Horizon Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Horizon Health and Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jun 13, 2025

  Based on observation, interview, and document review, the facility failed to maintain proper food storage practices in the dry storage area, and temperature control in the refrigerators. The deficient practice had the potential to compromise food safety and increase the risk of foodborne illness among residents. Findings include: On 06/10/2025 at 8:40 AM, a kitchen inspection was conducted alongside a cook, during which the following deficiencies were identified: - A refrigerator used for storing tray line salads, ham, salami, shredded and sliced cheese displayed a temperature of 42°F on its thermometer screen. However, an internal check showed temperatures ranging between 45-50°F. A bag of shredded cheese registered 50°F, while a packet of salami held at 45°F. […]

• No harm, potential for more than minimal, widespreadF812Jul 12, 2024

  Based on observation, interview, and document review, the facility failed to 1) procure a clean food preparation environment and 2) ensure food products that needed to be refrigerated were kept in a safe temperature range by accurately monitoring the temperature of the walk-in refrigerator. The deficient practice could potentially expose residents to foodborne illnesses. Findings included: On 07/09/24 in the morning, an inspection was conducted with the kitchen manager in the kitchen area. […]

• No harm, potential for more than minimal, widespreadF908Jul 12, 2024

  Based on observation, interview, and document review, the facility failed to ensure a walk-in refrigerator was maintained in working condition to keep refrigerated food products in a safe range of temperature. The deficient practice could potentially endanger the safety of the food, exposing residents to foodborne illnesses. Findings included: On 07/09/24 at 9:40 AM, the temperature reading in the external thermometer of the walk-in refrigerator indicated 44 degrees Fahrenheit ( F). The temperature log located at the door of the walk-in refrigerator documented a temperature of 40 F was obtained in the morning. The two thermometers situated inside the refrigerator read 58 F each. […]

• No harm, potential for more than minimal, widespreadF727Aug 4, 2023

  Based on interview, and document review, the facility failed to ensure the facility had a Director of Nursing (DON) in accordance with the facility assessment. The deficient practice had the potential to compromise supervision of nursing care and oversight. Findings include: The Facility Assessment tool reviewed on 01/18/2023, described staffing resources needed to provide care to the population based on care analysis would include one Director of Nursing, two Assistant Directors of Nursing (ADONs) and one Infection Preventionist/Director of Staff Development. The Facility Assessment tool was re-reviewed on 07/10/2023, which revealed the facility did not have a DON and the DON position had not been filled. […]

• No harm, potential for more than minimal, widespreadF803Sep 30, 2022

  Based on observation, interview, and document review, the facility failed to 1) serve the correct food texture consistency to residents on regular texture consistency diets, 2) provide adequate servings of fruit, vegetables, and grains to the residents, and 3) serve the correct portion sizes to residents on pureed and minced moist texture consistency diets. The failure to provide the correct food texture impacted 88 residents which resulted in the dislike of the meal. The failure to provide adequate servings of fruits, vegetables, and grains impacted all 121 current residents which resulted in these residents not receiving their daily nutritional needs. […]