New Horizons Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, and staff and resident representative interview, the facility failed to notify the responsible party following a change of condition in 1 of 3 sampled residents (#1) reviewed. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #1 had severe cognitive impairment, and had diagnoses which included, Alzheimer's dementia, diabetes mellitus, and urinary incontinence. Further review showed the resident required staff assistance with bed mobility and personal cares. Review of a 7/30/25 Braden score assessment showed the resident was at severe risk for developing pressure ulcers. The following concerns were identified:a. Review of the nursing progress note dated 7/13/25 and timed 12:14 PM showed . There was a small opening on [his/her] coccyx. Wound was cleaned and a 4X4 Mepilex was applied.b. Review of the nursing progress note dated 7/14/25 and timed 12:23 PM showed . Spoke with wound care nurse. about residents coccyx wound. if worsening occurs to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident representative and staff interview, and policy and procedure review, the facility failed to notify family of changes for 1 of 3 sample residents (#1). The findings were: 1. Review of the annual MDS assessment dated [DATE] showed resident #1 had a BIMS score of 12 out of 15, which indicated s/he had moderate cognitive impairment, and diagnoses which included cerebral infarction due to occlusion. Review of the facility incident review showed the resident had a fall during a transfer on 2/16/25. The following concerns were identified: a. Review of a progress note dated 2/18/25 and timed 3:30 AM showed the resident's representative called the facility on 2/17/25 at 7:40 PM to express a concern that the resident had a fall on 2/16/25 that was not reported to her, and the resident may have hurt [his/her] wrist. Further review showed that following the call the resident was assessed by the nurse and had no obvious open areas, no deformities or swelling, no apparent guarding or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. The MDS showed the resident had a mood score of 0, which indicated no signs or symptoms of depression, and the resident exhibited behaviors such as verbal behavior directed at others and wandering. Further review showed the resident received antipsychotic medication and antidepressent medication during the look-back period. Review of the physician orders showed the resident received…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review, staff interview, and facility policy and procedure review, the facility failed to ensure residents right to request/refuse/discontinue treatment for 1 of 1 sample residents (#45) with a do not resuscitate (DNR) status. The findings were: 1. Review of the electronic medical record on 1/7/25 at 2:26 PM showed resident #45 had a DNR code status, however there was no evidence the resident elected the DNR code status. 2. Interview with the DON on 1/9/25 at 10 AM revealed the electronic medical record showed no sign of a declaration of code status. Further interview revealed the provider should have filled out the code status; however, it was not in the electronic medical record. 3. Review of the facility's policy DNR Policy updated 3/15/18 showed .1. At the time of admission the Social Services person or Charge Nurse shall determine if the resident has executed a Living Will or has a signed statement for DNR.5. The physician shall assume the responsibility for writing the DNR order by: a. Writing and dating the order on the Physician's order sheet b. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interview, medical record review, and policy and procedure review, the facility failed to ensure residents received services to maintain good personal hygiene for 2 of 3 sample residents (#7, #33) reviewed for activities of daily living. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #7 had a BIMS score of 14 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included cerebrovascular accident, transient ischemic attack, or stroke and Parkinson's disease. Further review showed the resident required partial/moderate assistance with bathing and upper and lower body dressing. The following concerns were identified: a. Interview with the resident on 1/7/25 at 9:21 AM revealed s/he did not feel there was enough staff because s/he did not get showers regularly. b. Review of the bathing records for October, November, and December of 2024 and January of 2025 showed the resident went 6 days without a shower from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, medical record review, and policy and procedure review, the facility failed to ensure an appropriate diagnoses and attempt removal of an indwelling urinary catheter for 1of 1 sample resident (#7). The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #7 had a BIMS score of 14 out 15, which indicated the resident was cognitively intact, and no genitourinary diagnoses except renal insufficiency, renal failure, or end-stage renal disease. Further review showed the resident was independent with toileting hygiene, personal hygiene, and toilet transfer, was always continent of bowel, was not on a toileting program, and had an indwelling catheter placed. The following concerns were identified: a. Observation on 1/7/25 at 9:21 AM showed the resident was in his/her room and a catheter drainage bag was hanging on the side of the resident's trash can. b. Review of a hospital discharge note dated 6/13/24 showed the resident was discharged from the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on resident representative and staff interview, grievance review, state survey agency incident database review, and policy and procedure review, the facility failed to ensure allegations of abuse were reported for 1 of 4 sample residents (#3) reviewed for allegations for abuse. The findings were: 1. Interview with the resident representative for resident #3 on 8/27/24 at 6:02 PM revealed the resident's spouse reported a CNA had pushed the resident down onto a chair on 8/25/24; however, she did not think the facility believed the spouse. 2. Review of a Complaint/Grievance form dated 8/25/24 showed [Spouse of resident #3] said CNA pushed [resident] down to sit in chair. 2. Review of the state survey agency incident database showed no evidence an allegation of abuse was reported for resident #3 on or after 8/25/24. 3. Interview with CNA #4 on 8/27/24 at 6:21 PM revealed she was providing 1 to 1 care for resident #3 on 8/25/24. Further interview revealed the DON arrived at the facility and sent the CNA home due to an allegation of abuse; however, after the DON watched the camera…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure care plans were developed and implemented for 2 of 4 sample residents (#1, #2) following resident to resident altercations. 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. Review of an incident dated 7/21/24 showed resident #3 walked up to resident #1, grabbed resident #1's face, and resident #1 slapped resident #3 in the face. The following concerns were identified: a. Review of the care plan for resident #1 last updated 7/1/24 showed no resident specific interventions related to altercations on 7/21/24 or 8/4/24. b. Review of the care plan for resident #2 last updated 7/20/24 showed no resident specific interventions related to aggression toward other residents or staff and no updated interventions related to the altercation on 8/4/24. 2. Interview with CNA #1 on 8/28/24 at 10:58 PM revealed resident #2 was kind of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and staff interview, the facility failed to complete a discharge summary which included a recapitulation of the resident's stay for 1 of 1 resident (#58) reviewed for discharge to another nursing home or swing bed. The findings were: 1. Review of the 9/13/23 discharge MDS assessment for resident #58 showed s/he had been discharged to Another nursing home or swing bed and a return to the facility was not anticipated. The following concerns were identified: a. Review of the resident's medical record showed a 9/13/23 Facility Transfer form had been completed which indicated the resident had been transferred to a swing bed. Further review of the medical record showed no evidence a discharge summary had been completed. Interview with the DON on 10/17/23 at 5:19 PM confirmed the discharge summary had not been completed.

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. Further, she stated the cook takes the temperature of the food prior to serving the plates. The food temperature is not checked again after that initial check. Once the trays are loaded in the carts they go directly to the different pods. Once delivered to the pod, it is the nursing staff that serves the trays to the residents. Interview with resident #31 on 8/16/22 at 1:19 PM revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, medical record review, staff interview, and review of policy and procedures the facility failed to develop and implement a comprehensive person-centered care plan or 1 of 6 residents (# 18) reviewed for behavior indicators. The findings were: 1. Review of the care plan for resident #18, dated 6/10/22, showed diagnoses of Alzheimer's dementia, history of cerebral vascular accident, and chronic left hip pain. Review of the progress note dated 7/9/22 at 11:44 PM showed [Res #18] and another resident wanting to go out outside after supper. Review of the progress note dated 7/12/22 at 6:24 PM showed Resident has attempted at least 5 times during 3p-7p shift to go out the patio doors. Resident has attempted to get on the elevator twice, stating [s/he] needed to go downstairs and outside to look for [her/his] phone. Review of the progress note dated 7/13/22 at 9:11 PM showed Resident wanting to go out on the patio or downstairs this evening; no extra staff to go with [her/him]. Complains to other residents which makes them angry also. Trying to get on elevator to get…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.