New Horizons Care Center

In the surveyor’s words

From the most serious findings on record at New Horizons Care Center, in the surveyor’s own words.

• Actual harm, isolatedF600Jun 10, 2026

  Based on medical record review, staff interview, incident report review, and policy and procedure review, the facility failed to protect the resident's right to be from physical abuse by a resident for 1 of 4 sample residents (#3) reviewed for abuse. This failure resulted in actual harm to resident #3 who suffered fractures. The findings were: 1.Review of the quarterly MDS assessment dated [DATE] showed resident #3 had a BIMS score of 3 out of 15, which indicated severe cognitive impairment, and had diagnoses which included Alzheimer's dementia, anxiety disorder, and depression. Further review showed resident #3 (victim) was independent with mobility, including walking. […]

• Actual harm, isolatedF600Aug 28, 2024

  Based on medical record review, resident representative and staff interview, and policy and procedure review, the facility failed to protect the residents' right to be free from physical abuse by a resident for 2 of 4 sample residents (#1, #3) reviewed for allegations of abuse. This failure resulted in actual harm to resident #1. The findings were: 1. Review of an incident dated 8/4/24 showed resident #2 punched resident #1 in the mouth with his/her fist. Further review showed resident #1 had a small cut and mild swelling. The following concerns were identified: a. Interview with RN #1 on 8/28/24 at 10:32 AM revealed resident #1 was demonstrating sundowners and was moving and straightening chairs. […]

• Actual harm, isolatedF600May 23, 2023

  Based on review of medical records, staff interview and policy review the facility failed to protect the resident's right to be free from physical abuse by other residents for 1 of 8 sample residents (#7) reviewed for resident-to-resident abuse. This failure resulted in harm to resident #7, who sustained bruising from altercations with other residents. The findings were: 1. Review of the [DATE] admission MDS assessment for resident #7 showed the resident was admitted on [DATE] and had diagnoses which included arthritis, Alzheimer's disease, anxiety disorder, depression, cervical disc disorder with radiculopathy and other chronic pain. Further review showed the resident was unable to be understood and unable to complete a BIMS interview. The following concerns were identified: a. […]

• No harm, potential for more than minimal, patternF758Jan 9, 2025

  Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure target symptoms were identified and monitored for 6 of 6 sample residents (#2, #9, #36, #44, #45, #47) and failed to ensure PRN orders for psychotropic medications were limited to 14 days for 1 of 6 sample residents (#44) reviewed for unnecessary psychotropic medications. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #44 had a BIMS score of 5 out of 15, which indicated severe cognitive impairment and diagnoses which included Alzheimers/dementia with agitation and depression. […]

• No harm, potential for more than minimal, patternF804Aug 18, 2022

  Based on observation, resident interview, staff interview, and policy review the facility failed to ensure food temperatures were maintained at an acceptable temperature for 1 of 3 units (Pod 2). The findings were: Observation on 8/17/22 at 11 AM showed covered food was in the steamer table ready for staff to plate. Further observation showed plated food was delivered to Pod 2 at 12 PM. At 12:15 PM one of the last trays was served to the residents. The last tray of food was checked by the dietary manager. The meat temperature was measured at 102 Fahrenheit (F) and the vegetables at 120 degrees F. Interview at that time with the dietary manager confirmed the temperatures were lower than they should be. […]