Noble Horizons

In the surveyor’s words

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

• Immediate jeopardy, patternF880Feb 27, 2026

  Based on facility documentation review, staff interviews, and observations, the facility failed to develop and implement a water management plan to prevent, identify, and mitigate Legionella contamination in the facility water system, resulting in Immediate Jeopardy to resident health and safety. Water testing performed in June 2024 and June 2025 identified multiple locations positive for Legionella, including Legionella pneumophila serogroups 1-14, at levels requiring immediate action in a high risk healthcare setting; however, facility leadership did not recognize the significance of the results, did not implement corrective measures, and did not communicate findings to the Infection Preventionist or Medical Director. […]

• Immediate jeopardy, isolatedF806Aug 2, 2021

  Based on clinical record reviews, review of facility documentation, facility policy and interviews for one of three sampled residents (Resident #1) who had food allergies, the facility failed to ensure that the resident received the appropriate diet which resulted in an allergic reaction. As a result of the facility's failure, a finding of Immediate Jeopardy was identified. The findings include: Resident #1's diagnoses included diabetes, asthma, [CONDITION(S)] and dementia. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had moderately impaired cognition, required supervision with eating and was on a therapeutic diet. The Resident Care Plan dated 5/26/21 identified Resident #1 was allergic to nuts, peanuts, bananas and aspartame. […]

• Actual harm, isolatedF689Feb 27, 2026

  Based on record review, staff interviews, and facility documentation, the facility failed to ensure Resident #27 received the level of assistance identified in the care plan to prevent accidents, when staff provided only one person's assistance during a transfer despite the resident's assessed need for two person assistance. The MDS, therapy caregiver training, and the resident's care plan all directed that two staff assist with transfers using a walker; however, on 8/17/25 NA #1 attempted to transfer the resident alone, resulting in the resident losing balance, falling, and sustaining a right clavicle fracture that required pain management, orthopedic follow up, sling immobilization, and a change to mechanical lift transfers. […]

• Actual harm, isolatedF689Jul 9, 2024

  Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for accidents, the facility failed to ensure the resident used an assistive device while ambulating in accordance with the plan of care resulting in a fall with injury. The finding includes: Resident #1 had diagnoses that included unilateral osteoarthritis of right knee, and was status post right knee arthroplasty. Review of Resident #1's fall risk assessment dated [DATE] identified Resident #1 was at a high risk for falls. […]

• Actual harm, isolatedF689Apr 24, 2024

  Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for accidents, the facility failed to ensure that staff provided the resident with the required assistance while ambulating and failed to use a safety device resulting in a fall with injury. The finding includes: Resident #1 had diagnoses that included cerebral infarction (stroke), muscle weakness, abnormalities of gait and mobility. Review of Resident #1's caregiver training record dated 3/25/2024 identified Resident #1 required the assistance of two (2) staff with use of a walker and gait belt while ambulating and the use of a gait belt and walker with transfers. […]