Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
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 Limestone during CMS and state inspections, most recent first.
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.
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 | — | 0 | 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 | — | 0 | 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.