New Horizons Limestone

In the surveyor’s words

From the most serious findings on record at New Horizons Limestone, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Feb 13, 2025

  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], 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. […]

• No harm, potential for more than minimal, patternF695Mar 12, 2026

  Based on observations, interviews, record reviews, and review of the facility policy titled Oxygen Administration, Transport and Storage - Patient Care, the facility failed to ensure that oxygen (O2) therapy was administered according to physician's orders for two residents (R) (R9 and R180) of 27 residents reviewed for oxygen use. The deficient practice had the potential to increase the residents' risk of respiratory complications and adverse clinical outcomes. Findings Include: Review of the facility's undated policy titled Oxygen Administration, Transport and Storage – Patient Care, documented in section for oxygen administration A physician or advanced practice professional (APP) order is required prior to administering oxygen. The policy specifies that the order must include: a. […]

• No harm, potential for more than minimal, isolatedF554Mar 12, 2026

  Based on observations, record review, staff interviews, and review of facility policy titled, Self-Administration of Medications, the facility failed to ensure two residents (R) (R130 and R57) could safely self-administration medications by leaving medications at the bedside unsupervised. This deficient practice had the potential to increase the risk of clinical complications. Findings include: Record review of the facility's policy titled, Self-Administration of Medications, revealed under section titled, III Policy, if a resident requests to self-administer medication (s) it is the responsibility of the interdisciplinary team (IDT) to determine that it is safe before the resident exercises that right. […]

• No harm, potential for more than minimal, isolatedF656Mar 12, 2026

  Based on observations, staff and resident interviews, record review, and review of the facility's policy titled Care Plan - LTC - Patient Care, the facility failed to develop and implement comprehensive, person-centered care plan for one resident (R) (R9) of 60 sampled residents. Specifically, the facility failed to develop and implement care plan interventions related to oxygen administration. This deficient practice had the potential to result in inadequate monitoring and improper oxygen administration, which could compromise the resident's health and safety.Findings include:Review of the undated facility policy titled Care Plan - LTC - Patient Care, documented in Section III Policy Do not leave blanks or incomplete sections. Further review revealed that Complete the . […]

• No harm, potential for more than minimal, isolatedF761Mar 12, 2026

  Based on observation, staff interview, review of manufacturer package inserts, and facility policy titled Medication Storage, the facility failed to ensure proper medication labeling, expiration dating, discard procedures, and secure storage for one of eight medication carts. This deficient practice had the potential to place residents at risk for administration of expired, improperly labeled, or unsecured medications, which could compromise resident health and safety. Findings Include: Review of the facility's policy titled Medication Storage, dated 8/22/2023, documented All medication storage areas will inspected. to ensure that all medications are being properly and safely stored in accordance with manufacturer's instructions. IN addition, documented in section Procedures III. […]