Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 New Horizons Limestone during CMS and state inspections, most recent first.
Oxygen Therapy Not Given per Orders: Two residents received O2 at settings that did not match physician orders. One resident with severe cognitive impairment had an order for 2 LPM via NC PRN for SOB, but the concentrator was observed at 3 LPM until an LPN checked the order and adjusted it. Another resident with COPD and other respiratory history had an order for 3 LPM via NC PRN and tolerated, but was observed at 2 LPM and later at 5 LPM; an RN confirmed the 5 LPM setting did not match the order.
A facility failed to ensure two residents could safely self-administer medications when medications were left at the bedside unsupervised. One resident with multiple diagnoses, including CVA and CKD, had triple antibiotic ointment observed on the bedside table, while another resident with expressive aphasia and moderate cognitive impairment had simethicone tablets left in a cup at the bedside for hours. Staff and leadership stated residents who self-administer medications must be assessed, but no such assessment was documented for either resident.
A resident with severe cognitive impairment and diagnoses including asthma, lung disorder, and heart failure had an active order for O2 via NC at 2 LPM PRN for SOB, but the care plan did not address oxygen use. Surveyors observed the oxygen concentrator set at 3 LPM on two occasions, and an LPN later confirmed the incorrect setting and adjusted it to match the order. The MDS nurse acknowledged the oxygen intervention was missed from the care plan until later, and the DON stated care plan updates should be completed promptly for staff reference.
An LPN left a medication cart unlocked and unattended near the nurses' station, and another cart was found with an expired antacid, an unlabeled and undated Lantus insulin pen, and a Lantus vial with an incorrect discard date. The DON stated carts must remain locked unless in direct eyesight, and insulin must be labeled with the open date and discard date.
Facility A was found to have expired and improperly stored food items, including therapeutic shakes, tortillas, and other products, during a survey. Opened items were unlabeled and undated, and expired items were found in the pantry, freezer, and cooler. Interviews with the EC and DKM revealed lapses in oversight and a need for more diligent staff management and training. The Administrator emphasized the risk of foodborne illness due to these deficiencies.
A resident at Facility A was found with inhalers at her bedside without a proper assessment or physician's order for self-administration, despite the facility's policy requiring an interdisciplinary team to determine the safety of self-administration. Staff interviews revealed a lack of awareness and documentation, leading to a deficiency due to the potential for serious health complications.
Facility B did not provide a written bed hold notice for a resident transferred to a hospital, as required by their policy. The facility's document outlines Medicaid coverage for up to seven nights of bed hold during hospitalization, but no evidence of a notice was found in the resident's records. Interviews revealed that the Administrator and LPN were unaware of the need for a notice at the time of transfer, potentially risking the resident's re-admission and room retention.
Facility B failed to properly store a nebulizer mask for a resident with COPD, chronic respiratory failure, and other conditions. The resident's nebulizer mask was observed uncovered and improperly stored on two occasions. The Unit Manager confirmed that the responsibility for ensuring proper storage lay with the Saturday supervisor and CNAs, who were expected to conduct spot checks.
Facility A failed to discard an expired Glucometer Control Solution Level 3 found in a medication cart on Hall 300. An LPN incorrectly believed it was still usable, while interviews with staff, including the DON, confirmed that expired solutions should be discarded to ensure accurate glucometer readings.
Oxygen Therapy Not Administered According to Physician Orders
Penalty
Summary
The facility failed to ensure oxygen therapy was administered according to physician orders for two residents, R9 and R180. The facility policy titled Oxygen Administration, Transport and Storage - Patient Care required a physician or APP order before oxygen administration and specified that the order include the oxygen delivery device and the liter flow and/or oxygen concentration. R9 had diagnoses including atrial fibrillation, asthma, disorder of the lung, and heart failure, and had severe cognitive impairment with a BIMS of 00. R9's order was for oxygen via nasal cannula at 2 LPM as needed for shortness of breath, but observations on 03/10/2026 and 03/11/2026 showed the oxygen concentrator running at 3 LPM while R9 wore oxygen via nasal cannula. During observation and interview on 03/11/2026, an LPN confirmed R9's concentrator remained at 3 LPM, reviewed the physician order, and then adjusted the concentrator to 2 LPM. The nurse acknowledged she had not yet verified the setting during the current shift. R180 had diagnoses including COPD, OSA, history of pulmonary embolus, and edema, with a BIMS of 13. R180's care plan included administering oxygen as ordered, and the physician order was for oxygen via nasal cannula at 3 LPM as needed and tolerated. However, observations showed R180 receiving oxygen at 2 LPM on 03/10/2026 and at 5 LPM on 03/12/2026, with the 5 LPM setting continuing later that day. An RN confirmed the oxygen setting was 5 LPM and that the order was for 3 LPM. The DON stated it was her expectation that nursing staff ensure oxygen is administered by physician orders and that oxygen equipment is maintained clean and properly functioning.
Unsupervised Medications Left at Bedside Without Self-Administration Assessment
Penalty
Summary
The facility failed to ensure two residents could safely self-administer medications by leaving medications at the bedside unsupervised. The facility policy stated that the interdisciplinary team must determine it is safe before a resident self-administers medications, and that consideration must be given to cognitive status, ability to follow directions, understanding of medications, and ability to store medications safely and securely. The record review and staff interviews showed no documentation that either resident had been assessed for self-administration of medications. For one resident, the record showed diagnoses including cerebral infarction, hypertension, depression, mood disorder, chronic kidney disease, and unsteadiness. The resident’s MDS documented a BIMS score of 15, and the care plan included cognition-related interventions and behaviors such as refusing care and meals. On three observations, a tube of triple antibiotic ointment was seen on the resident’s bedside table. Staff interviews confirmed that medications found at the bedside should be removed and secured, and the DON and Administrator stated residents who self-administer medications are typically assessed, but no assessment was documented for this resident. For the second resident, the record showed diagnoses including history of CVA with residual deficit, expressive aphasia, debility, abdominal distention, abdominal pain, and gastroparesis. The MDS documented Spanish as the preferred language, need for an interpreter, unclear speech, and a BIMS score of 11 indicating moderate cognitive impairment. The resident’s care plan addressed cognitive and communication impairment, and the physician note described the resident as minimally verbal. During observation, two white pills were found in a medication cup at the bedside while the resident was out of the room, and they remained there for hours until the resident returned. The RN identified the pills as simethicone 80 mg after removing them, and the DON stated the resident had not been assessed for self-administration due to impaired cognition.
Failure to Include Oxygen Therapy in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for one resident, R9, related to oxygen administration. R9 was admitted with diagnoses including atrial fibrillation, asthma, lung disorder, and heart failure, and had severe cognitive impairment with a BIMS score of 00. The resident was dependent on staff for all activities of daily living, including wheelchair mobility. Review of the care plan updated 03/11/2026 showed that oxygen use was not addressed, even though the physician had ordered oxygen therapy via nasal cannula at 2 LPM as needed for shortness of breath. Observations showed R9 wearing oxygen via nasal cannula while the oxygen concentrator was set at 3 LPM on 03/10/2026 and again on 03/11/2026. During an observation and interview on 03/11/2026, an LPN confirmed the concentrator was set at 3 LPM, reviewed the physician order, and then adjusted it to 2 LPM, acknowledging the setting had not yet been verified during the shift. The MDS nurse later confirmed that oxygen use was only added to the care plan on 03/11/2026, despite the oxygen order dating back to 02/13/2025, and stated the update had been missed. The DON stated the MDS nurse is responsible for updating the care plan promptly, ideally within 24 hours, because the care plan is used as a reference for nursing interventions, including confirming oxygen orders when a resident shows shortness of breath.
Medication Cart Left Unlocked and Medications Improperly Labeled or Expired
Penalty
Summary
The facility failed to ensure proper medication labeling, expiration dating, discard procedures, and secure storage for one of eight medication carts. The facility policy titled Medication Storage stated that medication storage areas are to be inspected, expired medications are to be segregated until removed, outdated medications are to be kept in a designated area until returned to the supplier, and medication carts must be kept locked at all times unless in a nurse's direct eyesight. The Lantus package insert stated that opened vials must be discarded 28 days after opening. During observation on 03/10/2026, a medication cart was found unlocked and positioned near the nurses' station with no nurse present or in the immediate area. The DON observed the cart but did not address it at that time. The DON later stated the cart belonged to an LPN who was performing a blood sugar check and that carts are not supposed to be left unlocked. On 03/11/2026, the 1-South medication cart contained an expired bottle of calcium carbonate tablets with an expiration date of 12/2025, one unlabeled and undated Lantus insulin pen, and one Lantus insulin vial with an incorrect discard date of 03/30/2026 instead of 03/29/2026 based on the opening date of 03/01/2026. The LPN stated she planned to discard the expired antacid, was unsure of the owner and opening date of the unlabeled insulin pen, and corrected the insulin vial discard date.
Expired and Improperly Stored Food Items Found
Penalty
Summary
Facility A failed to adhere to its Nutrition Food and Supply Storage Procedures, resulting in the presence of expired and improperly stored food items. During an observation, surveyors found numerous expired items in the pantry, including therapeutic shakes, flour tortillas, coconut milk, granola cereal, and other food products. Additionally, several opened food items were found unlabeled and undated, such as loaves of bread, croutons, pecan pieces, and vanilla wafers. In the freezer, expired tortillas, whipped cream, and blue cheese were discovered, along with unlabeled burger packets. The cooler also contained expired items, including a bottle of chocolate drink and cottage cheese. Interviews with the Executive Chef (EC) and Dietary Kitchen Manager (DKM) revealed lapses in oversight and adherence to food safety protocols. The EC admitted that the freezer might have been neglected and expressed a need for more diligent staff management. The DKM highlighted the issue of excessive inventory leading to confusion and emphasized the necessity for staff training on the first in, first out method. Both the EC and DKM acknowledged their responsibility in ensuring staff compliance with food safety procedures. The Administrator reiterated the importance of following guidelines to prevent foodborne illness, which poses a significant risk to residents' health.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
Facility A failed to adequately assess a resident, R71, for self-administration of medication, which could lead to serious health complications. The facility's policy requires the interdisciplinary team (IDT) to determine the safety of self-administration before allowing a resident to exercise this right. However, R71, who was admitted with diagnoses including peripheral neuropathy and mood and anxiety disorder, was found with two inhalers at her bedside without a care plan or physician's order for self-administration. Despite having intact cognition as indicated by a BIMS score of 15, there was no documented assessment or approval for R71 to self-administer medication. During interviews and observations, it was revealed that the staff, including a CNA, LPN, RN, and the Director of Nursing, were unaware of the inhalers at R71's bedside. The LPN and RN confirmed that a physician's order and a self-administration assessment were necessary for residents to have medications at their bedside. The DON stated that the presence of medication at the bedside without proper assessment and documentation could lead to contraindications, drug interactions, potential overdose, or over-sedation. The facility's failure to follow its policy and ensure proper assessment and documentation for self-administration of medication resulted in a deficiency.
Failure to Provide Bed Hold Notice for Hospitalized Resident
Penalty
Summary
Facility B failed to provide a written bed hold notice for a resident (R179) who was transferred to a hospital, as required by their policy. The facility's document titled [Name] Bed Hold Notice outlines that Medicaid will cover up to seven nights of bed hold during hospitalization, and residents are informed of their financial obligations related to bed hold decisions. However, upon review of R179's electronic health records, there was no evidence of a bed hold notice being provided to the resident or their representative upon transfer to the hospital. Interviews with facility staff revealed a lack of adherence to the bed hold notice policy. The Administrator confirmed that no written bed hold notices were provided to residents transferred to the hospital, and the policy was only included in the admission packet. The Licensed Practical Nurse (LPN) responsible for completing bed hold notices stated that the family was informed of the policy upon admission but was unaware that a notice needed to be signed at the time of transfer. This oversight had the potential to place R179 at risk of denial of re-admission and loss of their room following the hospital transfer.
Improper Storage of Nebulizer Mask for Resident with COPD
Penalty
Summary
Facility B failed to ensure proper storage of a nebulizer mask for one of its residents, identified as R150, who was receiving respiratory therapy. R150 was admitted with chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, acid reflux, and chest congestion. The resident's electronic health records indicated intact cognition and ongoing oxygen therapy. Physician orders included albuterol nebulizer solution, an albuterol inhaler, and a fluticasone-vilanterol inhaler. Observations on two separate occasions revealed that R150's nebulizer mask was not covered or properly stored, once found in a dresser. The Unit Manager confirmed that the responsibility for ensuring proper storage of such items lay with the Saturday supervisor and Certified Nurse Assistants, who were expected to conduct spot checks. This oversight had the potential to increase the risk of respiratory infections for R150.
Expired Glucometer Control Solution Not Discarded
Penalty
Summary
Facility A failed to discard an expired Glucometer Control Solution Level 3, which was stored in one of the medication carts on Hall 300. This deficiency was identified during an observation by a surveyor, who found the expired solution in the medication cart's upper drawer alongside other diabetic supplies. When questioned, an LPN stated that the solution was still acceptable for use, believing that the glucometer would display an error message if the solution was ineffective. However, this understanding was incorrect according to the facility's policy, which mandates that expired control solutions must be discarded to ensure accurate and reliable blood glucose readings. Interviews with various staff members, including the Unit Managers for Halls 300 and 100, and the Director of Nursing (DON), confirmed that expired control solutions should not be used and must be discarded. The DON acknowledged the presence of the expired solution in the medication cart but was unsure why it had not been removed, despite assurances that it would not be used. The failure to discard the expired solution posed a risk of compromising the accuracy and functionality of the glucometer, potentially leading to unreliable blood glucose readings.
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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 Gainesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth - Limestone | 0.6 mi | ★★★★★ | 0 | 0 |
| Bell Minor Home, The | 0.9 mi | ★★★★★ | 1 | 0 |
| Willowbrooke Court At Lanier Village Estates | 5.6 mi | ★★★★★ | 3 | 0 |
| Crossroads Of Flowery Branch Of Journey Llc, The | 11 mi | ★★★★★ | 15 | 0 |
| Gateway Health And Rehab | 15.6 mi | ★★★★★ | 3 | 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.