New Horizons Limestone

F-F657, Comprehensive Care Plans) to determine that it is safe before the resident exercises that right. A resident may only self-administer medications after the IDT has determined which medications may be self-administered .The decision that a resident has the ability to self-administer medication is subject to periodic assessment by the IDT, based on changes in the resident's medical and decision-making status .If self-administration is determined not to be safe, the IDT should consider, based on the assessment of the resident's abilities, options that allow the resident to actively participate in the administration of their medications to the extent that is safe (i.e., the resident may be assessed as not able to self-administer their medications because they are not able to manage a locked box in their room, but they may be able to get the medications from the nurse at a designated location and then safely self-administer them).

A review of electronic health record (EHR) for Resident R71 revealed she was admitted to the facility with diagnoses including but not limited to peripheral neuropathy, mood and anxiety disorder.

A review of Resident R71's quarterly Minimum Data Set (MDS) dated [DATE REDACTED] documented in Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) of 15, which indicated intact cognition.

A review of Resident R71's care plan with a start date of 10/24/2024 revealed, there was no care plan for self-administration of medication.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 7 115487 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115487 B. Wing 02/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

New Horizons Limestone 2020 Beverly Road NE Gainesville, GA 30501

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0554 A review of Resident R71's physician orders revealed, there was no order for self-administration of medications.

Level of Harm - Minimal harm or During an interview and observation on 2/11/2025 at 11:34 am with the Resident R71, two [name] inhalers (used to potential for actual harm treat or prevent bronchospasms) was observed at Resident R71's bedside table. Resident R71 revealed that she had them for [AGE] years and had been at the facility for about four months. She stated, the inhalers had been brought in Residents Affected - Few with her upon admission. Resident R71 further stated that the staff was aware of the inhalers and did not tell her she couldn't have them.

An observation on 2/12/2025 at 10:21 am in Resident R71's room revealed, two [name] inhalers was observed at Resident R71's bedside table. Resident R71 stated, that she used them when she needed them.

An interview and observation on 2/12/2025 at 10:26 am with Certified Nursing Assistant (CNA) DD revealed that this was her first time seeing the inhalers at the resident's bedside table. CNA DD explained that if she notices medication at the bedside, she must inform the floor nurse, and the nurse would take the medication.

An interview and observation on 2/12/2025 at 10:37 am with Licensed Practical Nurse (LPN) EE revealed that the resident was not allowed to have the inhalers at the bedside. LPN DD explained that if the resident needed them, they would typically keep the inhalers in the cart. She stated that a physician's order would be required to keep medications at bedside. LPN DD further mentioned that a self-administration assessment would be needed for the resident to self-administer medication.

An interview on 2/12/2025 at 10:41 am with Registered Nurse (RN)/ Unit Manager CC revealed, that residents who self-administer medication must be assessed and demonstrate proper usage. RN CC stated that they also require the medication order to include a notation for self-administration. RN CC further clarified that residents were not supposed to have medication at the bedside, and over-the-counter medications were discouraged due to the potential for drug interactions.

An interview on 2/13/2025 at 11:14 am with the Director of Nursing (DON) revealed, that if medication was found at the bedside, the nurse or unit manager must be notified, and the attending physician would be contacted. The DON stated the physician would determine if the resident was allowed to self-administer the medication. If approved, the nurse and unit manager would provide patient education to ensure the resident understands and follows the medication directions. The family would also be notified, and an order would be written. DON confirmed Resident R71 should not have had the inhalers at the bedside, as there was no diagnosis for

the medication at the time of admission, and it was not communicated to the staff. The DON stated some possible negative outcomes include contraindications, drug interactions, potential overdose, or over-sedation, especially if the resident was already receiving similar medication. The DON stated his expectation was that staff should immediately notify the nurse or unit manager if any medication was found at the bedside.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 7 115487 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115487 B. Wing 02/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

New Horizons Limestone 2020 Beverly Road NE Gainesville, GA 30501

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50374 potential for actual harm Based on observations, staff interviews and record review, Facility B failed to ensure that one of 14 residents Residents Affected - Few (R) (Resident R150) receiving respiratory therapy, nebulizer mask was covered or properly stored. This deficient practice had the potential to put Resident R150 at risk for increased respiratory infections.

Findings include:

Review of the electronic health records (EHR) revealed, Resident R150 was admitted to the facility with diagnoses of chronic obstruction pulmonary disease (COPD), chronic respiratory failure with hypoxia (reduced oxygen in

the blood), acid reflex, and chest congestions.

Review of Resident R150's Quarterly Minimum Data Set (MDS) dated [DATE REDACTED] revealed, Section C (Cognitive Patterns)

a Brief Interview of Mental Status (BIMS) score of 14 which indicated his cognition was intact; Section O (Special Treatments and Programs) revealed, Resident R64 received oxygen therapy.

Review of Resident R150's physicians orders revealed, orders for albuterol (Proventil) 2.5 milligrams (mg)/ 3 milliliters (mL) (0.083 percent) nebulizer solution 2.5 mg; albuterol (HFA) (ProAir/Proventil/Ventolin HFA) 90 microgram (mcg)/arcuation inhaler one puff and fluticasone-vilanterol 100-25 mcg/dose Diskus inhaler one puff.

During an observation on 2/11/2025 at 11:45 am revealed Resident R150's nebulizer mask was not covered or properly stored.

During an observation on 2/11/2024 at 8:25 am revealed Resident R150's nebulizer mask was in his dresser not covered or properly stored.

During an interview and observation on 2/12/2025 at 5:07 pm with the Unit Manager (UM) AA revealed that

the Saturday supervisor and Certified Nurse Assistants (CNAs) were responsible for doing spot check on items to ensure that they were properly covered, labeled and dated. UM AA confirmed Resident R150's nebulizer mask was not covered or properly stored.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 7 115487 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115487 B. Wing 02/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

New Horizons Limestone 2020 Beverly Road NE Gainesville, GA 30501

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50940 Residents Affected - Few Based on observations, staff interviews, and a review of the facility's policy titled Laboratory Services-, d+[DATE REDACTED]-POC Glucose Testing with [Name] Glucometer, Facility A failed to discard expired Glucometer Control Solution Level 3, that was stored in one of four medication carts (Hall 300 medication cart). This deficiency created a risk of the expired solution being used, potentially compromising the accuracy and functionality of the glucometer, which could lead to unreliable blood glucose readings.

Review of the undated facility policy Laboratory Services-,d+[DATE REDACTED]-POC Glucose Testing with [Name] Glucometer under the section titled III. Equipment and Supplies revealed, D. [Name] glucose control solutions: Levels 1 and 3 .2. Unopened reagent bottles are good until the expiration dated printed on the container. 3. When opened, the bottles are good for 90 days or until the manufacturer's expiration date, whichever comes first. MUST BE LABELED WITH NEW EXPIRATION DATE.

An observation on [DATE REDACTED] 8:20 am of the medication cart on Hall 300 revealed, an expired unopened Glucometer Control Solution Level 3 with an expiration date of [DATE REDACTED] was found on the medication cart right upper drawer with other diabetic related supplies. When the surveyor asked Licensed Practical Nurse (LPN) AA about it, she stated that it was still acceptable to use because if it were no longer effective, the glucometer would display an error message and prevent testing.

In an interview on [DATE REDACTED] at 9:06 am, with the Unit Manager for Hall 300, Registered Nurse (RN) BB, she revealed that expired control solution must be discarded.

In an interview on [DATE REDACTED] at 9:30 am, with Unit Manager for Hall 100, RN, CC she stated that expired control solutions should not be used.

In an interview on [DATE REDACTED] at 10:44 am, with the Director of Nursing (DON), he confirmed that expired control solutions must be discarded, as they may compromise the accuracy and proper functioning of the glucometer, leading to unreliable blood glucose readings.

In an interview on [DATE REDACTED] at 1:45 pm, the DON showed the surveyor the medication cart and the carrying case for the [Name] Glucometer that was stored on the side of the medication cart. The case contained all

the control testing supplies, with control bottles labeled with expiration dates. The DON stated he was unsure why the expired control solution #3 was kept in the medication cart drawer, even though he assured the surveyor that it would not be used.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 7 115487 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115487 B. Wing 02/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

New Horizons Limestone 2020 Beverly Road NE Gainesville, GA 30501

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50272

Residents Affected - Many Based on observations, staff interviews, record review, and review of facility's policy titled, Nutrition Food and Supply Storage Procedures, Facility A failed to properly discard expired food items, label food items with expiration dates, and properly refrigerate opened food items. This deficient practice had the potential to result in foodborne illness affecting 77 out of 82 residents who receive food orally at Facility A.

Findings include:

Record review of facilities policy titled, Nutrition Food and Supply Storage Procedures dated [DATE REDACTED], under section titled, Purpose revealed, All food, non-food items and supplies used in food preparation shall be stored in such manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. (A.) General Storage .2. The use-by date is the last date that a food can be consumed; do not sell products in retail areas or place on patient trays/resident plates past the date on the product. Foods past the use-by date should be discarded. 3. Cover, label and date unused portions and open packages. Use the [NAME] orange label; complete all sections on the label. (B.) Dry Storage .7. Date and rotate items; first in, first out (FIFO). 8. Remove from storage any items for which the expiration date has expired. Return for credit if possible. (C.) Refrigerated Storage .4. Date and rotate items; first in, first out (FIFO). Discard food past the use-by expiration date. (D.) Frozen Storage .9. Date and rotate items; first in, first out (FIFO). Discard food past the use-by expiration date.

An observation was conducted on [DATE REDACTED] at 9:00 am with the Executive Chef (EC) and continued at 9:10 am with the Dietary Kitchen Manager (DKM) and the following expired items were found in the pantry:

-There were 44 bottles of [Name] compact therapeutic shake (vanilla) with an expiration date of [DATE REDACTED].

-There were 16 bottles of [Name] therapeutic nutrition (chocolate) with an expiration date of [DATE REDACTED].

-There was one bag of [Name] flour tortillas with an expiration date of [DATE REDACTED].

-There were four cans of [Name] coconut milk, all of which expired on [DATE REDACTED].

-There were three bags of [Name] oats and honey granola cereal, all of which had an expiration date of [DATE REDACTED].

The following unlabeled and unrefrigerated items were also observed in the pantry:

-There were three loaves of opened bread, which were unlabeled and not dated.

-There was one bag of croutons, which was opened and not labeled or dated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 7 115487 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115487 B. Wing 02/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

New Horizons Limestone 2020 Beverly Road NE Gainesville, GA 30501

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 -There was one bag of [Name] pecan pieces, which was opened and not labeled or dated.

Level of Harm - Minimal harm or -There was one bag of vanilla wafers with no expiration date. potential for actual harm -There was one bottle of pancake & waffle syrup [Name] with an expiration date of [DATE REDACTED]. Residents Affected - Many -There was one bottle of light unsulfured molasses with an expiration date of [DATE REDACTED].

-There was one bottle of [Name] jelly, which was opened and found unrefrigerated in the pantry.

An observation was conducted on [DATE REDACTED] at 9:51 am with the DKM and the following items were observed in

the freezer:

-There were four packets of [Name] flour tortillas, which had an expiration date of [DATE REDACTED].

-There were two packets of burgers, which were unlabeled or dated.

-There was one bag of whipped cream with an expiration date of [DATE REDACTED].

-There was one bag of blue cheese with an expiration date of [DATE REDACTED].

An observation was conducted on [DATE REDACTED] at 9:45 am with the DKM and the following items were observed in

the cooler:

-There was one bottle of [Name] (chocolate) with an expiration date of [DATE REDACTED].

-There was one container of [Name] cottage cheese with an expiration date of [DATE REDACTED].

An interview was conducted on [DATE REDACTED] at 9:54 pm with the EC, and he revealed when asked who oversees checking for expired foods and labeling and dating items, he stated that the freezer might have been neglected but the pantry was checked often. The EC further stated that all staff have assignments, and each shift comes in and checks for cleanliness, organization, and the dating and labeling of items in the cooler, pantry, and freezer. The EC also mentioned that his expectations was for the staff to be more diligent, and that maybe they need to be micromanaged. The EC highlighted that one negative outcome of expired food and unlabeled items was that expired foods could be served to residents.

An interview was conducted on [DATE REDACTED] at 11:27 am with the DKM, revealed her expectations for staff members are for more training and increased accountability from staff. DKM stated that there was currently too much inventory, which becomes confusing, and emphasized the need for more training on the first in, first out method. DKM also mentioned that both she and the EC were responsible for checking employees to ensure they were fulfilling their assignments. DKM further stated that a possible negative outcome of expired or improperly labeled food was the risk of foodborne illness spreading to the floor, potentially affecting every resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 7 115487 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115487 B. Wing 02/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

New Horizons Limestone 2020 Beverly Road NE Gainesville, GA 30501

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 An interview was conducted on [DATE REDACTED] at 11:33 am with the Administrator, who expect staff to follow guidelines for refrigerating, labeling, and checking expired items. The Administrator also emphasized that Level of Harm - Minimal harm or improper refrigeration and expired food could lead to foodborne illness, posing a significant risk to the potential for actual harm residents' health.

Residents Affected - Many

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 7 115487