Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Pruitthealth - Limestone during CMS and state inspections, most recent first.
The facility did not thoroughly investigate or document falls resulting in injuries for several residents with cognitive impairment and fall risk, failing to include staff interviews, root cause analysis, or evaluation of interventions, as required by policy.
Surveyors found that the facility did not consistently follow prescribed menus or provide adequate menu variety. A resident with severe cognitive impairment and a pureed diet order was served meals with incorrect textures and items not matching the menu. Multiple residents reported receiving repetitive side dishes, especially vegetables and potatoes, over several days. Dietary staff and the RD demonstrated a lack of oversight and communication regarding menu adherence, and the facility lacked a written menu policy.
Two residents had inaccurate MDS assessments: one was incorrectly coded as receiving insulin injections despite no orders or administration, and another was coded as discharged to a hospital when she was actually discharged home. These errors were confirmed by MDS coordinators and the DON after reviewing the EMR and progress notes.
Certified nurse aides failed to perform hand hygiene after removing dirty gloves and before donning clean gloves during incontinence care for two residents, contrary to facility policy and infection control standards. Staff interviews confirmed awareness of the required procedure, but the step was missed during observed care.
A resident with dementia and behavioral symptoms received a new diagnosis of unspecified psychosis and was prescribed haloperidol, but the facility did not submit an updated PASRR Level I Assessment. Staff interviews revealed confusion about who was responsible for PASRR updates, and the facility lacked a written PASRR policy.
Failure to Investigate and Document Resident Falls
Penalty
Summary
The facility failed to thoroughly investigate falls that resulted in injuries for four out of ten residents reviewed for accidents. The facility's policy required immediate and comprehensive documentation of occurrences, including witness statements, details of the incident, and a root cause analysis, but these steps were not consistently followed. For each resident, the documentation lacked pertinent details such as the circumstances of the fall, staff and resident interviews, and whether care plan interventions were in place or effective at the time of the incident. One resident with severe cognitive impairment and a history of falls experienced multiple unwitnessed falls, including one resulting in a subdural hematoma and hospitalization. The investigation reports for these incidents did not document the resident's activity at the time of the fall, staff interviews, or a root cause analysis. Another resident, also with significant cognitive impairment and a history of falls, suffered a fracture after falling from bed. The investigation into this fall did not include sufficient details about the circumstances, staff interviews, or an evaluation of the effectiveness of existing interventions. Additional cases included a resident with muscle weakness and a history of falls who was found on the floor with head and arm injuries, and another resident who sustained a head and wrist injury after a fall. In both cases, the documentation failed to include staff or resident interviews, a root cause analysis, or a timely and thorough investigation. The DON and other staff confirmed that the required investigative steps were not completed, and the lack of detailed documentation prevented evaluation of whether interventions were effective in preventing further falls.
Failure to Follow Prescribed Menus and Provide Menu Variety
Penalty
Summary
The facility failed to follow prescribed menus and provide adequate menu variety for several residents, as evidenced by observations, interviews, and record reviews. One resident with severe cognitive impairment, Alzheimer's disease, diabetes, and dysphagia was repeatedly served meals that did not match the pureed diet ordered by the physician and outlined in the care plan. Meals provided to this resident included regular textured foods and ground meats instead of pureed options, and the textures of pureed foods were inconsistent, sometimes being too firm. Additionally, the resident was served a frozen supplement that could not be consumed as intended. Multiple residents reported dissatisfaction with the lack of menu variety, particularly with vegetables and side dishes. Residents expressed that they were served the same types of mixed vegetables and potatoes multiple times within a week, leading to complaints about repetitive meals. The facility's menu records confirmed that similar vegetable blends and potatoes were served frequently over a short period. Interviews with dietary staff and the Registered Dietitian revealed a lack of oversight and communication regarding menu adherence and resident preferences. The facility did not have a written menu policy, and the new Dietary Manager was unfamiliar with the reasons for menu inconsistencies. Although the facility had a Performance Improvement Plan related to food palatability, it did not address resident complaints about repetitive menus or lack of variety.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents, as required by the Resident Assessment Instrument (RAI) manual and the facility's own policy. For one resident, the admission MDS indicated that insulin injections were administered for all seven days of the assessment look-back period, despite a review of the electronic medical record (EMR) and Medication Administration Record (MAR) showing no insulin orders or administration. The resident also confirmed during an interview that she did not use insulin. MDS coordinators reviewed the record and acknowledged that the insulin was incorrectly coded on the MDS. For another resident, the discharge MDS was inaccurately coded as a discharge to a short-term general hospital, while progress notes and a follow-up call indicated the resident had actually been discharged home and was receiving physical therapy locally. MDS coordinators and the Director of Nursing confirmed the discrepancy between the discharge location documented in the MDS and the actual discharge destination. These inaccuracies in MDS coding had the potential to affect care planning and the provision of required services.
Failure to Perform Hand Hygiene During Incontinence Care
Penalty
Summary
Staff failed to follow infection control standards during incontinence care for two residents. Specifically, certified nurse aides did not wash their hands after removing dirty gloves and before donning clean gloves to apply a clean brief. This was observed during care for two residents, where the aides discarded dirty briefs and gloves but did not perform hand hygiene as required by facility policy. The facility's infection prevention policy, dated 10/15/24, requires hand washing or hand rub when moving from a contaminated to a clean body site and immediately after removing personal protective equipment. Interviews with staff confirmed that they had received training on proper hand hygiene but missed this step during the observed care. The Infection Preventionist and Director of Nursing both stated that the expectation is for staff to wash their hands between clean and dirty care processes.
Failure to Update PASRR Assessment After New Mental Illness Diagnosis
Penalty
Summary
The facility failed to submit a new Pre-admission Screening and Resident Review (PASRR) Level I Assessment after a resident received a new diagnosis of unspecified psychosis and was prescribed haloperidol for treatment. The resident, who had a history of dementia with agitation and depression, was involved in a behavioral incident where she hit another resident, leading to police notification. The original PASRR Level I Assessment completed at admission did not identify a primary diagnosis of serious mental illness. However, after the new diagnosis and initiation of antipsychotic medication, no updated PASRR was completed or submitted. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for completing and updating PASRR assessments. The Social Services Director, Admissions Director, and MDS Coordinator each indicated that they did not handle PASRR updates, and the Administrator was unsure if a new PASRR had been submitted for the resident's new diagnosis. Additionally, the facility did not have a written PASRR policy available upon request.
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What surveyors actually found near you
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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) |
|---|---|---|---|---|
| New Horizons Limestone | 0.6 mi | ★★★★★ | 9 | 0 |
| Bell Minor Home, The | 1.4 mi | ★★★★★ | 1 | 0 |
| Willowbrooke Court At Lanier Village Estates | 5 mi | ★★★★★ | 3 | 0 |
| Crossroads Of Flowery Branch Of Journey Llc, The | 11.2 mi | ★★★★★ | 15 | 0 |
| Gateway Health And Rehab | 15.1 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.