Inspection Reports for
Life Care Center of Gwinnett

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.

All deficiencies cited in the previous Recertification Survey were found to be corrected during this revisit survey.

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.

The visit was complaint-related, focusing on failures in care planning and assessment related to side rails and indwelling urinary catheters. The complaint was substantiated based on observations, interviews, and record reviews.

The facility failed to develop baseline care plans addressing the use of side rails for multiple residents and failed to include the use of an indwelling urinary catheter in a resident's baseline care plan. Additionally, the facility did not complete initial and quarterly assessments for the use and safety of side rails for several residents, and did not properly document consents or reassessments as required by policy.

Complaint Intake Number GA000253947 was investigated in conjunction with the standard survey and was found to be unsubstantiated.

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.

The facility failed to develop baseline care plans addressing the use of side rails for three residents and failed to include the use of an indwelling urinary catheter in the baseline care plan for one resident. This failure created potential risks for unmet care and safety needs.

Complaints GA00240905, GA00241248, GA00246613, and GA00252628 were unsubstantiated. Complaint GA00244049 was substantiated.

Four complaints were found unsubstantiated, one complaint was substantiated, and no deficiencies were cited during the survey.

All previously cited survey tags have been corrected as noted by the surveyor.

The report contains initial comments but does not provide specific findings or deficiencies in the provided page.

All deficiencies cited in the previous September 13, 2023 Standard Survey were found to be corrected during this revisit survey.

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.

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.

The facility was found deficient in maintaining a safe and clean environment, proper PASARR screening, development of comprehensive care plans, professional nursing standards in medication administration, and appropriate use of psychotropic medications. Several residents were affected by these deficiencies, with issues ranging from environmental cleanliness to medication errors and incomplete care planning.

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.

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).

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.

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.

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).

No deficiencies were identified during the licensure survey.

Complaint Intake Numbers GA00220888, GA00219035, GA00217908, and GA00217533 were investigated and all complaints were unsubstantiated.

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.

No health deficiencies were found during the inspection.

The report contains initial comments but does not provide detailed findings or deficiencies in the provided page.

The revisit survey was conducted following a complaint survey on June 24, 2021. All cited deficiencies were corrected.

All deficiencies cited as a result of the June 24, 2021 Complaint Survey were found to be corrected.

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.

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.

Complaint Intake Numbers investigated were: #GA00204867, #GA00202102, #GA00201845, #GA00201551, #GA00201422, #GA00201370, #GA00200442 and #GA00200055. All complaints were unsubstantiated.

All complaints investigated were found to be unsubstantiated and no regulatory violations were cited during the survey.

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.

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.

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.

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.

The visit was a follow-up to a complaint survey conducted on August 9, 2019; all cited deficiencies were corrected.

All deficiencies cited as a result of the August 9, 2019 Complaint Survey were found to be corrected.

All deficiencies cited as a result of the 4/26/19 Standard Survey were found to be corrected.

The survey noted that all previously cited survey tags have been corrected.

Complaint Intake Number GA00196158 was investigated in conjunction with the standard survey.

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.

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.

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.

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.

The survey was conducted in response to complaints # GA00193664 and GA# 192657; no deficiencies were found.

No deficiencies were cited during the complaint survey.

Investigations of complaints GA 00190478, GA 00192396, and GA 00191044 were unsubstantiated.

All investigations were unsubstantiated with no deficiencies identified during the survey.

Investigation of complaint GA00189739; identification of unsubstantiated complaints was required.

The survey was initiated and concluded on July 19, 2018, with instructions to identify which complaint was unsubstantiated.

The surveyor noted that all previously cited deficiencies had been corrected during the follow-up visit.

All deficiencies cited as a result of the 3/29/18 standard survey were found to be corrected during the revisit survey.

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.

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.

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.

The investigation was complaint-related, focusing on catheter care and adherence to physician orders. Substantiation status is not explicitly stated.

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.

The document contains no detailed findings or deficiencies; it only includes initial comments and references to a plan of correction without specific deficiency descriptions.

The revisit survey was related to complaint GA00180739; all cited deficiencies were corrected.

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.

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.

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.

The surveyor noted that all previously cited survey tags have been corrected during the follow-up survey.

All deficiencies identified in the previous recertification survey were corrected at the time of this follow-up visit.

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.