Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at New Horizons Care Center during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment experienced a fall during a transfer, resulting in a wrist bruise. The CNA reported the incident to the nurse, but the resident's family was not notified as required by facility policy. The omission was discovered when the family member learned of the fall during a visit and contacted the facility with concerns.
The facility failed to identify and monitor target symptoms for residents receiving psychotropic medications, and did not adhere to policy regarding PRN orders, which should be limited to 14 days. Residents with cognitive impairments and diagnoses such as Alzheimer's and anxiety were prescribed medications without documented target symptoms, and one resident's PRN order lacked a stop date. The DON confirmed the lack of monitoring, violating the facility's policy for managing psychotropic medications.
A facility failed to ensure a resident's right to request or refuse treatment by not documenting the resident's election of a DNR status. The electronic medical record showed a DNR code status without evidence of the resident's choice. The DON confirmed the absence of a declaration, and the facility's policy requiring documentation and regular updates by the physician was not followed.
The facility failed to provide adequate personal hygiene services to two residents, both cognitively intact, who reported not receiving regular showers due to insufficient staffing. Bathing records confirmed extended periods without showers, and the DON acknowledged the lack of a plan to ensure bathing when staff were unavailable, contrary to facility policy.
A facility failed to ensure an appropriate diagnosis and attempt removal of an indwelling urinary catheter for a resident who was cognitively intact and independent with toileting. The resident had no genitourinary diagnoses except renal issues and was always continent of bowel. Despite this, the resident had a catheter placed without a valid diagnosis, and the facility did not attempt bladder retraining or use of an external catheter. The catheter was initially placed to prevent infections in leg wounds, but the facility's policy on bowel and bladder training was not followed.
The facility failed to protect residents from physical abuse, resulting in harm. In one case, a resident was punched by another, causing injury. Staff noted the aggressor's history of aggression. In another incident, two residents engaged in a physical altercation, surprising both. The facility's abuse prevention policy was not effectively implemented.
A facility failed to report an alleged abuse incident involving a resident to the state survey agency. The resident's spouse claimed a CNA pushed the resident into a chair, but the facility did not document the allegation in the incident database. The CNA was sent home, and an investigation was initiated, but the incident was not reported as required by the facility's policy.
The facility did not update care plans for two residents after altercations, including one where a resident was punched, resulting in a cut and swelling. Staff interviews revealed reliance on personal knowledge rather than documented interventions, and the MDS coordinator confirmed care plans were not updated post-incident, contrary to facility policy.
Failure to Notify Family After Resident Fall
Penalty
Summary
The facility failed to notify the family member of a resident following a fall that occurred during a transfer. The resident, who had a moderate cognitive impairment and a history of cerebral infarction, experienced a fall when the resident pulled up a foot during a transfer, causing the CNA to lower the resident to the floor. The CNA reported the incident to the nurse on duty, but the resident's representative was not informed of the fall. The omission was discovered when the resident's representative visited and learned of the incident directly from the resident, who also showed a bruise on the wrist. Medical record review confirmed that the resident's representative called the facility to express concern about not being notified of the fall and a possible wrist injury. Subsequent assessment and x-ray showed no fracture, but a bruise and a small scab were noted. Staff interviews revealed that the nurse on duty at the time was a traveler and was unaware of the facility's policy requiring family notification after a fall. The facility's policy clearly states that family members must be notified in the event of a fall or possible injury.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure that target symptoms were identified and monitored for six residents who were receiving psychotropic medications. These residents, who had varying degrees of cognitive impairment and diagnoses such as Alzheimer's, dementia, anxiety, and depression, were prescribed medications like olanzapine, sertraline, lorazepam, quetiapine, venlafaxine, trazodone, fluoxetine, and buspirone. Despite the administration of these medications, the medical records lacked evidence of identified or monitored medication-specific target symptoms, which is a critical step in ensuring the appropriateness and effectiveness of psychotropic medication use. Additionally, the facility did not adhere to the policy regarding PRN orders for psychotropic medications, which should be limited to 14 days unless a documented rationale for continuation is provided. In the case of one resident, lorazepam was re-ordered without a specified stop date, violating the facility's policy that requires PRN orders to be reviewed and justified for continuation beyond the initial 14-day period. This oversight indicates a lack of compliance with established procedures for managing psychotropic medications. An interview with the Director of Nursing confirmed that the facility had not identified or monitored medication-specific target symptoms for the psychotropic medications administered to the residents. The facility's policy, which was last reviewed in May 2023, outlines the necessity for documenting specific conditions and symptoms that warrant the use of such medications, as well as the requirement for PRN orders to have a stop date and be reviewed for appropriateness. The failure to follow these guidelines resulted in deficiencies related to the management of psychotropic medications for the residents involved.
Failure to Document Resident's DNR Status
Penalty
Summary
The facility failed to ensure a resident's right to request, refuse, or discontinue treatment, specifically regarding a Do Not Resuscitate (DNR) status. A review of the electronic medical record revealed that a resident had a DNR code status, but there was no evidence that the resident had elected this status. An interview with the Director of Nursing (DON) confirmed that the electronic medical record lacked a declaration of code status, which should have been completed by the provider. The facility's DNR policy requires that at the time of admission, the Social Services person or Charge Nurse should determine if the resident has executed a Living Will or a signed DNR statement, and the physician is responsible for writing and updating the DNR order every 30 days. However, these procedures were not followed, leading to the deficiency.
Inadequate Personal Hygiene Services Due to Staffing Issues
Penalty
Summary
The facility failed to ensure that residents received adequate services to maintain good personal hygiene, specifically in providing regular showers. Resident #7, who is cognitively intact with a BIMS score of 14, reported not receiving showers regularly due to insufficient staffing. The bathing records indicated that Resident #7 went several days without a shower on multiple occasions, with no documented refusals, highlighting a lack of consistent care. Similarly, Resident #33, also cognitively intact with a BIMS score of 15, reported that showers were only offered twice a week and sometimes missed due to staffing shortages. The records showed multiple instances where Resident #33 went several days without a shower, with some documented refusals but no evidence of alternative arrangements being made. The Director of Nursing confirmed that the facility did not have a plan to ensure bathing when staff were unavailable, and the facility policy indicated that residents should receive at least one full-body bath per week, with more frequent bathing if desired or necessary.
Inappropriate Use of Indwelling Catheter Without Diagnosis
Penalty
Summary
The facility failed to ensure an appropriate diagnosis and attempt removal of an indwelling urinary catheter for a resident. The resident, who was cognitively intact with a BIMS score of 14 out of 15, had no genitourinary diagnoses except renal insufficiency, renal failure, or end-stage renal disease. The resident was independent with toileting hygiene, personal hygiene, and toilet transfer, and was always continent of bowel. Despite this, the resident had an indwelling catheter placed, and there was no evidence of an appropriate diagnosis for its placement in the physician orders. An observation noted the catheter drainage bag was improperly placed, hanging on the side of the resident's trash can. The hospital discharge note indicated the resident was to continue with a Foley catheter due to urine incontinence and recurrent infection. However, the Director of Nursing (DON) revealed that the catheter was initially placed to prevent infections in the resident's leg wounds, and no attempts were made to use an external catheter or bladder retraining. The facility's policy on bowel and bladder training, which requires reassessment of residents' conditions quarterly, was not followed, as the resident did not have any conditions that would disqualify them from retraining. This oversight led to the inappropriate use of an indwelling catheter without a valid medical diagnosis.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, resulting in harm to two residents. In one incident, a resident punched another resident in the mouth, causing a small cut and mild swelling. Interviews with staff revealed that the aggressor was known to be dangerous and had previously attacked staff and other residents without provocation. The victim was upset and shocked by the incident, and staff confirmed the aggressor's history of aggression. In another incident, a resident grabbed another resident's face, leading to a physical altercation where both residents ended up hitting each other. Staff interviews indicated that both residents were surprised by the incident. The facility's policy on abuse prevention, which was last reviewed in May 2023, emphasizes protecting residents from abuse by anyone, including other residents. However, the facility's failure to prevent these incidents indicates a lapse in adhering to this policy.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the state survey agency. The incident involved a resident whose spouse reported that a CNA had pushed the resident down onto a chair. Despite the spouse's report, the facility did not believe the allegation, and the incident was not documented in the state survey agency's incident database. The CNA involved was providing one-to-one care for the resident at the time and was sent home by the DON after the allegation was made. The DON confirmed that an investigation was initiated, but the allegation was not reported to the state survey agency as required by the facility's Abuse Prevention Program policy.
Failure to Update Care Plans After Resident Altercations
Penalty
Summary
The facility failed to develop and implement care plans for two residents following altercations. Resident #2 punched Resident #1, resulting in a small cut and mild swelling for Resident #1. Another incident involved Resident #3 grabbing Resident #1's face, leading to Resident #1 slapping Resident #3. Despite these incidents, the care plan for Resident #1, last updated on 7/1/24, did not include specific interventions related to these altercations. Similarly, Resident #2's care plan, last updated on 7/20/24, lacked interventions addressing aggression towards other residents or staff and was not updated following the altercation on 8/4/24. Interviews with staff revealed that care plans were not effectively communicating necessary interventions. CNA #1 described Resident #2 as dangerous and aggressive, often targeting Resident #1, and noted that staff relied on their knowledge rather than documented care plans. The MDS assessment coordinator acknowledged that care plans were a struggle and confirmed that no analysis was completed following incidents, resulting in care plans not being updated with identified interventions. The facility's policy on resident altercations, revised on 6/2/20, required staff to review events with supervisors and update care plans, which was not adhered to in these cases.
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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 Lovell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Powell Valley Care Center | 19.2 mi | — | 1 | 0 |
| Wyoming Retirement Center | 36.5 mi | — | 1 | 0 |
| Cody Regional Health Long Term Care Center | 39.3 mi | — | 5 | 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 August 2026) and official state health department websites.