrator was often below the desired level, which the resident reported made it harder for her to breathe. The resident was cognitively intact and dependent on staff for most activities of daily living. She experienced shortness of breath with exertion and when lying flat, requiring continuous oxygen therapy. Despite this, the facility staff did not consistently ensure that her oxygen was administered at the correct flow rate, nor did they maintain the water level in the concentrator as per the resident's preference, which was not documented in her care plan. The resident expressed concerns about the water level and reported having to remind staff to fill the container. Interviews with staff revealed a lack of adherence to the physician's orders and facility policies regarding oxygen administration. The registered nurse (RN) and certified nurse aides (CNAs) acknowledged that the oxygen settings were not always correctly maintained, and the nasal cannula frequently fell off the resident's face. The director of nursing (DON) confirmed that only nurses should adjust oxygen settings and that the resident's preferences regarding the water level should have been care planned. The facility's quality assurance and improvement coordinator noted that oxygen had not been identified as a recent concern, despite the issues observed.
Failure to Document Skin Condition in Resident's Medical Record
Penalty
Summary
The facility failed to ensure the medical record was complete and accurate for a resident reviewed for skin breakdown. The resident, over the age of 65, had a history of conditions including gastroesophageal reflux disease, transient ischemic attack, and muscle weakness. Despite being cognitively intact and able to reposition himself, the resident was at high risk for skin breakdown due to malnutrition and weakness. During an interview, the resident was observed with a large maroon bruise on his left forearm, which he attributed to bumping into things. However, this bruise was not documented in the nursing weekly skin checks or progress notes for October and November 2024. The Director of Nursing (DON) confirmed that any bruises or changes in skin condition should be documented on a skin assessment. Despite the bruise being visible on 11/4/24, it was not documented by the nursing staff who worked with the resident between 11/4/24 and 11/7/24. The DON acknowledged the oversight and noted that the resident's skin was very fragile, indicating a need for additional precautions. The lack of documentation and assessment of the bruise represents a failure to maintain accurate medical records in accordance with accepted standards of practice.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Eckert
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willow Tree Care Center | 8.2 mi | — | 14 | 0 |
| Colorow Care Center | 14.5 mi | — | 2 | 0 |
| Paonia Care And Rehabilitation Center | 21.7 mi | — | 0 | 0 |
| Hope Springs Care Center | 24.6 mi | — | 0 | 0 |
| Valley Manor Care Center | 25.2 mi | — | 1 | 0 |
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