Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Horizons Living And Rehab Center during CMS and state inspections, most recent first.
The facility failed to provide written transfer or discharge notices to several residents and their representatives when transferred to a hospital. Interviews revealed that notices were not consistently issued, particularly if residents were not admitted to the hospital, leading to a lack of documentation for required notifications.
The facility failed to provide bed hold notices, including daily costs, to residents or their representatives upon hospital transfers. This affected multiple residents, with no documentation of notices being issued during their transfers. The Admissions Director confirmed the oversight.
The facility failed to ensure all staff maintained CPR certification, resulting in shifts without CPR-certified personnel for 8 out of 27 days. The DON was not CPR certified and unaware of staff certifications. This posed a risk to residents, especially those who are Full Code and could require CPR. Documentation showed only a few RNs, LPNs, and CNAs had current CPR certifications.
The facility did not perform annual performance evaluations for CNAs employed for over a year. A review of employee files revealed that five CNAs, hired between 2020 and 2022, had no documented annual reviews. The DON confirmed the absence of these evaluations.
The facility was cited for multiple deficiencies, including failure to accommodate a resident's preferences, lack of a grievance policy, and inadequate notification of hospital transfers. Staff training lapses were noted, particularly in CPR certification, affecting resident care. Additionally, the facility failed to conduct annual evaluations for CNAs and maintain updated policies, impacting overall resident well-being.
The facility failed to maintain effective training programs for nursing staff, lacking CPR certification for most staff and not implementing skills fairs or competencies. Several CNAs did not receive required training in dementia care, resident rights, or annual continuing education. The DON and Administrator confirmed these deficiencies.
The facility failed to ensure CNAs received the required 12 hours of annual in-service education, including dementia care and resident rights training. Four CNAs employed for over a year did not meet these requirements, with varying deficiencies in training hours and specific mandatory topics. The Director of Nursing confirmed these findings.
A resident's preference for morning showers twice a week was not accommodated, despite informing staff multiple times. The facility's outdated shower schedule and CNA confirmation revealed the resident did not receive showers as preferred, with the last documented shower occurring several days prior.
A facility failed to provide follow-up care for a resident with a pacemaker. The EMR lacked details about the pacemaker, and the care plan's requirement to monitor the pulse rate was not met. Interviews revealed that staff were unaware of the pacemaker, and there was no documentation of cardiology follow-up. The DON confirmed the standard of care was not met.
The facility was found to have unsanitary conditions in the main dining room refrigerator, with no temperature monitoring documentation and a large amount of red fluid in the freezer. The food service manager confirmed these issues during the inspection.
The facility lacked a grievance policy, leaving residents unaware of how to file grievances, including anonymously. Interviews revealed that residents were unaware of the grievance process, and complaint boxes were inaccessible, particularly for those in wheelchairs. The Director of Social Services and the Administrator confirmed the absence of a formal grievance process, with residents expected to bring concerns directly to the Administrator.
Failure to Provide Written Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide timely written notification of transfer or discharge to residents, their families, or representatives, as required. This deficiency was identified for five residents who were transferred to an acute care hospital. The clinical records for these residents lacked evidence of written transfer or discharge notices. Specifically, Resident #7 was transferred on two occasions, Resident #108 was transferred and returned without notice, Resident #31 was transferred twice for overnight observation, Resident #28 was transferred twice and admitted, and Resident #35 was transferred three times and admitted. In each case, there was no documentation of the required notices being provided. Interviews with facility staff revealed a lack of consistent procedures for issuing transfer or discharge notices. The nurse manager indicated that notices were not sent with residents at the time of transfer, and the Admissions Director confirmed that notices were only sent if a resident was admitted to the hospital. This practice resulted in several residents and their representatives not receiving the necessary written notifications, as confirmed by the Admissions Director during interviews.
Failure to Provide Bed Hold Notices
Penalty
Summary
The facility failed to issue bed hold notices, which include the daily bed hold cost, to residents or their representatives upon transfer to a hospital. This deficiency was identified for five out of six sampled residents who were transferred to an acute care hospital. The clinical records of these residents lacked evidence of written bed hold notices being provided upon their transfers. Specifically, residents were transferred on multiple occasions, yet there was no documentation indicating that they or their representatives received the required notices. During an interview, the Admissions Director confirmed that the residents and/or their representatives were not provided with the written bed hold notices upon transfer. This oversight affected residents who were transferred to hospitals on various dates, with some residents experiencing multiple transfers without receiving the necessary documentation. The absence of these notices represents a failure in the facility's process to inform residents or their representatives about the bed hold policy and associated costs during hospital transfers.
Deficiency in CPR Certification Among Staff
Penalty
Summary
The facility failed to ensure that all staff maintained training in cardiopulmonary resuscitation (CPR) for Healthcare Providers, resulting in staff being responsible for providing CPR without an active CPR certificate for 8 out of 27 days reviewed. This deficiency was identified through interviews and record reviews, revealing that the Director of Nursing (DON) was not CPR certified and was unaware of which staff members held current CPR certifications. The facility's emergency response policy mandates providing emergency care during life-threatening situations, yet the lack of CPR-certified staff on certain shifts posed a risk to residents, particularly those who are Full Code and could require CPR. The report highlights that during the month of August, there were multiple shifts, particularly night shifts, where no staff members were available with current CPR certification. This was confirmed by both the Administrator and the DON, who acknowledged that 7 out of 56 residents were Full Code and could potentially require CPR. Additionally, all residents were at risk for choking, further emphasizing the need for CPR-certified staff. Documentation provided by the facility showed that only a small fraction of Registered Nurses, Licensed Practical Nurses, and Certified Nurses Aids held current CPR certifications, underscoring the facility's failure to comply with its own emergency response policies.
Failure to Conduct Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to conduct annual performance evaluations for Certified Nursing Assistants (CNAs) who have been employed for more than one year. This deficiency was identified during a review of employee files and interviews conducted on August 28, 2024. Specifically, the files of five CNAs, hired between 2020 and 2022, lacked evidence of any annual performance reviews being completed since their respective dates of hire. The Director of Nursing confirmed that these evaluations had not been conducted for the five CNAs in question.
Multiple Deficiencies in Resident Care and Staff Training
Penalty
Summary
The facility was found to have multiple deficiencies during a recertification survey, indicating a failure to administer the facility in a manner that ensures residents attain or maintain their highest practicable well-being. The deficiencies were cited under various federal regulations, including resident rights, resident notification, quality of life, quality of care, nursing services, food safety, and training requirements. Specific issues included the failure to accommodate a resident's bathing schedule and preferences, lack of a grievance policy, and failure to notify residents and their families about transfers or discharges to acute care hospitals. The facility also failed to issue bed hold notices with the required information, such as daily bed hold costs, to residents or their representatives. There were significant lapses in staff training and competency, particularly in cardiopulmonary resuscitation (CPR), with staff lacking active CPR certification for several days. Additionally, the facility did not provide follow-up care for a resident with a pacemaker and failed to ensure that newly hired nursing staff had the necessary skills and competencies to perform CPR, potentially affecting residents with a Full Code status. Further deficiencies were noted in the facility's failure to conduct annual performance evaluations for Certified Nursing Assistants (CNAs) and to develop and implement continuing education and competency evaluations for nursing staff. The facility's policies and procedures were outdated, and there was a lack of job descriptions for various nursing roles. Food safety practices were also inadequate, with unsanitary conditions observed in the main dining room refrigerator. The facility's administration confirmed the absence of a grievance policy and the lack of skills fairs or competency assessments for nursing staff.
Deficiencies in Staff Training and Certification
Penalty
Summary
The facility failed to implement and maintain effective training programs for nursing staff, specifically in the areas of CPR, nursing competencies, dementia care, resident rights, and the required 12 hours of annual in-service education for CNAs. The Director of Nursing (DON) admitted to not being CPR certified and stated that the facility does not require CPR certification for staff. Documentation showed that only a small fraction of the nursing staff, including Registered Nurses, Licensed Practical Nurses, and Certified Nurses Aids, had current CPR certifications. Additionally, the facility had not developed or implemented a skills fair or competencies for nursing staff, neither upon hire nor annually. Employee education files for several CNAs lacked documentation of training in dementia care, resident rights, and the required annual continuing education hours. These deficiencies were confirmed during interviews with the Administrator and the DON, who acknowledged the lack of proper training and documentation.
Deficiency in CNA Training Compliance
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received the required 12 hours of annual in-service education training, including mandatory yearly trainings for dementia care and resident rights. This deficiency was identified during a review of employee education records and interviews. Specifically, four CNAs employed for over a year did not meet these requirements. CNA #13, hired in August 2021, lacked evidence of dementia and resident rights training and completed only 7.5 of the required 12 hours of continuing education for 2023. CNA #14, hired in August 2022, lacked dementia training and completed 9 of the required 12 hours. CNA #15, hired in September 2021, lacked both dementia and resident rights training and completed 11 of the required 12 hours. CNA #16, hired in July 2020, lacked resident rights training and completed only 5.5 of the required 12 hours. The Director of Nursing confirmed these findings during an interview.
Failure to Accommodate Resident's Bathing Preferences
Penalty
Summary
The facility failed to accommodate the bathing preferences of a resident, leading to a deficiency in care. Resident #24 expressed a preference for morning showers twice a week, which was communicated to various staff members, including a CNA, a Registered Nurse, and a Nurse Practitioner. Despite these communications, the resident did not receive a shower for seven days. The posted shower schedule was outdated, indicating showers on Wednesday evenings, while the updated schedule showed Thursday evenings once a week. The CNA confirmed that the resident did not receive showers twice weekly as preferred. Documentation showed the last shower was on the evening shift of 8/18/24, and the resident's admission data emphasized the importance of choosing their bathing options.
Failure to Monitor Pacemaker in Resident
Penalty
Summary
The facility failed to provide follow-up care for a resident with an implanted pacemaker. The admission Minimum Data Set (MDS) assessment noted the presence of a pacemaker, but the Electronic Medical Record (EMR) lacked details about the pacemaker or any follow-up and monitoring of its functioning. The care plan required the Registered Nurse (RN) to monitor, document, and report a pulse rate lower than the programmed rate, but the programmed rate was not found in the EMR. Interviews revealed that a Licensed Practical Nurse (LPN) was unaware of the resident's pacemaker, and an RN could not provide documentation on the pacemaker's programmed rate or confirm if the resident had been followed by a cardiologist since admission. The Director of Nursing confirmed that the standard of care for the pacemaker was not met.
Sanitation Issues in Dining Room Refrigerator
Penalty
Summary
The facility failed to maintain sanitary conditions in the main dining room refrigerator. During an observation, it was noted that there was no documentation of temperature monitoring for the refrigerator. Additionally, a large amount of red fluid was found covering the bottom of the freezer. The food service manager confirmed these observations during the inspection.
Lack of Grievance Policy and Inaccessible Complaint Boxes
Penalty
Summary
The facility failed to develop and implement a grievance policy that includes the residents' rights to file grievances, the process for filing grievances, including anonymously, and the response or resolution to grievances. During interviews, residents were unaware of their ability to file grievances or the process to do so. One resident mentioned that a complaint box was present but was inaccessible due to its location behind a medication cart and being too high for residents in wheelchairs. Observations confirmed that comment and suggestion boxes on all units were inaccessible for wheelchair-bound residents. Interviews with the Director of Social Services and the Administrator revealed that the facility lacked a formal grievance process or policy, and residents were expected to bring concerns directly to the Administrator, who would then determine if the concern was a grievance.
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What surveyors actually found near you
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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 Brunswick
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mid Coast Senior Health Center | 0.1 mi | ★★★★★ | 0 | 0 |
| Winship Green Center For Health & Rehab, Llc | 8.4 mi | ★★★★★ | 4 | 0 |
| Hawthorne House | 9.2 mi | ★★★★★ | 1 | 0 |
| Coastal Manor | 12.5 mi | ★★★★★ | 36 | 0 |
| Brentwood Center For Health & Rehabilitation, Llc | 13.1 mi | ★★★★★ | 23 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.