Horizon Project

During a review conducted on November 5, 2025, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) more than 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plan, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended again. Further details of the administrator?s failure to ensure compliance include the following: Your operation was issued a corrective action from Residential Contracts, and the corrective action plan was accepted on 6/10/2025. The corrective action contained violations in one or more trend/pattern categories on your Heightened Monitoring Plan. - Operation failed to satisfy the conditions of the plan - Operation failed to demonstrate 6 months of successive compliance with the contract requirements that led to heightened monitoring. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan.

Resolution: Corrected: 2025-11-06

During a review conducted on November 5, 2025, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) more than 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plan, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended again. Further details of the administrator?s failure to ensure compliance include the following: Your operation was issued a corrective action from Residential Contracts, and the corrective action plan was accepted on 6/10/2025. The corrective action contained violations in one or more trend/pattern categories on your Heightened Monitoring Plan. - Operation failed to satisfy the conditions of the plan - Operation failed to demonstrate 6 months of successive compliance with the contract requirements that led to heightened monitoring. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan.

Resolution: Corrected: 2025-11-06

During a review conducted on November 5, 2025, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) more than 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plan, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended again. Further details of the administrator?s failure to ensure compliance include the following: Your operation was issued a corrective action from Residential Contracts, and the corrective action plan was accepted on 6/10/2025. The corrective action contained violations in one or more trend/pattern categories on your Heightened Monitoring Plan. - Operation failed to satisfy the conditions of the plan - Operation failed to demonstrate 6 months of successive compliance with the contract requirements that led to heightened monitoring. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan.

Resolution: Corrected: 2025-11-06

It was determined that the operation did not follow the doctor's orders when it came to stopping a medication, Trileptal, and starting a second dose of Abilify.

Resolution: Corrected: 2025-04-03

It was determined that the operation did not follow the doctor's orders when it came to stopping a medication, Trileptal, and starting a second dose of Abilify.

Resolution: Corrected: 2025-04-03

It was determined that the operation did not follow the doctor's orders when it came to stopping a medication, Trileptal, and starting a second dose of Abilify.

Resolution: Corrected: 2025-04-03

The injury of a child that required medical treatment was not reported to the child's case worker immediately.

Resolution: Corrected: 2025-03-07

The injury of a child that required medical treatment was not reported to the child's case worker immediately.

Resolution: Corrected: 2025-03-07

The injury of a child that required medical treatment was not reported to the child's case worker immediately.

Resolution: Corrected: 2025-03-07

One of the children?s incident reports states that the child left through the front door, which contradicts information gathered from staff and resident interviews. According to the interviews, the child left through his bedroom window, and his absence was not discovered until staff conducted a headcount.

Resolution: Corrected: 2025-03-17

One of the children?s incident reports states that the child left through the front door, which contradicts information gathered from staff and resident interviews. According to the interviews, the child left through his bedroom window, and his absence was not discovered until staff conducted a headcount.

Resolution: Corrected: 2025-03-17

One of the children?s incident reports states that the child left through the front door, which contradicts information gathered from staff and resident interviews. According to the interviews, the child left through his bedroom window, and his absence was not discovered until staff conducted a headcount.

Resolution: Corrected: 2025-03-17

It was observed that all beds did not have a required mattress covering or protector.

Resolution: Corrected: 2025-02-21

The child's service plan required a Safety Plan to be implemented to address his aggressive behaviors, particularly his pattern of targeting younger peers. The Safety plan was not created as documented. His supervision plan also mandated 1:1 supervision whenever the youth exhibited verbal or physical aggression. Residents and staff reported multiple incidents where the child hit or called younger peers names without provocation. Despite these behaviors, staff only intervened by separating the youth from peers or removing youth from the situation. However, 1:1 supervision was not implemented as required by the service plan following these incidents.

Resolution: Corrected: 2025-04-02

The child's service plan required a Safety Plan to be implemented to address his aggressive behaviors, particularly his pattern of targeting younger peers. The Safety plan was not created as documented. His supervision plan also mandated 1:1 supervision whenever the youth exhibited verbal or physical aggression. Residents and staff reported multiple incidents where the child hit or called younger peers names without provocation. Despite these behaviors, staff only intervened by separating the youth from peers or removing youth from the situation. However, 1:1 supervision was not implemented as required by the service plan following these incidents.

Resolution: Corrected: 2025-04-02

It was observed that all beds did not have a required mattress covering or protector.

Resolution: Corrected: 2025-02-21

The child's service plan required a Safety Plan to be implemented to address his aggressive behaviors, particularly his pattern of targeting younger peers. The Safety plan was not created as documented. His supervision plan also mandated 1:1 supervision whenever the youth exhibited verbal or physical aggression. Residents and staff reported multiple incidents where the child hit or called younger peers names without provocation. Despite these behaviors, staff only intervened by separating the youth from peers or removing youth from the situation. However, 1:1 supervision was not implemented as required by the service plan following these incidents.

Resolution: Corrected: 2025-04-02

It was observed that all beds did not have a required mattress covering or protector.

Resolution: Corrected: 2025-02-21

CCI Investigator observed staff sleeping at the facility while on duty and supervising children in care. Administrator was notified of the incident.

Resolution: Corrected: 2024-12-09

CCI Investigator observed staff sleeping at the facility while on duty and supervising children in care. Administrator was notified of the incident.

Resolution: Corrected: 2024-12-09

CCI Investigator observed staff sleeping at the facility while on duty and supervising children in care. Administrator was notified of the incident.

Resolution: Corrected: 2024-12-09

During the review of one staff file, it was observed that staff annual Truama training has expired. Staff took training last on 7-3-23. Staff took training immediately as such citation was corrected at inspection and copy of the training certificate taken.

Resolution: Corrected at inspection

During the review of one staff file, it was observed that staff annual Truama training has expired. Staff took training last on 7-3-23. Staff took training immediately as such citation was corrected at inspection and copy of the training certificate taken.

Resolution: Corrected at inspection

During the review of one staff file, it was observed that staff annual Truama training has expired. Staff took training last on 7-3-23. Staff took training immediately as such citation was corrected at inspection and copy of the training certificate taken.

Resolution: Corrected at inspection

1 Bag of Krogger Pinto Beans was found to be open with beans inside in the kitchen cabinet during the walkthrough of the Northeast Building.

Resolution: Corrected at inspection

1 Bag of Krogger Pinto Beans was found to be open with beans inside in the kitchen cabinet during the walkthrough of the Northeast Building.

Resolution: Corrected at inspection

1 Bag of Krogger Pinto Beans was found to be open with beans inside in the kitchen cabinet during the walkthrough of the Northeast Building.

Resolution: Corrected at inspection

During the review of one childs file today, it was noted that the invite to DFPS caseworker for the initial service plan meeting was not sent timely. Initial service plan was completed on 6-2-24 while the invite was sent on 6-3-24 a day after the plan meeting was completed.

Resolution: Corrected: 2024-06-17

During the review of one childs file today, it was noted that the invite to DFPS caseworker for the initial service plan meeting was not sent timely. Initial service plan was completed on 6-2-24 while the invite was sent on 6-3-24 a day after the plan meeting was completed.

Resolution: Corrected: 2024-06-17

During the review of one childs file today, it was noted that the invite to DFPS caseworker for the initial service plan meeting was not sent timely. Initial service plan was completed on 6-2-24 while the invite was sent on 6-3-24 a day after the plan meeting was completed.

Resolution: Corrected: 2024-06-17

There was an inconsistency between the annual AWOL log and incident report regarding a resident AWOL.

Resolution: Corrected: 2024-06-18

There was an inconsistency between the annual AWOL log and incident report regarding a resident AWOL.

Resolution: Corrected: 2024-06-18

There was an inconsistency between the annual AWOL log and incident report regarding a resident AWOL.

Resolution: Corrected: 2024-06-18

During todays walkthrough at the East building kitchen, one pack of bread was found to be open as the wrap was not sealed. TA was issued to the operation for this same standard during the last HM inspection on 2-22-24.

Resolution: Corrected at inspection

During todays walkthrough at the East building kitchen, one pack of bread was found to be open as the wrap was not sealed. TA was issued to the operation for this same standard during the last HM inspection on 2-22-24.

Resolution: Corrected at inspection

During todays walkthrough at the East building kitchen, one pack of bread was found to be open as the wrap was not sealed. TA was issued to the operation for this same standard during the last HM inspection on 2-22-24.

Resolution: Corrected at inspection

One window in the children room was found during the walkthrough to be damaged. Window glass was not properlly sealed and had opening which may result to insects / resptiles crawling inside the room from outside thereby posing safety concern to the children.

Resolution: Corrected at inspection

One window in the children room was found during the walkthrough to be damaged. Window glass was not properlly sealed and had opening which may result to insects / resptiles crawling inside the room from outside thereby posing safety concern to the children.

Resolution: Corrected at inspection

One window in the children room was found during the walkthrough to be damaged. Window glass was not properlly sealed and had opening which may result to insects / resptiles crawling inside the room from outside thereby posing safety concern to the children.

Resolution: Corrected at inspection

One of five child records reviewed was found to be missing the medication administration record from a medication administered the night of the 12/28/23.

Resolution: Corrected: 2024-01-04

One of five child records reviewed was found to be missing the medication administration record from a medication administered the night of the 12/28/23.

Resolution: Corrected: 2024-01-04

One of five child records reviewed was found to be missing the medication administration record from a medication administered the night of the 12/28/23.

Resolution: Corrected: 2024-01-04

During the walkthrough of the East building, one damaged window blind was observed in one resident toilet. Maintenance staff was able to replace the damaged blind during inspection.

Resolution: Corrected at inspection

During the walkthrough of the East building, one damaged window blind was observed in one resident toilet. Maintenance staff was able to replace the damaged blind during inspection.

Resolution: Corrected at inspection

During the walkthrough of the East building, one damaged window blind was observed in one resident toilet. Maintenance staff was able to replace the damaged blind during inspection.

Resolution: Corrected at inspection

During the walkthrough of the facility, one of the beds in the children room in East building was observed without a pillow case and no sheet. This was corrected at inspection.

Resolution: Corrected at inspection

During the walkthrough of the facility, one of the beds in the children room in East building was observed without a pillow case and no sheet. This was corrected at inspection.

Resolution: Corrected at inspection

During the walkthrough of the facility, one of the beds in the children room in East building was observed without a pillow case and no sheet. This was corrected at inspection.

Resolution: Corrected at inspection

During the review of SIR reports, it was observed that the operation called in several serious incident reports involving unauthorize absences of children later than 6 hours from when the absence was discovered according to the time incidents were received by statewide intake in class. Incidents occured on 10-28-23 in investigation #3039668, on 11-3-23 in investigation #3041001 and on 11-5-23 in investigation #3041113

Resolution: Corrected: 2023-11-15

During the review of SIR reports, it was observed that the operation called in several serious incident reports involving unauthorize absences of children later than 6 hours from when the absence was discovered according to the time incidents were received by statewide intake in class. Incidents occured on 10-28-23 in investigation #3039668, on 11-3-23 in investigation #3041001 and on 11-5-23 in investigation #3041113

Resolution: Corrected: 2023-11-15

During the review of SIR reports, it was observed that the operation called in several serious incident reports involving unauthorize absences of children later than 6 hours from when the absence was discovered according to the time incidents were received by statewide intake in class. Incidents occured on 10-28-23 in investigation #3039668, on 11-3-23 in investigation #3041001 and on 11-5-23 in investigation #3041113

Resolution: Corrected: 2023-11-15

Child's service plan does not clearly document the child's supervision needs, but instead is generalized.

Resolution: Corrected: 2023-10-25

Child's service plan does not clearly document the child's supervision needs, but instead is generalized.

Resolution: Corrected: 2023-10-25

Child's service plan does not clearly document the child's supervision needs, but instead is generalized.

Resolution: Corrected: 2023-10-25

It was noticed during the review of one childs medication record that the medication count documentation for 7-17-23 was not accurate. The correct count was suppose to be 48 but the record has 58. Medication record was corrected by the staff that completed it to reflect 48 counts.

Resolution: Corrected at inspection

It was observed during the walkthrough of the East Campus that one of the children restroom has damaged tile on the wall and staff were not aware of the damage and no work order was created for the damage.

Resolution: Corrected: 2023-07-24

It was observed during the walkthrough of the East Campus that one of the children restroom has damaged tile on the wall and staff were not aware of the damage and no work order was created for the damage.

Resolution: Corrected: 2023-07-24

It was observed during the walkthrough of the East Campus that one of the children restroom has damaged tile on the wall and staff were not aware of the damage and no work order was created for the damage.

Resolution: Corrected: 2023-07-24

It was noticed during the review of one childs medication record that the medication count documentation for 7-17-23 was not accurate. The correct count was suppose to be 48 but the record has 58. Medication record was corrected by the staff that completed it to reflect 48 counts.

Resolution: Corrected at inspection

It was noticed during the review of one childs medication record that the medication count documentation for 7-17-23 was not accurate. The correct count was suppose to be 48 but the record has 58. Medication record was corrected by the staff that completed it to reflect 48 counts.

Resolution: Corrected at inspection

2 residents physically assaulted one resident at the facility which resulted to the victim child sustaining concussion and head fracture.

Resolution: Corrected: 2023-11-20

Staff failed to intervene timely in a physical altercation between children causing one child to sustained significant injuries.

Resolution: Corrected: 2023-11-20

Staff failed to intervene timely in a physical altercation between children causing one child to sustained significant injuries.

Resolution: Corrected: 2023-11-20

2 residents physically assaulted one resident at the facility which resulted to the victim child sustaining concussion and head fracture.

Resolution: Corrected: 2023-11-20

Staff failed to intervene timely in a physical altercation between children causing one child to sustained significant injuries.

Resolution: Corrected: 2023-11-20

2 residents physically assaulted one resident at the facility which resulted to the victim child sustaining concussion and head fracture.

Resolution: Corrected: 2023-11-20

The evacuation plan policy did not address who will be designating an employee during an emergency.

Resolution: Corrected at inspection

The evacuation plan policy did not address who will be designating an employee during an emergency.

Resolution: Corrected at inspection

The evacuation plan policy did not address who will be designating an employee during an emergency.

Resolution: Corrected at inspection