Inspection Reports for Life Care Center of Lawrenceville
210 Collins Industrial Way, Lawrenceville, GA 30043, United States, GA, 30043
Back to Facility ProfileInspection Report Summary
The most recent inspection on March 18, 2025, found no deficiencies and confirmed correction of prior issues, with an unsubstantiated complaint investigation. Earlier inspections showed a pattern of deficiencies related mainly to infection control, oxygen therapy care, and safety concerns such as unsafe water temperatures and incomplete background checks for employees. Notably, in August 2023, the facility faced immediate jeopardy due to inadequate COVID-19 outbreak management, resulting in multiple resident and staff infections, hospitalizations, and one death; this was resolved by late August with corrective actions. Complaint investigations were mostly unsubstantiated except for the substantiated COVID-19 outbreak-related issues in 2023, which did not result in fines or license actions listed in the available reports. The facility’s recent clean inspections suggest improvement following earlier challenges, particularly in infection control and care planning.
Deficiencies (last 10 years)
Deficiencies (over 10 years)
6.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
27% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
84 residents
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 18, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Life Care Center of Lawrenceville, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Follow-Up
Census: 84
Deficiencies: 0
Date: Mar 18, 2025
Visit Reason
A health revisit survey was conducted to verify correction of deficiencies cited in the prior Recertification and Complaint Investigation survey concluded on January 30, 2025. The revisit also included investigation of Complaint Intake Number GA00253798.
Complaint Details
Complaint Intake Number GA00253798 was investigated during the revisit survey and was found unsubstantiated.
Findings
The revisit survey found all previously cited deficiencies corrected and the complaint investigated was unsubstantiated.
Inspection Report
Follow-Up
Census: 84
Deficiencies: 0
Date: Mar 17, 2025
Visit Reason
A health revisit survey was conducted in conjunction with a complaint investigation to verify correction of previous deficiencies and investigate Complaint Intake Number GA00253798.
Complaint Details
Complaint Intake Number GA00253798 was investigated and found unsubstantiated.
Findings
All deficiencies cited in the prior recertification and complaint investigation survey concluded on January 30, 2025, were found to be corrected. The complaint was found unsubstantiated.
Inspection Report
Life Safety
Census: 81
Capacity: 120
Deficiencies: 0
Date: Jan 30, 2025
Visit Reason
The survey was conducted to review the Emergency Preparedness Program and to assess compliance with the Life Safety Code requirements for participation in Medicare/Medicaid.
Findings
The facility was found to be in substantial compliance with the Emergency Preparedness Program requirements and the Life Safety Code standards as per 42 CFR Subpart 483.90(a) and NFPA 101 Life Safety Code 2012 edition.
Inspection Report
Annual Inspection
Census: 82
Deficiencies: 4
Date: Jan 30, 2025
Visit Reason
The inspection was conducted as a State Licensure survey from January 28 through January 30, 2025, to determine compliance with the State Long Term Care Requirements.
Findings
The facility was cited for multiple deficiencies including failure to conduct fingerprint criminal background checks for six employees, failure to maintain sanitary conditions for respiratory supplies and medication pass hygiene, failure to develop a comprehensive care plan for oxygen therapy for one resident, and unsafe water temperatures in four resident rooms.
Deficiencies (4)
Failure to ensure fingerprint criminal background checks were conducted for six employees.
Failure to maintain sanitary conditions for storing respiratory supplies for one resident and failure to sanitize shared medical equipment and perform proper hand hygiene during medication passes.
Failure to develop a person-centered, comprehensive care plan related to oxygen therapy for one resident.
Failure to keep residents free of accident hazards due to water temperatures above 110 degrees Fahrenheit in four resident rooms.
Report Facts
Facility census: 82
Residents reviewed for respiratory treatments: 19
Residents reviewed for oxygen administration: 19
Residents reviewed for medication pass observations: 24
Water temperature measurements: 127.8
Water temperature measurements: 127.2
Water temperature measurements: 127
Water temperature measurements: 126.7
Water temperature measurements after adjustment: 106.3
Water temperature measurements after adjustment: 105.9
Water temperature measurements after adjustment: 105.9
Water temperature measurements after adjustment: 105.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN AA | Registered Nurse | Observed failing to sanitize hands and clean glucometer during medication pass. |
| RN FF | Staff Development Coordinator / Interim Infection Control Preventionist | Provided expectations for hand hygiene and respiratory supplies storage. |
| RN EE | Registered Nurse | Corporate nurse who confirmed expectations for respiratory supplies storage and hand hygiene. |
| RN DD | Registered Nurse | Corporate nurse who confirmed expectations for respiratory supplies storage and hand hygiene. |
| Human Resources Director | Responsible for background checks; interviewed regarding missing fingerprint checks. | |
| Administrator and Chief Executive Officer | Interviewed regarding fingerprint background check requirements. | |
| Regional Coordinator of Clinical Services EE | Confirmed lack of oxygen therapy care plan for resident. | |
| Unit Care Coordinator LPN UU | Licensed Practical Nurse | Confirmed care plan should have been developed for oxygen therapy during admission. |
| Assistant Maintenance Director | Conducted water temperature checks. | |
| Maintenance Director | Interviewed about water temperature issues and adjustments. |
Inspection Report
Routine
Census: 82
Deficiencies: 5
Date: Jan 30, 2025
Visit Reason
A standard survey was conducted from January 28 through January 30, 2025, including investigation of multiple complaint intake numbers, to assess compliance with Medicare/Medicaid regulations for the Life Care Center of Lawrenceville.
Complaint Details
The survey included investigation of complaint intake numbers GA00253462, GA00251981, GA00253521, GA00253003, GA00253541, GA00250624, and GA00253362.
Findings
The facility was found not in substantial compliance with federal regulations, with deficiencies including failure to ensure PASARR Level II evaluations, lack of comprehensive care plans for oxygen therapy, unsafe water temperatures in resident rooms, improper oxygen therapy administration, unsanitary storage of respiratory supplies, failure to sanitize shared medical equipment, and inadequate hand hygiene practices.
Deficiencies (5)
Failure to ensure one resident (R13) was evaluated by the state designated authority for PASARR Level II despite diagnoses warranting it.
Failure to develop a person-centered, comprehensive care plan related to oxygen therapy for one resident (R41).
Water temperatures above 110 degrees Fahrenheit in four resident rooms, posing burn risk.
Failure to administer oxygen therapy according to physician orders for one resident (R41).
Failure to maintain sanitary conditions for storing respiratory supplies and failure to sanitize shared medical equipment and perform proper hand hygiene during medication passes.
Report Facts
Residents present: 82
Water temperature readings: 127.8
Water temperature readings: 127.2
Water temperature readings: 127
Water temperature readings: 126.7
Oxygen flow rate ordered: 1
Oxygen flow rate observed: 2
Medication pass observations: 4
Residents reviewed for oxygen therapy: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| KK | Social Services Assistant | Confirmed lack of PASARR Level II evaluation for resident R13 |
| MM | Business Office Manager | Confirmed diagnoses warrant PASARR Level II but lacked clinical background to complete it |
| LPN UU | Unit Care Coordinator | Confirmed care plan for oxygen therapy should have been developed for resident R41 |
| AMD | Assistant Maintenance Director | Conducted water temperature checks revealing unsafe hot water temperatures |
| MD | Maintenance Director | Confirmed water heater thermostat was set at 130 degrees Fahrenheit |
| LPN TT | Licensed Practical Nurse | Confirmed oxygen flow meter was set incorrectly for resident R41 |
| RN AA | Registered Nurse | Observed failing to store respiratory supplies properly and not sanitizing hands or equipment during medication pass |
| RN FF | Staff Development Coordinator/Interim Infection Control Preventionist | Provided expectations for hand hygiene and respiratory supply storage |
| RN EE | Registered Nurse | Corporate nurse confirming expectations for hand hygiene and respiratory supply storage |
| RN DD | Registered Nurse | Corporate nurse confirming expectations for hand hygiene and respiratory supply storage |
Inspection Report
Abbreviated Survey
Census: 79
Deficiencies: 0
Date: Sep 11, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00244994 and GA00245858.
Complaint Details
Complaints GA00244994 and GA00245858 were investigated and found to be unsubstantiated.
Findings
The complaints GA00244994 and GA00245858 were unsubstantiated, and no deficiencies were cited during the survey.
Inspection Report
Abbreviated Survey
Census: 82
Deficiencies: 0
Date: Mar 4, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00242593 and #GA00243091.
Complaint Details
Complaints #GA00242593 and #GA00243091 were investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaints #GA00242593 and #GA00243091 were unsubstantiated with no deficiencies cited during the survey.
Inspection Report
Re-Inspection
Census: 96
Deficiencies: 0
Date: Nov 1, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the August 31, 2023 Standard Survey.
Findings
All deficiencies cited in the prior August 31, 2023 Standard Survey were found to be corrected during the revisit survey.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 1, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction following an inspection of the facility.
Findings
The report contains a summary statement of deficiencies identified during the inspection, but no specific deficiencies or severity levels are detailed in the provided page.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 23, 2023
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Abbreviated Survey
Census: 84
Deficiencies: 7
Date: Aug 31, 2023
Visit Reason
An abbreviated survey was conducted to verify removal of Immediate Jeopardy related to a COVID-19 outbreak and to investigate Complaint Number GA00238040.
Complaint Details
Complaint Number GA00238040 was investigated and substantiated without deficiencies.
Findings
The facility failed to implement an effective Infection Prevention Control Program to prevent and control the spread of COVID-19, including failure to conduct outbreak testing and contact tracing, resulting in 28 residents and 7 staff testing positive, 3 hospitalizations, and 1 death. The facility also had deficiencies in dental assessments, wound care, oxygen therapy, and other care areas. Corrective actions were implemented and the Immediate Jeopardy was removed on 8/25/2023.
Deficiencies (7)
Failure to implement an effective Infection Prevention Control Program to prevent or reduce the spread of COVID-19.
Failure to implement outbreak testing of residents and staff when two residents tested positive for COVID-19 on August 2, 2023.
Failure to initiate contact tracing or broad-based testing consistent with CDC and Department of Public Health guidance.
Failure to provide documentation of ongoing facility-wide surveillance including data collection and root-cause analysis.
Failure to ensure accurate comprehensive dental assessment for one resident.
Failure to provide care in accordance with professional standards related to maintaining skin integrity for one resident.
Failure to follow physician orders for oxygen therapy care for one resident.
Report Facts
Residents positive for COVID-19: 28
Staff positive for COVID-19: 7
COVID-19 related hospitalizations: 3
COVID-19 related deaths: 1
Resident census: 84
Staff education attendance: 159
Resident education attendance: 159
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN FF | Back-up Infection Preventionist | Interviewed regarding outbreak response and testing procedures. |
| RN GG | Full-time Infection Preventionist | Interviewed regarding outbreak response and testing procedures. |
| Executive Director | Informed of Immediate Jeopardy, responsible for oversight of infection control program. | |
| Director of Nursing | Interviewed regarding infection control and outbreak management. | |
| Regional Director of Clinical Services | Provided education and oversight related to infection control policies. | |
| Staff Development Coordinator/Infection Preventionist | Provided education and participated in outbreak testing and surveillance. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 31, 2023
Visit Reason
A Revisit Survey was initiated on August 29, 2023 and concluded on August 31, 2023 in conjunction with a Complaint Survey to investigate Complaint Number GA00238040.
Complaint Details
Complaint Number GA00238040 was investigated and substantiated without any deficiency cited.
Findings
The complaint was substantiated without deficiency cited.
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 2
Date: Aug 31, 2023
Visit Reason
The inspection was conducted due to a complaint investigation triggered by an outbreak of COVID-19 cases in the facility, with concerns about the facility's failure to maintain an effective Infection Prevention Control Program (IPCP) and follow current guidelines for resident and staff testing.
Complaint Details
The visit was complaint-related due to a COVID-19 outbreak starting August 2, 2023. The facility was found non-compliant with infection control requirements causing or likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was declared on August 15, 2023, and removed on August 25, 2023 after corrective plans were validated.
Findings
The facility failed to implement appropriate infection control measures during a COVID-19 outbreak, resulting in 28 residents and 8 staff testing positive, 3 hospitalizations, and 1 death. The facility did not follow recommended broad-based testing protocols and relied primarily on contact tracing, despite rising cases. Interviews revealed lack of discussion on testing strategies during meetings, and the Administrator was responsible for oversight but did not ensure compliance with testing guidelines until local Health Department intervention.
Deficiencies (2)
Failure to maintain an effective Infection Prevention Control Program (IPCP) that identifies and investigates infection outbreaks to prevent or reduce the spread of COVID-19 by not following current guidelines for resident and staff testing (contact tracing or broad based testing).
Facility remained out of compliance at a lower scope and severity with deficiencies F835, F880, and F882 all at Scope/Severity: F while continuing management level staff oversight and implementing a Plan of Correction.
Report Facts
COVID-19 positive residents: 28
COVID-19 positive staff: 8
COVID-19 related hospitalizations: 3
COVID-19 related deaths: 1
Census: 99
Inspection Report
Monitoring
Census: 84
Deficiencies: 0
Date: Aug 20, 2023
Visit Reason
A State Monitoring visit was conducted at Life Care of Lawrenceville related to an ongoing immediate jeopardy.
Findings
No additional concerns were identified during the monitoring visit.
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 2
Date: Aug 17, 2023
Visit Reason
The inspection was conducted as a licensure survey from August 3 through August 17, 2023, triggered by concerns about an infection outbreak and failure to maintain an effective Infection Prevention Control Program to prevent or reduce the spread of COVID-19.
Complaint Details
The investigation was complaint-related due to concerns about the facility's failure to control a COVID-19 outbreak, resulting in multiple positive cases, hospitalizations, and a death. The Immediate Jeopardy was declared on August 15, 2023, and was ongoing at exit on August 17, 2023.
Findings
The facility failed to implement effective infection control measures during a COVID-19 outbreak, including inadequate testing protocols, failure to obtain physician orders for COVID-19 testing for many residents, lack of documentation of negative test results, and insufficient staff testing. This resulted in 28 residents and 8 staff testing positive, 3 hospitalizations, and 1 resident death. Immediate Jeopardy was identified due to the risk of serious harm to residents.
Deficiencies (2)
Failure to maintain an effective Infection Prevention Control Program to identify and investigate a COVID-19 outbreak, including inadequate resident and staff testing.
Failure to obtain physician orders for COVID-19 testing for 21 of 28 COVID-positive residents and failure to maintain documentation of negative test results for residents and staff.
Report Facts
Residents tested positive for COVID-19: 28
Staff tested positive for COVID-19: 8
Resident hospitalizations: 3
Resident deaths: 1
Residents without physician orders for COVID-19 testing: 21
Census: 99
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN IP FF | Registered Nurse Infection Preventionist (Back-up) | Provided information about outbreak start, testing procedures, and documentation issues |
| RN IP GG | Registered Nurse Infection Preventionist (Full-time) | Provided information about outbreak start, testing procedures, and documentation issues |
| Administrator | Responsible for facility operations and infection control oversight; provided information on outbreak and testing policies | |
| Epidemiology Assistant | Local Health Department staff who provided guidance on outbreak management and testing recommendations |
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 6
Date: Aug 17, 2023
Visit Reason
A standard survey was conducted in conjunction with complaint investigations related to infection control and other care concerns, including a COVID-19 outbreak at the facility.
Complaint Details
The visit was complaint-related, triggered by multiple complaint intake numbers (GA00231753, GA00237553, GA00232626, GA00228281) concerning infection control and COVID-19 outbreak management. The complaint investigation found substantiated deficiencies including failure to conduct appropriate outbreak testing and contact tracing, and failure to maintain an effective infection prevention program.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with multiple deficiencies including failure to implement an effective Infection Prevention Control Program, failure to conduct appropriate COVID-19 outbreak testing and contact tracing, inadequate dental and wound care assessments, failure to follow physician orders for respiratory care, and failure of the Infection Preventionist to adequately manage the infection control program. The COVID-19 outbreak resulted in 28 residents and 8 staff testing positive, 3 hospitalizations, and 1 death.
Deficiencies (6)
Failure to implement an effective Infection Prevention Control Program to investigate and control COVID-19 outbreak.
Failure to ensure accurate comprehensive dental assessment for one resident.
Failure to provide care in accordance with professional standards related to skin integrity and clean geri-sleeves for one resident.
Failure to follow physician orders for oxygen tubing, nebulizer circuit changes, and cleaning of concentrator filter for one resident.
Failure to implement initial and ongoing COVID-19 testing of residents and staff as recommended by CDC and Georgia Department of Public Health, including failure to obtain physician orders for testing and maintain documentation of negative test results.
Failure of Infection Preventionist to adequately assess, develop, implement, monitor, and manage the Infection Control and Prevention Program, resulting in uncontrolled COVID-19 outbreak.
Report Facts
Residents tested positive for COVID-19: 28
Staff tested positive for COVID-19: 8
COVID-19 related hospitalizations: 3
COVID-19 related deaths: 1
Resident census: 99
Residents reviewed for COVID testing orders: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Informed of Immediate Jeopardy and responsible for facility operations and infection control oversight | |
| Regional Director of Clinical Services | Informed of Immediate Jeopardy | |
| Regional Vice President | Informed of Immediate Jeopardy | |
| Division Director of Clinical Services | Informed of Immediate Jeopardy | |
| MDS Coordinator EE | Registered Nurse | Named in dental assessment deficiency for resident #26 |
| RN DD | Registered Nurse | Named in respiratory care deficiency for resident #35 |
| RN IP FF | Registered Nurse Infection Preventionist (Back-up) | Named in infection prevention deficiency and outbreak management |
| RN IP GG | Registered Nurse Infection Preventionist (Full-time) | Named in infection prevention deficiency and outbreak management |
| Unit Manager AA | Named in wound care deficiency for resident #23 | |
| Wound Care Nurse | Named in wound care deficiency for resident #23 |
Inspection Report
Life Safety
Census: 95
Capacity: 125
Deficiencies: 3
Date: Aug 12, 2023
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with sprinkler system maintenance and testing requirements per NFPA 25. Deficiencies included missing spare sprinkler heads, lack of a list of sprinkler head types on the spare head box, and absence of an approved informational sign on dry sprinkler risers.
Deficiencies (3)
All types of sprinkler heads used throughout the facility were not provided in the spare sprinkler head box in the riser room.
A list of all types of sprinkler heads used throughout the facility was not provided on the spare sprinkler head box.
An approved informational sign that is metal or rigid plastic was not properly attached to the dry sprinkler risers.
Report Facts
Census: 95
Total Capacity: 125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M interviewed and confirmed findings during the inspection |
Inspection Report
Deficiencies: 0
Date: Apr 19, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for the Life Care Center of Lawrenceville following a state inspection.
Findings
The report contains initial comments and a summary statement of deficiencies identified during the inspection; however, no specific deficiencies or severity levels are detailed in the provided page.
Inspection Report
Re-Inspection
Census: 76
Deficiencies: 0
Date: Apr 19, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the standard survey on 2022-02-03.
Findings
All deficiencies cited in the prior standard survey were found to be corrected as of 2022-03-18.
Report Facts
Facility census: 76
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 4
Date: Feb 3, 2022
Visit Reason
A State Licensure survey was conducted including complaint investigations of multiple complaint intake numbers, with one complaint resulting in a cited deficiency related to wound care and pain management.
Complaint Details
Complaint Intake numbers GA00218921, GA00215413, and GA00214755 were investigated with no deficiencies cited. Complaint Intake number GA00214740 was investigated and resulted in a cited deficiency (F686).
Findings
The facility was found not in substantial compliance due to failure to provide appropriate wound care and pain management for a resident with pressure ulcers, and failure to follow transmission-based COVID-19 precautions and proper glucometer disinfection procedures.
Deficiencies (4)
Failure to ensure a resident with pressure ulcers received appropriate wound care and complete evaluations, including lack of depth measurements and nutritional monitoring.
Failure to develop an interdisciplinary and resident-centered plan of care to manage chronic pain for a resident.
Failure to ensure staff followed transmission-based precautions for COVID-19 for newly admitted residents on quarantine.
Failure to ensure multiuse glucometers were cleaned and disinfected according to manufacturer's instructions and facility policy.
Report Facts
Resident census: 68
Pressure ulcer measurements: 4
Pressure ulcer measurements: 7.5
Pressure ulcer measurements: 3.3
Pressure ulcer measurements: 1.4
Pressure ulcer measurements: 0.2
Weight: 276
Weight loss: 9.8
Pain scores: 93
Pain score level 3: 5
Pain score level 5: 1
Pain score level 6: 1
Pain score level 0: 86
County COVID positivity rate: 27.88
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse 10 | Registered Nurse | Acknowledged missing wound depth measurements in documentation |
| Director of Nursing | Director of Nursing | Acknowledged wounds had depth and staff should document all wound characteristics; acknowledged nursing staff must evaluate pain using numeric scale and facility policy |
| Registered Dietician | Registered Dietician | Acknowledged resident's poor nutritional intake and lack of prealbumin testing; described informal interdisciplinary communication due to COVID outbreak |
| Medical Doctor 1 | Attending Medical Doctor | Acknowledged wounds were unavoidable and pain management was problematic; noted resident abuses opiates |
| LPN 7 | Licensed Practical Nurse | Observed performing glucometer cleaning and acknowledged incomplete cleaning; did not document resident pain level on 01/31/22 |
| Assistant Director of Rehabilitation Services | Assistant Director of Rehabilitation Services | Reported resident's last time out of bed was 01/24/22 due to pain |
| Physical Therapy Assistant 12 | Physical Therapy Assistant | Reported resident has not participated in therapy since 01/25/22 due to pain |
| Occupational Therapist 8 | Occupational Therapist | Observed not wearing gown during therapy session with resident on quarantine; acknowledged gown should have been worn |
| Certified Occupational Therapy Aide 5 | Certified Occupational Therapy Aide | Observed entering resident room on contact precautions without gown; acknowledged signage requiring gown use |
| LPN 3 | Licensed Practical Nurse | Observed performing glucometer cleaning with incomplete procedure; acknowledged glucometer dried within one minute |
| Infection Control Preventionist | Infection Control Preventionist | Acknowledged training staff to clean glucometers with one wipe and dry time of two minutes |
Inspection Report
Recertification
Census: 68
Deficiencies: 4
Date: Feb 3, 2022
Visit Reason
A Recertification and Complaint survey was conducted from 1/31/2022 through 2/3/2022, including investigation of multiple complaint intakes related to resident care and compliance with Medicare/Medicaid regulations.
Complaint Details
Complaint Intake numbers GA00218921, GA00215413 and GA00214755 were investigated with no deficiencies cited. Complaint Intake number GA00214740 was investigated and deficiency F686 was cited.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies related to failure to properly document and honor resident advance directives, inadequate pressure ulcer care and assessment, insufficient pain management documentation and care, and lapses in infection control practices including improper use of PPE and inadequate cleaning of multiuse glucometers.
Deficiencies (4)
Failure to ensure resident wishes were correctly entered into orders to reflect preferred code status, failure to obtain and file copies of advance directives, and failure to provide advance directive education to residents.
Failure to ensure complete wound evaluations including depth measurements and appropriate nutritional monitoring for a resident with pressure ulcers.
Failure to develop an interdisciplinary, resident-centered pain management plan and to document pain assessments comprehensively.
Failure to follow transmission-based precautions for COVID-19 for newly admitted residents on quarantine and failure to properly clean and disinfect multiuse glucometers according to manufacturer instructions and facility policy.
Report Facts
Resident census: 68
Pressure ulcer wound measurements: 4
Pressure ulcer wound measurements: 7.5
Weight loss: 27
Pain scores: 93
Employees mentioned
| Name | Title | Context |
|---|---|---|
| R29 | Resident | Named in advance directive deficiency related to failure to obtain and document advance directives. |
| R38 | Resident | Named in advance directive deficiency related to failure to document code status and advance directives. |
| R23 | Resident | Named in advance directive deficiency related to discrepancy between documented code status and resident/family wishes. |
| R19 | Resident | Named in advance directive deficiency related to failure to file living will in medical record. |
| RN10 | Registered Nurse | Acknowledged incomplete wound documentation for Resident 36. |
| RD | Registered Dietician | Acknowledged suboptimal nutritional intake and lack of prealbumin monitoring for Resident 36. |
| MD1 | Attending Medical Doctor | Acknowledged wounds were unavoidable and nutritional status impacted healing for Resident 36. |
| LPN7 | Licensed Practical Nurse | Observed cleaning glucometer with one wipe and acknowledged incomplete pain documentation for Resident 36. |
| OT8 | Occupational Therapist | Observed not wearing gown during therapy session with resident on quarantine. |
| COTA5 | Certified Occupational Therapy Aide | Observed not wearing gown when entering resident room on quarantine. |
| LPN3 | Licensed Practical Nurse | Observed cleaning glucometer with one wipe and improper disinfection procedure. |
| ADOR | Assistant Director of Rehabilitation Services | Described therapy limitations due to resident pain. |
| PTA12 | Physical Therapy Assistant | Reported resident pain limiting therapy participation. |
| DON | Director of Nursing | Acknowledged nursing staff must evaluate pain using numeric scale and follow glucometer disinfection policy. |
| ICP | Infection Control Preventionist | Described glucometer cleaning training and acknowledged staff instructions. |
Inspection Report
Life Safety
Census: 66
Capacity: 125
Deficiencies: 0
Date: Feb 3, 2022
Visit Reason
The visit was conducted as a Life Safety Code Survey to assess compliance with fire safety regulations and emergency preparedness requirements.
Findings
The facility was found in compliance with the Life Safety Code requirements and the Emergency Preparedness Program was in substantial compliance. The Miranda Hallway with 12 beds was not surveyed due to COVID-19 isolation, but all other life safety provisions were met.
Report Facts
Beds in Miranda Hallway: 12
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 7, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00203618, GA00206111, GA00207423, and GA00209646.
Complaint Details
Complaints GA00203618, GA00206111, GA00207423, and GA00209646 were investigated and found to be unsubstantiated.
Findings
The complaints investigated were unsubstantiated and no deficiencies were cited during this survey.
Inspection Report
Routine
Census: 59
Deficiencies: 0
Date: Oct 28, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations for COVID-19.
Report Facts
Total census: 59
Inspection Report
Routine
Census: 42
Deficiencies: 0
Date: Jun 12, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) from June 11 to June 12, 2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 infection control regulations, implementing CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Census: 97
Deficiencies: 0
Date: Dec 4, 2019
Visit Reason
An abbreviated survey was conducted to investigate complaint number GA00200293.
Complaint Details
Complaint number GA00200293 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the survey.
Report Facts
Complaint number: 200293
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 18, 2019
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The survey noted that all previously cited deficiencies had been corrected.
Inspection Report
Annual Inspection
Census: 87
Deficiencies: 0
Date: Nov 29, 2018
Visit Reason
A standard survey was conducted at Life Care Center of Lawrenceville from November 26, 2018 through November 29, 2018 to assess compliance with Medicare/Medicaid regulations.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B - Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 87
Capacity: 125
Deficiencies: 5
Date: Nov 27, 2018
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with fire safety requirements, including improper maintenance of the fire alarm system, corridor smoke detectors, sprinkler system, electrical systems, and rated doors, placing 87 residents at risk in the event of a fire.
Deficiencies (5)
Fire alarm system not properly maintained: fire alarm breaker had no identification, was not red or locked, and fire alarm circuit was not identified on panel.
Facility failed to properly maintain corridor smoke detectors, including smoke detectors located in the airflow stream of HVAC supply.
Facility failed to properly maintain fire sprinkler system: dust and grease on sprinkler heads, missing hydraulic data signs on four fire sprinkler risers, and one fire sprinkler riser yellow tagged.
Facility failed to properly maintain electrical systems: flexible power cord above ceiling in storage room and open junction box with exposed wires above ceiling at Room 418.
Facility failed to properly maintain corridor rated fire doors: no routine inspections of rated doors.
Report Facts
Residents at risk: 87
Certified beds: 125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed findings during facility tours and interviews |
Inspection Report
Abbreviated Survey
Census: 88
Deficiencies: 0
Date: May 21, 2018
Visit Reason
An abbreviated survey was conducted to investigate complaint GA00187863 at Life Care Center of Lawrenceville.
Complaint Details
Investigation of complaint GA00187863; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B - Requirements for Long Term Care Facilities.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 2, 2018
Visit Reason
A complaint survey was conducted to investigate complaint #GA00186595 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint #GA00186595 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint investigation survey.
Inspection Report
Annual Inspection
Census: 84
Deficiencies: 0
Date: Dec 22, 2017
Visit Reason
A standard survey was conducted at Life Care Center of Lawrenceville from December 19, 2017 through December 22, 2017 to assess compliance with Medicare/Medicaid regulations.
Findings
The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations Part 483, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 84
Capacity: 125
Deficiencies: 0
Date: Dec 19, 2017
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found in substantial compliance with the Life Safety Code requirements, including the Emergency Preparedness plan review which met Appendix Z standards.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 1, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA00175697 to determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA00175697 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey at Life Care Center Lawrenceville.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 28, 2017
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for the Life Care Center of Lawrenceville following a survey completed on April 28, 2017.
Findings
The document does not provide specific findings or deficiencies; it primarily serves as a form for reporting deficiencies and the provider's plan of correction.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 21, 2017
Visit Reason
A revisit survey was conducted from 4/19/17 through 4/21/17 to verify correction of previously cited deficiencies.
Findings
The revisit survey found that all previously cited tags had been corrected in accordance with Medicare/Medicaid regulations at 42 CFR 483 Subpart B requirements for Long Term Care Facilities.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 21, 2017
Visit Reason
A revisit survey was conducted from 4/19/17 through 4/21/17 to verify correction of previously cited deficiencies.
Findings
The revisit survey found that all previously cited tags had been corrected, meeting Medicare/Medicaid regulations at 42 CFR 483 Subpart B requirements for Long Term Care Facilities.
Inspection Report
Follow-Up
Deficiencies: 4
Date: Feb 16, 2017
Visit Reason
This follow-up inspection was conducted to verify correction of previously cited deficiencies from the prior survey dated 2/6/2017.
Findings
The facility was cited for deficiencies related to notification of changes to residents and representatives, accuracy and coordination of assessments, treatment and services to prevent and heal pressure sores, and maintaining nutritional status. The report references a follow-up shell 03D012 dated 2/6/2017-2/16/2017 for detailed text of citations.
Deficiencies (4)
Failure to immediately inform the resident, consult with the resident’s physician, and notify the resident representative(s) of changes such as injury, significant decline, treatment alteration, or transfer/discharge.
Assessment inaccuracies and lack of proper coordination and certification by registered nurses.
Failure to provide treatment and services to prevent and heal pressure ulcers consistent with professional standards.
Failure to maintain acceptable nutritional status parameters and offer therapeutic diets when ordered.
Inspection Report
Re-Inspection
Census: 92
Deficiencies: 10
Date: Feb 16, 2017
Visit Reason
Revisit survey conducted in conjunction with an Abbreviated survey to investigate noncompliance and immediate jeopardy related to resident care and pressure ulcers.
Findings
The facility was found to be in continued noncompliance with Medicare/Medicaid regulations including immediate jeopardy related to failure in notification of changes, pressure ulcer care, and quality of care. The facility implemented a credible allegation of compliance and corrective actions including audits, staff education, and monitoring. Deficiencies were found in documentation accuracy, wound care, medication administration, infection control, and quality assurance processes.
Deficiencies (10)
Failure to notify physician and responsible party timely of resident's open wounds and pressure ulcers, resulting in immediate jeopardy.
Inaccurate Minimum Data Set (MDS) related to pressure sores for resident #412.
Failure to provide services by qualified persons per care plan, including wound care and pressure ulcer treatment.
Failure to provide necessary care and services to promote healing and prevent infection of pressure sores.
Failure to maintain acceptable nutritional status and timely implement nutritional supplement orders.
Failure to ensure drug regimen is free from unnecessary drugs; lack of documentation of medication efficacy.
Failure to remove expired medications from medication carts and properly label opened medications.
Failure to follow infection control procedures during wound care, including hand hygiene and equipment sanitation.
Failure to maintain complete, accurate, and accessible clinical records including wound documentation, medication records, and physician orders.
Failure of Quality Assessment and Assurance Committee to identify and correct quality deficiencies related to wound care and pressure ulcers.
Report Facts
Sample size: 32
Census: 92
Nutritional supplement order delay: 2
Medication refusal documented: 5
Medication refusal documented: 12
Medication refusal documented: 12
Medication refusal documented: 10
Medication refusal documented: 5
Medication refusal documented: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DD | Licensed Practical Nurse | Observed failing to sanitize scissors and change gloves during wound care; documented wound care inconsistently |
| HH | Assistant Director of Nursing | Interviewed regarding medication administration and infection control expectations |
| SS | Attending Physician | Interviewed regarding nephrology consult and nutritional supplement orders |
| DON | Director of Nursing | Interviewed regarding wound care documentation, monitoring, and quality assurance |
| Executive Director | Interviewed regarding performance improvement plan and oversight | |
| Regional Vice President | Interviewed regarding training and oversight of performance improvement committee |
Inspection Report
Abbreviated Survey
Census: 92
Deficiencies: 5
Date: Feb 16, 2017
Visit Reason
An abbreviated complaint investigation and a revisit survey were conducted due to noncompliance with Medicare/Medicaid regulations, including immediate jeopardy related to complaint GA00169281.
Complaint Details
The abbreviated complaint investigation was conducted in conjunction with a revisit survey due to complaints GA00169880 and GA00169281, with immediate jeopardy related to GA00169281.
Findings
The facility was found noncompliant with notification of changes, pressure ulcer prevention and treatment, care planning, nutritional supplementation, and medical record documentation. Deficiencies included failure to notify physicians timely, failure to implement appropriate treatments, and incomplete care plans.
Deficiencies (5)
Failure to notify physician of significant skin changes and obtain timely treatment orders for pressure ulcers.
Failure to revise care plans and implement appropriate interventions to prevent pressure ulcers.
Failure to provide services by qualified persons in accordance with the care plan, including wound care follow-up and documentation.
Failure to maintain nutrition status by timely implementing nutritional supplement orders and notifying physician/dietician of refusals.
Failure to maintain complete, accurate, and accessible medical records including documentation of skin condition and wound care.
Report Facts
Census: 92
Sample size: 32
Sample size: 10
Sample size: 15
Pressure ulcer size: 4.9
Pressure ulcer size: 2.5
Pressure ulcer size: 0.1
Nutritional supplement order delay: 8
Nutritional supplement refusal days: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CC | Licensed Practical Nurse | Named in relation to ileostomy bag leakage and skin irritation findings |
| SS | Physician | Named in relation to ileostomy care and nutritional supplement order findings |
| OO | Licensed Practical Nurse Wound Care Nurse | Named in relation to wound care follow-up and documentation |
| HH | Assistant Director of Nursing | Named in relation to wound care and nutritional supplement findings |
| MM | Unit Manager Licensed Practical Nurse | Named in relation to wound care and skin assessment findings |
| PP | MDS Nurse | Named in relation to care plan development and updates |
| BB | Licensed Practical Nurse | Named in relation to nursing progress notes on wound and nutritional status |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 7, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The survey noted that all previously cited deficiencies had been corrected.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Dec 28, 2016
Visit Reason
A follow-up survey was conducted to verify correction of previously cited deficiencies at the facility.
Findings
The facility failed to properly maintain smoke rated walls with multiple unprotected penetrations in various hallways and rooms, including use of non-approved expansion foam and walls not sealed to deck as required. These findings were confirmed by staff during the inspection.
Deficiencies (1)
Unprotected penetrations in smoke rated walls in multiple areas including Hall 200, Hall 100, Assisted Dining, and others, with non-approved materials used for sealing and walls not sealed to deck as required.
Report Facts
Penetrations: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings of unprotected penetrations during follow-up inspection |
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