Inspection Reports for Life Care Center of Gwinnett
3850 SAFEHAVEN DRIVE, LAWRENCEVILLE, GA, 30044
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 6, 2025, found no deficiencies after a follow-up survey verified correction of prior issues. Earlier inspections showed a pattern of deficiencies primarily related to incomplete care plans and assessments for the use and safety of side rails and indwelling urinary catheters, which posed potential safety risks. Complaint investigations included one substantiated case in December 2024 without cited deficiencies and several unsubstantiated complaints; no fines or enforcement actions were listed in the available reports. Prior surveys from 2023 and earlier noted issues with medication administration, life safety code compliance, and infection control, but these were generally corrected in subsequent follow-ups. The facility’s inspection history shows improvement over time, with recent surveys indicating compliance after addressing earlier cited deficiencies.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
7.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
61% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
100% occupied
Based on a April 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 6, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Life Care Center of Gwinnett, summarizing deficiencies identified during the inspection completed on June 6, 2025.
Findings
The report contains initial comments and a summary statement of deficiencies identified during the inspection. No specific deficiencies or severity levels are detailed in the provided page.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 6, 2025
Visit Reason
A health revisit survey was conducted to verify correction of deficiencies cited in the prior Recertification Survey dated April 10, 2025.
Findings
All deficiencies cited in the previous Recertification Survey were found to be corrected during this revisit survey.
Inspection Report
Life Safety
Census: 91
Capacity: 91
Deficiencies: 0
Date: Apr 14, 2025
Visit Reason
The visit was conducted to review the Emergency Preparedness Program and to perform a Life Safety Code Survey for compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code 2012 edition.
Findings
The Emergency Preparedness Program was found to be in substantial compliance with 42 CFR & 483.73. The facility was also found in substantial compliance with Life Safety Code requirements for participation in Medicare/Medicaid.
Inspection Report
Life Safety
Census: 91
Capacity: 91
Deficiencies: 0
Date: Apr 14, 2025
Visit Reason
The visit was conducted to perform a Life Safety Code Survey to assess compliance with Medicare/Medicaid participation requirements and related fire safety standards.
Findings
The facility was found to be in substantial compliance with the requirements set forth in 42 CFR & 483.73 and the NFPA 101 Life Safety Code 2012 edition.
Inspection Report
Life Safety
Census: 91
Capacity: 91
Deficiencies: 0
Date: Apr 14, 2025
Visit Reason
The visit was conducted to perform a Life Safety Code Survey to assess compliance with Medicare/Medicaid participation requirements and related fire safety standards.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Subpart 483.90(a), Life Safety from Fire, and the NFPA 101 Life Safety Code 2012 edition.
Report Facts
Census: 91
Total Capacity: 91
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 4
Date: Apr 10, 2025
Visit Reason
A standard survey was conducted from April 7 to April 10, 2025, including investigation of Complaint Intake Number GA000253947, which was found to be unsubstantiated.
Complaint Details
Complaint Intake Number GA000253947 was investigated in conjunction with the standard survey and was found to be unsubstantiated.
Findings
The facility failed to develop baseline and comprehensive care plans specific to the use of side rails for multiple residents and failed to include the use of an indwelling urinary catheter in a baseline care plan. Additionally, the facility failed to complete initial and quarterly assessments for the use and safety of side rails for several residents, creating potential safety risks.
Deficiencies (4)
Failed to develop a baseline care plan specific to the use of side rails for three of nine residents reviewed for physical restraints.
Failed to develop a baseline care plan identifying the use of an indwelling urinary catheter for one resident reviewed.
Failed to develop a comprehensive care plan specific to the use of side rails for six of nine residents reviewed for physical restraints.
Failed to complete initial and quarterly assessments for the use and safety of side rails for six of nine residents reviewed for physical restraints.
Report Facts
Residents present: 91
Residents reviewed for physical restraints: 9
Residents with baseline care plan deficiencies: 3
Residents with comprehensive care plan deficiencies: 6
Residents lacking initial and quarterly side rail assessments: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 1 | Licensed Practical Nurse | Stated side rails should be included in baseline and comprehensive care plans and described evaluation responsibilities |
| Licensed Practical Nurse 2 | Licensed Practical Nurse | Stated side rails should be included in baseline and comprehensive care plans and described evaluation responsibilities |
| Licensed Practical Nurse 4 | Licensed Practical Nurse | Stated indwelling urinary catheter should be included in baseline care plan |
| MDS Coordinator | MDS Coordinator | Stated indwelling urinary catheter and side rails should be included in care plans for staff awareness |
| Director of Nursing | Director of Nursing | Confirmed deficiencies in care plans and assessments for side rails and indwelling urinary catheter; described responsibilities and importance of evaluations |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Apr 10, 2025
Visit Reason
The inspection was conducted as a State Licensure survey at Life Care Center of Gwinnett from April 7, 2025 through April 10, 2025, to determine compliance with the State Long Term Care Requirements.
Findings
The facility failed to develop comprehensive care plans specific to the use of side rails for six of nine residents reviewed, and failed to complete initial and quarterly assessments for the use and safety of side rails for six of nine residents. These failures created potential safety risks, including unmet care needs, risk of injury, and risk of entrapment.
Deficiencies (2)
Failure to develop a comprehensive care plan specific to the use of side rails for six of nine residents reviewed for physical restraints.
Failure to complete initial and quarterly assessments for the use and safety of side rails for six of nine residents reviewed for physical restraints.
Report Facts
Residents reviewed for physical restraints: 9
Residents with care plan deficiencies: 6
Residents with assessment deficiencies: 6
BIMS scores: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) 4 | Stated side rails should be on the care plan to communicate care needed for residents | |
| MDS Coordinator (MDSC) | Stated side rails should be on the care plan so staff know resident needs | |
| Licensed Practical Nurse (LPN) 1 | Stated side rails should be included in the comprehensive care plan and described evaluation responsibilities | |
| Licensed Practical Nurse (LPN) 2 | Stated side rails should be included in the comprehensive care plan and described evaluation responsibilities | |
| Director of Nursing (DON) | Confirmed care plans did not address side rails for six residents and described evaluation and care planning responsibilities |
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 3
Date: Apr 10, 2025
Visit Reason
A standard survey was conducted from April 7, 2025 through April 10, 2025, including investigation of Complaint Intake Number GA000253947, which was found to be unsubstantiated.
Complaint Details
Complaint Intake Number GA000253947 was investigated in conjunction with the standard survey and was found to be unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations related to failure to develop baseline and comprehensive care plans specific to the use of side rails and indwelling urinary catheters for several residents. Additionally, the facility failed to complete initial and quarterly assessments for the use and safety of side rails for multiple residents, creating potential safety risks.
Deficiencies (3)
Failed to develop a baseline care plan specific to the use of side rails for three residents and failed to develop a baseline care plan identifying the use of an indwelling urinary catheter for one resident.
Failed to develop a comprehensive care plan specific to the use of side rails for six residents.
Failed to complete initial and quarterly assessments for the use and safety of side rails for six residents.
Report Facts
Residents reviewed for physical restraints: 9
Residents with baseline care plan deficiencies: 3
Residents with comprehensive care plan deficiencies: 6
Residents with assessment deficiencies: 6
Facility census: 91
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 1 | Licensed Practical Nurse | Stated side rails should be included on baseline and comprehensive care plans and described evaluation responsibilities. |
| Licensed Practical Nurse 2 | Licensed Practical Nurse | Confirmed side rails should be included in baseline and comprehensive care plans and described evaluation process. |
| Licensed Practical Nurse 4 | Licensed Practical Nurse | Stated indwelling urinary catheter should be included on baseline care plan and side rails should be on care plan. |
| MDS Coordinator | MDS Coordinator | Stated indwelling urinary catheter and side rails should be included on care plans to communicate resident needs. |
| Director of Nursing | Director of Nursing | Confirmed deficiencies in care planning and assessments for side rails and indwelling urinary catheter and described responsible staff and importance of evaluations. |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Apr 10, 2025
Visit Reason
The inspection was a State Licensure survey conducted from April 7, 2025 through April 10, 2025, to determine compliance with the State Long Term Care Requirements.
Findings
The facility failed to develop comprehensive care plans specific to the use of side rails for six of nine residents reviewed, and failed to complete initial and quarterly assessments for the use and safety of side rails for six of nine residents. This failure posed potential risks for unmet care needs, safety issues, and injury due to improper use or lack of evaluation of side rails.
Deficiencies (2)
Failure to develop a comprehensive care plan specific to the use of side rails for six of nine residents reviewed for physical restraints.
Failure to complete initial and quarterly assessments for the use and safety of side rails for six of nine residents reviewed for physical restraints.
Report Facts
Residents reviewed for physical restraints: 9
Residents with deficient care plans: 6
Residents with deficient assessments: 6
Dates of admission for residents: Admission dates ranged from 2022 to 2025 for residents reviewed
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 1 | Licensed Practical Nurse | Stated responsibility for completing side rail evaluations and importance of evaluations |
| Licensed Practical Nurse 2 | Licensed Practical Nurse | Stated residents are assessed upon admission and quarterly for side rail use |
| Licensed Practical Nurse 4 | Licensed Practical Nurse | Stated side rails should be on the care plan to communicate resident care needs |
| MDS Coordinator | MDS Coordinator | Stated side rails should be on the care plan so staff know resident needs |
| Director of Nursing | Director of Nursing | Confirmed care plans did not address side rail use and described responsibilities for evaluation and care planning |
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 4
Date: Apr 10, 2025
Visit Reason
A standard survey was conducted from April 7 through April 10, 2025, including investigation of Complaint Intake Number GA000253947, which was found to be unsubstantiated.
Complaint Details
Complaint Intake Number GA000253947 was investigated in conjunction with the standard survey and was found to be unsubstantiated.
Findings
The facility failed to develop baseline and comprehensive care plans specific to the use of side rails for multiple residents and failed to include the use of an indwelling urinary catheter in a baseline care plan. Additionally, the facility failed to complete initial and quarterly assessments for the use and safety of side rails for several residents, creating potential risks for unmet care needs, safety issues, and injury.
Deficiencies (4)
Failed to develop baseline care plans specific to the use of side rails for three of nine residents reviewed for physical restraints.
Failed to develop baseline care plan identifying the use of an indwelling urinary catheter for one resident reviewed.
Failed to develop comprehensive care plans specific to the use of side rails for six of nine residents reviewed for physical restraints.
Failed to complete initial and quarterly assessments for the use and safety of side rails for six of nine residents reviewed for physical restraints.
Report Facts
Residents reviewed for physical restraints: 9
Residents with baseline care plan deficiencies: 3
Residents with comprehensive care plan deficiencies: 6
Residents lacking initial and quarterly side rail assessments: 6
Facility census: 91
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 1 | Licensed Practical Nurse | Stated side rails should be included in baseline and comprehensive care plans and described evaluation responsibilities. |
| Licensed Practical Nurse 2 | Licensed Practical Nurse | Confirmed side rails should be included in baseline and comprehensive care plans and described evaluation responsibilities. |
| Licensed Practical Nurse 4 | Licensed Practical Nurse | Stated indwelling urinary catheter should be included in baseline care plan. |
| MDS Coordinator | MDS Coordinator | Stated indwelling urinary catheter and side rails should be included in care plans for staff awareness. |
| Director of Nursing | Director of Nursing | Confirmed deficiencies in care planning and assessments for side rails and indwelling catheter; described responsible parties and importance of evaluations. |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Apr 10, 2025
Visit Reason
The inspection was conducted as a State Licensure survey at Life Care Center of Gwinnett from April 7 through April 10, 2025, to determine compliance with State Long Term Care Requirements.
Findings
The facility failed to develop comprehensive care plans specific to the use of side rails for six of nine residents reviewed, and failed to complete initial and quarterly assessments for the use and safety of side rails for six of nine residents. These failures posed potential risks for unmet care needs, safety issues, and injury due to improper use or lack of evaluation of side rails.
Deficiencies (2)
Failure to develop a comprehensive care plan specific to the use of side rails for six of nine residents reviewed for physical restraints.
Failure to complete initial and quarterly assessments for the use and safety of side rails for six of nine residents reviewed for physical restraints.
Report Facts
Residents reviewed for physical restraints: 9
Residents with deficient care plans: 6
Residents with deficient assessments: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 1 | Licensed Practical Nurse | Stated responsibility for completing side rail evaluations and importance of evaluating residents for side rail use |
| Licensed Practical Nurse 2 | Licensed Practical Nurse | Stated residents are assessed upon admission and quarterly for bed rail use and safety |
| Licensed Practical Nurse 4 | Licensed Practical Nurse | Stated side rails should be on the care plan to communicate care needed |
| MDS Coordinator | MDS Coordinator | Stated side rails should be on the care plan so staff know resident needs |
| Director of Nursing | Director of Nursing | Confirmed care plans did not address side rails and described responsibility for adding side rails to care plans and evaluations |
Inspection Report
Abbreviated Survey
Census: 88
Deficiencies: 0
Date: Dec 11, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints numbered GA00240905, GA00241248, GA00244049, GA00246613, and GA00252628.
Complaint Details
Complaints GA00240905, GA00241248, GA00246613, and GA00252628 were unsubstantiated. Complaint GA00244049 was substantiated.
Findings
Four complaints were found unsubstantiated, one complaint was substantiated, and no deficiencies were cited during the survey.
Report Facts
Complaints investigated: 5
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 6, 2023
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey tags.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 6, 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
Plan of Correction
Deficiencies: 0
Date: Nov 3, 2023
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Life Care Center of Gwinnett, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific findings or deficiencies in the provided page.
Inspection Report
Re-Inspection
Census: 94
Deficiencies: 0
Date: Nov 3, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the September 13, 2023 Standard Survey.
Findings
All deficiencies cited in the previous September 13, 2023 Standard Survey were found to be corrected during this revisit survey.
Inspection Report
Life Safety
Census: 96
Capacity: 163
Deficiencies: 1
Date: Oct 16, 2023
Visit Reason
A Life Safety Code Federal Monitoring Survey was conducted following a state agency survey to assess compliance with Medicare/Medicaid participation requirements related to life safety and fire protection codes.
Findings
The facility was found not in substantial compliance with life safety code requirements due to failure to maintain the smoke and ½ hour fire resistance of smoke barriers. Specifically, a smoke barrier was penetrated by a plastic sleeve with a blue wire that was not firestopped.
Deficiencies (1)
The A Hall smoke barrier was penetrated by a plastic sleeve containing a blue wire, and the area around the sleeve was not firestopped, compromising the smoke barrier's fire resistance.
Report Facts
Census: 96
Total Capacity: 163
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Present when deficiency was identified and identified the wall as a smoke barrier |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Sep 14, 2023
Visit Reason
The inspection was a State Licensure survey conducted from September 11 through September 14, 2023, to determine compliance with the State Long Term Care Requirements.
Findings
The facility failed to maintain professional nursing standards by administering narcotic medication from another resident's supply and failing to limit PRN psychotropic medications to no more than 14 days without proper documentation. Additionally, the facility failed to develop a care plan for a resident diagnosed with PTSD and did not maintain clean air filters in certain resident rooms.
Deficiencies (4)
Licensed Practical Nurses and Registered Nurse administered narcotic medication using another resident's medication.
Failure to limit PRN psychotropic medications to no more than 14 days with documentation for use after the 14-day timeframe.
Failure to develop a care plan for diagnosis of Post Traumatic Stress Disorder for one resident.
Failure to maintain clean air filters in Packaged Terminal Air Conditioners in rooms 115 and 117 and stained, broken window blind in room 115.
Report Facts
Sample size: 34
Residents reviewed for unnecessary drugs: 5
Residents sampled: 25
Rooms inspected on B Hall: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN FF | Licensed Practical Nurse | Interviewed regarding medication administration practices and borrowing medications |
| Pharmacist BB | Pharmacist in charge | Interviewed regarding narcotics handling and Omnicell authorizations |
| RN DD | Registered Nurse | Interviewed regarding administration of narcotic medication from another resident |
| LPN CC | Licensed Practical Nurse | Interviewed regarding narcotic medication orders and resident anxiety |
| LPN LL | Licensed Practical Nurse | Interviewed regarding medication administration and narcotic sheet signature |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration practices and care plan development |
| Administrator | Administrator | Interviewed regarding medication administration practices and staff education |
| MDS Coordinator KK | MDS Coordinator | Interviewed regarding care plan and diagnosis documentation |
| Medical Record Director | Medical Record Director | Interviewed regarding diagnosis documentation and care plan |
| LPN GG | Licensed Practical Nurse | Interviewed regarding psychotropic medication orders |
| Certified Nursing Assistant HH | Certified Nursing Assistant | Interviewed regarding resident anxiety triggers |
| Housekeeping Supervisor | Housekeeping Supervisor | Interviewed regarding environmental sanitation and maintenance responsibilities |
Inspection Report
Life Safety
Census: 91
Capacity: 163
Deficiencies: 4
Date: Sep 13, 2023
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 life safety requirements, including missing documentation for monthly emergency lighting testing, a fire sprinkler head improperly positioned inside a ceiling, exterior sprinkler heads covered in debris, lint accumulation behind main dryers, and power strips placed on the floor in patient care areas.
Deficiencies (4)
Facility failed to provide documentation for monthly emergency lighting testing/inspection upon request.
Fire sprinkler head found up inside the ceiling in C hall and three exterior fire sprinkler heads covered in debris.
Space behind main dryers was covered in lint and roof vent was sucking up lint covering part of the exterior roof.
Power strips were found on the floor in the corner of E hall and room 117.
Report Facts
Census: 91
Total Capacity: 163
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews |
Inspection Report
Annual Inspection
Census: 92
Deficiencies: 5
Date: Sep 11, 2023
Visit Reason
A Standard Survey was conducted from September 11 through September 14, 2023, including investigation of multiple complaints, to assess compliance with Medicare/Medicaid regulations for Life Care Center of Gwinnett.
Complaint Details
Multiple complaints (GA00225466, GA00226333, GA00231302, GA00231831, GA00233813, GA00233920, GA00234831, GA00238453) were investigated. Six complaints were unsubstantiated, one was substantiated with deficiencies (GA00233813), and one was substantiated without deficiencies (GA00233920).
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to maintain a safe environment, failure to submit required PASARR Level II application for a resident, failure to develop a care plan for PTSD diagnosis, improper medication administration involving narcotics, and failure to limit PRN psychotropic medications to 14 days without documented rationale.
Deficiencies (5)
Failed to maintain clean air filters in PTACs in rooms 115 and 117 and had a stained and broken window blind in room 115.
Failed to submit application for Level II PASARR for evaluation for one resident (R30).
Failed to develop a care plan for diagnosis of PTSD for one resident (R62).
One LPN and one RN administered narcotic medication to resident #401 using another resident's medication supply.
Failed to limit PRN psychotropic medications to no more than 14 days with documentation of rationale for extension for one resident (R49).
Report Facts
Resident census: 92
Sample size: 34
Sample size: 25
Medication doses: 2
BIMS score: 11
Pain scale: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN FF | Licensed Practical Nurse | Administered narcotic medication from another resident's supply to R#401 |
| RN DD | Registered Nurse | Administered narcotic medication from another resident's supply to R#401 and communicated with physician and administrator |
| LPN CC | Licensed Practical Nurse | Interviewed regarding medication administration policies and narcotic handling |
| Pharmacist BB | Pharmacist in charge | Handled narcotic prescriptions and Omnicell authorizations |
| MDS Coordinator KK | MDS Coordinator | Confirmed care plan omissions for PTSD diagnosis |
| Medical Record Director | Medical Record Director | Confirmed care plan omissions for PTSD diagnosis and medical record details |
| Housekeeping Supervisor | Confirmed dusty PTAC filters and broken window blind | |
| Social Services Director | Interviewed about PASARR Level II process education and responsibilities | |
| Admissions Staff | Responsible for verifying PASARR Level I and document handling | |
| Director of Nursing | Director of Nursing | Interviewed about PASARR process and care plan requirements |
Inspection Report
Routine
Census: 75
Deficiencies: 0
Date: Feb 24, 2022
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with federal regulations related to emergency preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 for emergency preparedness and in substantial compliance with 42 CFR §483.80 infection control regulations, implementing CMS and CDC recommended practices for COVID-19.
Inspection Report
Life Safety
Census: 82
Capacity: 163
Deficiencies: 0
Date: Feb 1, 2022
Visit Reason
The visit was conducted to perform a Life Safety Code Survey to assess compliance with Medicare/Medicaid participation requirements and the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition.
Findings
The facility was found to be in substantial compliance with the Emergency Preparedness Program requirements under 42 CFR 483.73 and the Life Safety Code requirements under 42 CFR Subpart 483.90(a).
Inspection Report
Original Licensing
Deficiencies: 0
Date: Jan 28, 2022
Visit Reason
The inspection was conducted as a licensure survey for the facility.
Findings
No deficiencies were identified during the licensure survey.
Inspection Report
Routine
Census: 82
Deficiencies: 0
Date: Jan 28, 2022
Visit Reason
A standard survey was conducted at Life Care Center of Gwinnett from January 25, 2022 through January 28, 2022, including investigation of multiple complaint intake numbers.
Complaint Details
Complaint Intake Numbers GA00220888, GA00219035, GA00217908, and GA00217533 were investigated and all complaints were unsubstantiated.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B. All complaints investigated were unsubstantiated.
Report Facts
Complaint Intake Numbers Investigated: 4
Inspection Report
Deficiencies: 0
Date: Aug 27, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction for Life Care Center of Gwinnett, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies in the provided page.
Inspection Report
Re-Inspection
Census: 68
Deficiencies: 0
Date: Aug 27, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the June 24, 2021 Complaint Survey.
Complaint Details
The revisit survey was conducted following a complaint survey on June 24, 2021. All cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the June 24, 2021 Complaint Survey were found to be corrected.
Report Facts
Census: 68
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 1
Date: Jun 24, 2021
Visit Reason
A complaint survey was conducted at Life Care Center of Gwinnett from June 22, 2021 through June 24, 2021 by Ascellon on behalf of the Georgia Department of Community Health. Several complaint intake numbers were investigated, with some substantiated and others unsubstantiated.
Complaint Details
Complaint Intake Number GA00213848 was substantiated with deficiencies related to delayed urine specimen collection and treatment for UTI in Resident #1. Other complaint intake numbers were either substantiated without deficiency or unsubstantiated.
Findings
The facility was found not in compliance with 42 CFR §483 related to infection prevention and control. Specifically, the facility failed to provide a urine sample to the lab in a timely manner for Resident #1 who had a urinary tract infection (UTI), resulting in delayed treatment. Multiple interviews and record reviews confirmed delays in specimen collection, lab pickup, and antibiotic administration.
Deficiencies (1)
Failure to provide a urine sample to the lab in a timely manner for Resident #1 with a UTI.
Report Facts
Complaint Intake Numbers: 6
Resident Census: 64
Urinalysis specimen dates: 4
BIMS score: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Treatment nurse who communicated with family and passed information about UTI but did not follow through with urine specimen collection |
| LPN BB | Licensed Practical Nurse | Floor nurse responsible for urine specimen collection; had no memory of collecting specimen or UTI |
| CNA CC | Certified Nurse Aide | Provided care to Resident #1 and reported no knowledge of UTI |
| NP | Nurse Practitioner | Reported that urinalysis orders are done immediately upon UTI symptoms and was unaware of treatment delay |
| Medical Director | Reported expectation that urine specimen should have been sent out timely and noted delay in treatment |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 19, 2020
Visit Reason
An unannounced Abbreviated/Partial Extended Complaint Survey was conducted to investigate multiple complaint intake numbers related to the facility.
Complaint Details
Complaint Intake Numbers investigated were: #GA00204867, #GA00202102, #GA00201845, #GA00201551, #GA00201422, #GA00201370, #GA00200442 and #GA00200055. All complaints were unsubstantiated.
Findings
All complaints investigated were found to be unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Routine
Deficiencies: 0
Date: Aug 21, 2020
Visit Reason
A Desk Review for the COVID-19 Focused Infection Control Survey was conducted by the Centers for Medicare & Medicaid Services (CMS).
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices.
Inspection Report
Abbreviated Survey
Census: 50
Deficiencies: 1
Date: Jun 10, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on June 9-10, 2020, to assess compliance with infection prevention and control requirements during the COVID-19 pandemic.
Findings
The facility was found not in substantial compliance with Medicare regulations related to infection prevention and control. The main deficiency was failure to maintain consistent staffing on the COVID-19 and Non-COVID-19 care units, resulting in increased risk of COVID-19 transmission between units.
Deficiencies (1)
Failure to follow the established policy to maintain consistent staffing on the COVID-19 care unit and Non-COVID-19 care unit, allowing staff to work on both units and increasing risk of COVID-19 transmission.
Report Facts
Census: 50
Days worked on COVID-19 care unit: 8
Days worked on Non-COVID-19 care unit: 4
Days worked on COVID-19 care unit: 7
Days worked on Non-COVID-19 care unit: 3
Days worked on COVID-19 care unit: 5
Days worked on Non-COVID-19 care unit: 5
Days worked on Non-COVID-19 care unit: 6
Days worked on COVID-19 care unit: 2
Days worked on COVID-19 care unit: 3
Days worked on Non-COVID-19 care unit: 4
Days worked on COVID-19 care unit: 5
Days worked on Non-COVID-19 care unit: 1
Days worked on COVID-19 care unit: 7
Days worked on Non-COVID-19 care unit: 1
Days worked on COVID-19 care unit: 5
Days worked on Non-COVID-19 care unit: 2
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 10, 2020
Visit Reason
The visit was conducted as an investigation of complaint GA00204573 through desk review and later onsite COVID-19 Focused Infection Control Survey.
Complaint Details
Complaint GA00204573 was investigated via desk review from 4/21/2020 to 5/1/2020 and onsite survey on 6/9-10/2020; the complaint was not substantiated.
Findings
The complaint was not substantiated, no abuse, neglect, or immediate jeopardy concerns were noted, and no regulatory violations were cited during the COVID-19 Focused Infection Control Survey.
Inspection Report
Re-Inspection
Census: 94
Deficiencies: 0
Date: Sep 30, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the August 9, 2019 Complaint Survey.
Complaint Details
The visit was a follow-up to a complaint survey conducted on August 9, 2019; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the August 9, 2019 Complaint Survey were found to be corrected.
Inspection Report
Re-Inspection
Census: 103
Deficiencies: 0
Date: Jun 6, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 4/26/19 Standard Survey.
Findings
All deficiencies cited as a result of the 4/26/19 Standard Survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 3, 2019
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.
Findings
The survey noted that all previously cited survey tags have been corrected.
Inspection Report
Routine
Census: 108
Deficiencies: 4
Date: Apr 26, 2019
Visit Reason
A standard routine survey was conducted from April 23, 2019 through April 26, 2019, including investigation of Complaint Intake Number GA00196158.
Complaint Details
Complaint Intake Number GA00196158 was investigated in conjunction with the standard survey.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to complete significant change assessments, failure to transmit discharge MDS assessments timely, failure to follow physician orders for TED hose application, and inadequate supervision leading to resident burns from hot beverages.
Deficiencies (4)
Failure to complete Significant Change Minimum Data Set (MDS) assessments after significant declines for residents #65 and #94.
Failure to ensure discharge MDS assessments were transmitted within 14 days for residents #1, #100, and #101.
Failure to follow physician orders for TED hose application for residents #67 and #42.
Failure to provide adequate supervision and assistance to prevent accidents, resulting in burns to residents #85, #99, and #33 from hot beverages.
Report Facts
Resident census: 108
Sample size: 38
Burn wound size: 8.3
Burn wound size: 12.5
Burn wound size: 0.1
Burn wound size: 22
Burn wound size: 21
Burn wound size: 0.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA MM | Certified Nursing Assistant | Named in burn incident involving resident #85; terminated for failure to follow facility policy on serving hot beverages |
| CNA LL | Certified Nursing Assistant | Named in burn incident involving resident #99; served hot coffee resulting in burn |
| LPN KK | Licensed Practical Nurse, MDS Coordinator | Interviewed regarding MDS assessments and transmission issues |
| LPN NN | Licensed Practical Nurse, MDS Coordinator | Interviewed regarding MDS assessments and transmission issues |
| LPN GG | Licensed Practical Nurse | Interviewed regarding TED hose order transcription failure |
| LPN II | Licensed Practical Nurse | Provided dressing change for resident #85's burn |
| LPN HH | Licensed Practical Nurse, Wound Care Nurse | Provided dressing change and interview regarding resident #85's burn |
| DON | Director of Nursing | Interviewed regarding burn incidents and facility policies |
| ADON | Assistant Director of Nursing | Interviewed regarding burn incident involving resident #85 |
| FSD | Food Service Director | Interviewed regarding kitchen access and hot beverage policies |
| SLP OO | Speech Language Pathologist | Interviewed regarding resident #99's swallowing and feeding supervision |
| Director of Rehabilitation Services | Interviewed regarding therapy services and resident #99's feeding needs |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 26, 2019
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to follow physician orders for residents related to wearing TED hose (compression stockings).
Complaint Details
The visit was complaint-related due to allegations that the facility did not follow physician orders for TED hose application for two residents. The complaint was substantiated based on observations, record reviews, and staff interviews.
Findings
The facility failed to follow physician orders for two residents (#67 and #42) concerning the application of TED hose. Observations and record reviews revealed that the residents were not wearing TED hose as ordered, and documentation was incomplete or missing. Staff interviews confirmed lack of awareness or failure to transcribe orders.
Deficiencies (2)
Failure to follow physician orders for resident #67 related to wearing TED hose as ordered.
Failure to follow physician orders for resident #42 related to wearing TED hose as ordered.
Report Facts
Sampled residents: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DD | Certified Nursing Assistant | Interviewed and stated unawareness of TED hose order for resident #67 |
| FF | Certified Nursing Assistant | Interviewed and stated resident #67 wore regular socks and no report was given to staff |
| GG | Licensed Practical Nurse | Interviewed and stated she received TED hose orders but forgot to enter them on the MARs |
Inspection Report
Life Safety
Census: 108
Capacity: 163
Deficiencies: 5
Date: Apr 23, 2019
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 life safety requirements, including failure to properly maintain exit lighting, emergency lighting, corridor smoke doors, electrical systems, and outside oxygen cylinder storage, placing residents at risk in emergencies.
Deficiencies (5)
Failed to properly maintain exit lighting; exit lighting not tested for 30 seconds monthly and 90 minutes annually.
Failed to properly maintain emergency lighting; emergency lighting not tested for 90 minutes annually.
Failed to properly maintain corridor smoke doors; ADL Kitchen door does not close and latch.
Failed to properly maintain facility electrical system; electrical tap not in junction box in boiler room and flexible cord ran into ceiling in sleeping room 210.
Failed to properly store outside oxygen cylinders; cylinders stored in sun without protection from high temperatures.
Report Facts
Census: 108
Total Capacity: 163
Exit light test duration: 30
Exit light test duration: 90
Emergency light test duration: 90
Residents at risk due to exit lighting deficiency: 108
Residents at risk due to emergency lighting deficiency: 81
Residents at risk due to corridor smoke doors deficiency: 45
Residents at risk due to oxygen storage deficiency: 108
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member interviewed and confirmed findings during facility tour |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 8, 2019
Visit Reason
A complaint survey was conducted to investigate complaints # GA00193664 and GA# 192657 to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
The survey was conducted in response to complaints # GA00193664 and GA# 192657; no deficiencies were found.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 1, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA 00190478, GA 00192396, and GA 00191044.
Complaint Details
Investigations of complaints GA 00190478, GA 00192396, and GA 00191044 were unsubstantiated.
Findings
All investigations were unsubstantiated with no deficiencies identified during the survey.
Inspection Report
Complaint Investigation
Census: 144
Deficiencies: 0
Date: Jul 19, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate Georgia complaint GA00189739.
Complaint Details
Investigation of complaint GA00189739; identification of unsubstantiated complaints was required.
Findings
The survey was initiated and concluded on July 19, 2018, with instructions to identify which complaint was unsubstantiated.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 2, 2018
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The surveyor noted that all previously cited deficiencies had been corrected during the follow-up visit.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 16, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the prior standard survey on 2018-03-29.
Findings
All deficiencies cited as a result of the 3/29/18 standard survey were found to be corrected during the revisit survey.
Inspection Report
Follow-Up
Census: 117
Deficiencies: 2
Date: May 14, 2018
Visit Reason
The visit was a Follow-Up Survey conducted to verify correction of previously cited deficiencies at the facility.
Findings
The facility failed to properly maintain the fire sprinkler system and rated walls, which could place 117 residents at risk in the event of a fire. Specific deficiencies included missing data plates on fire sprinkler risers, improperly adjusted sprinkler heads, mixing of fire protection products, and unprotected or improperly protected penetrations in rated walls and ceilings.
Deficiencies (2)
No data plate on 1 fire sprinkler risers and improperly adjusted heads throughout facility.
Mixing of fire protection products and unprotected or improperly protected penetrations in rated walls and ceilings.
Report Facts
Resident census: 117
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour on 05/14/2018 |
Inspection Report
Life Safety
Census: 117
Capacity: 163
Deficiencies: 16
Date: Mar 29, 2018
Visit Reason
The inspection was conducted to review the facility's compliance with emergency preparedness and life safety code requirements, including fire safety, emergency lighting, sprinkler systems, electrical systems, and gas equipment storage.
Findings
The facility was found not in substantial compliance with multiple life safety and emergency preparedness requirements, including deficiencies in emergency preparedness planning, exit and emergency lighting maintenance, smoke detector testing, kitchen hood cleaning, fire alarm system installation, sprinkler system maintenance, fire extinguisher placement, corridor door functionality, rated wall integrity, electrical system safety, HVAC installation, space heater use, generator maintenance, and oxygen cylinder storage security.
Deficiencies (16)
Emergency Preparedness Plan was not site specific and did not address all identified hazards.
Exit lighting not tested monthly for 30 seconds and annually for 90 minutes.
Emergency lighting not tested monthly for 30 seconds and annually for 90 minutes.
Sleeping room smoke detectors not tested and no maintenance program in place.
Kitchen cooking hood not cleaned at correct intervals.
Fire alarm system installation did not meet NFPA 72 requirements, including improper visual notification device placement and pull station mounting.
Fire alarm system initiation deficiencies including smoke detectors in air flow stream.
Sprinkler system deficiencies including fixed obstructions, unprotected areas, no quarterly inspections, corroded and painted heads, and improper head orientation.
Portable fire extinguishers improperly mounted (too high).
Corridor smoke doors failed to self-close and latch.
Rated walls had unsealed penetrations, mixing of fire protection products, and use of non-approved expansion foam.
Electrical system deficiencies including missing knockouts in junction boxes and flexible cords run through ceilings.
HVAC system deficiencies including improper venting of fuel fired furnace.
Unauthorized use of portable space heaters in staff areas without documentation of compliance.
Essential electrical system maintenance deficiencies including missing monthly load runs, no annual load bank testing, and only one remote annunciator.
Oxygen cylinder storage area outside was unsecured, allowing unauthorized entry.
Report Facts
Residents at risk: 117
Certified beds: 163
Census: 117
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed multiple findings during the inspection. | |
| Staff A | Staff member who confirmed emergency preparedness plan findings. |
Inspection Report
Routine
Census: 121
Deficiencies: 3
Date: Mar 29, 2018
Visit Reason
A standard survey was conducted at Life Care Center Gwinnett from 3/26/18 to 3/29/18 to assess compliance with Medicare/Medicaid regulations for Long Term Care Facilities.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies related to inadequate catheter care for residents, failure to follow physician orders for tube feeding residual checks, and failure to properly dispose of expired medications in medication carts.
Deficiencies (3)
Failure to provide adequate catheter care for two residents and failure to follow facility's Daily Cath Care Policy.
Failure to follow physician's orders to check residual for one resident receiving tube feedings.
Failure to ensure disposal of expired medications in two of ten medication carts.
Report Facts
Resident census: 121
Sample size: 24
Catheter size: 16
Number of medication carts: 10
Expired medications found: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assisted Director of Nursing (ADON) | Observed catheter size and balloon, confirmed catheter details for Resident #49 | |
| Licensed Practical Nurse (LPN) FF | Interviewed regarding intake and output documentation and tube feeding residual measurement | |
| Licensed Practical Nurse (LPN) CC | Interviewed regarding intake and output documentation | |
| Director of Nursing (DON) | Interviewed regarding catheter care expectations, intake and output documentation, and medication storage policies | |
| Licensed Practical Nurse (LPN) EE | Observed catheter tubing condition and medication cart with expired medications | |
| Licensed Practical Nurse (LPN) FF | Observed expired medications in medication cart and interviewed about medication expiration checks |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 29, 2018
Visit Reason
The inspection was conducted due to concerns about inadequate catheter care and failure to follow physician's orders for residents with catheters and tube feedings.
Complaint Details
The investigation was complaint-related, focusing on catheter care and adherence to physician orders. Substantiation status is not explicitly stated.
Findings
The facility failed to provide adequate catheter care for two residents with catheters, including failure to change catheters timely, lack of documentation of intake and output, and failure to follow physician orders for tube feeding residual measurement. Observations and interviews revealed catheter leakage, urinary tract infections, and improper catheter tubing maintenance.
Deficiencies (3)
Facility failed to provide adequate catheter care for two residents with catheters, including failure to change catheters timely and lack of daily catheter care documentation.
Failure to document intake and output for resident with indwelling Foley catheter.
Failure to follow physician's orders for tube feeding residual measurement for one resident.
Report Facts
Residents with catheters: 3
Residents with catheter care deficiencies: 2
UTIs reported: 2
Catheter balloon size: 10
Catheter size: 16
Tube feeding residual syringe size: 60
Tube feeding residual threshold: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN EE | Licensed Practical Nurse | Observed not accurately measuring tube feeding residual and involved in catheter care observation |
| LPN FF | Licensed Practical Nurse | Interviewed regarding lack of intake and output documentation |
| LPN CC | Licensed Practical Nurse | Interviewed regarding lack of intake and output documentation |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding catheter care expectations and documentation deficiencies |
| Assisted Director of Nursing | Assisted Director of Nursing (ADON) | Observed catheter size and balloon, communicated with resident about catheter issues |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 1, 2017
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Life Care Center of Gwinnett, indicating a regulatory inspection and subsequent corrective action plan.
Findings
The document contains no detailed findings or deficiencies; it only includes initial comments and references to a plan of correction without specific deficiency descriptions.
Inspection Report
Re-Inspection
Census: 118
Deficiencies: 0
Date: Dec 1, 2017
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited as a result of a complaint investigation on 10/11/2017.
Complaint Details
The revisit survey was related to complaint GA00180739; all cited deficiencies were corrected.
Findings
All deficiencies cited from the previous complaint-related inspection were found to be corrected, and the facility was in substantial compliance as of 11/17/2017.
Report Facts
Census: 118
Inspection Report
Complaint Investigation
Census: 132
Deficiencies: 1
Date: Oct 12, 2017
Visit Reason
An abbreviated survey was conducted to investigate a complaint regarding medication administration errors at the facility.
Complaint Details
The complaint alleged that the facility abruptly stopped administering Zoloft (Sertraline) to Resident #1 as prescribed, leading to mental health decline, worsening dementia, and a fall with injury. The investigation confirmed the medication was not administered from September 1 to September 16, 2017, due to a transcription error involving duplicate orders and discontinuation.
Findings
The facility failed to ensure medications were available and administered as ordered for one resident due to a transcription error that caused a delay in medication administration from September 1 to September 16, 2017. The issue was isolated and addressed with staff training and quality assurance measures.
Deficiencies (1)
Failure to ensure medications were available and administered as ordered for one resident due to transcription and discontinuation errors.
Report Facts
Resident census: 132
Duration medication not administered: 16
Medication dosage: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| HH | Registered Nurse/Unit Manager | Interviewed regarding medication transcription and administration errors |
| KK | Facility Pharmacy Consultant | Interviewed regarding medication tapering and impact of discontinuation |
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 23, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected during the follow-up survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 19, 2017
Visit Reason
A follow-up visit was conducted to verify correction of deficiencies identified in the prior recertification survey.
Findings
All deficiencies identified in the previous recertification survey were corrected at the time of this follow-up visit.
Inspection Report
Life Safety
Census: 131
Capacity: 163
Deficiencies: 2
Date: Apr 11, 2017
Visit Reason
The 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 fire safety requirements, including missing a fire sprinkler trim ring in a hopper room and patient room doors that did not properly resist smoke passage. These deficiencies could place residents and staff at risk in the event of a fire.
Deficiencies (2)
Missing fire sprinkler trim ring in Hopper room at Hall F.
Patient room doors and other corridor doors not sealing to resist passage of smoke, including rooms 157, 158, 230, Assistant Director of Nursing door to corridor, and shower room doors in E-Hall and D-Hall.
Report Facts
Census: 131
Total licensed beds: 163
Residents at risk: 4
Residents and staff at risk: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings of missing sprinkler trim ring and door deficiencies at time of discovery |
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