Inspection visit
Inspection
Citations
23 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
F561 - Self-determination
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
F584 - Safe Environment
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.
F644 - Coordination
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
F740 - Behavioral health services
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F865 - Quality assurance and performance improvement (QAPI) program
Have a plan that describes the process for conducting QAPI and QAA activities.
- 0004GeneralS&S Fpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0006GeneralS&S Epotential for harm
Conduct risk assessment and an All-Hazards approach.
- 0013GeneralS&S Dpotential for harm
Develop Emergency Preparedness policies and procedures.
- 0015GeneralS&S Epotential for harm
Address subsistence needs for staff and patients.
- 0293GeneralS&S Dpotential for harm
Have properly located and lighted "Exit" signs.
- 0355GeneralS&S Dpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0363GeneralS&S Dpotential for harm
Install corridor and hallway doors that block smoke.
F916 - Have a floor at or above grade level
Have a battery powered remote alarm panel in a location accessible by operating personnel.
F921 - Other Environmental Conditions
Ensure that testing and maintenance of electrical equipment is performed.
FAQ · About this visit
Common questions about this visit
What happened during the June 13, 2025 survey of HORIZON HEALTH AND REHABILITATION CENTER?
This was a inspection survey of HORIZON HEALTH AND REHABILITATION CENTER on June 13, 2025. The surveyor cited 23 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at HORIZON HEALTH AND REHABILITATION CENTER on June 13, 2025?
Yes, 23 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate ..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.