Inspection Reports for Life Care Center of Lawrenceville

This document is a Statement of Deficiencies and Plan of Correction for Life Care Center of Lawrenceville, indicating a regulatory inspection was conducted.

The report contains initial comments but does not provide specific details on deficiencies or findings.

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.

The revisit survey found all previously cited deficiencies corrected and the complaint investigated was unsubstantiated.

Complaint Intake Number GA00253798 was investigated during the revisit survey and was found unsubstantiated.

A health revisit survey was conducted in conjunction with a complaint investigation to verify correction of previous deficiencies and investigate Complaint Intake Number GA00253798.

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.

Complaint Intake Number GA00253798 was investigated and found unsubstantiated.

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.

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.

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.

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.

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.

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.

The survey included investigation of complaint intake numbers GA00253462, GA00251981, GA00253521, GA00253003, GA00253541, GA00250624, and GA00253362.

An abbreviated/partial extended survey was conducted to investigate complaints GA00244994 and GA00245858.

The complaints GA00244994 and GA00245858 were unsubstantiated, and no deficiencies were cited during the survey.

Complaints GA00244994 and GA00245858 were investigated and found to be unsubstantiated.

An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00242593 and #GA00243091.

The complaints #GA00242593 and #GA00243091 were unsubstantiated with no deficiencies cited during the survey.

Complaints #GA00242593 and #GA00243091 were investigated and found to be unsubstantiated with no deficiencies cited.

A revisit survey was conducted to verify correction of deficiencies cited in the August 31, 2023 Standard Survey.

All deficiencies cited in the prior August 31, 2023 Standard Survey were found to be corrected during the revisit survey.

This document is a Statement of Deficiencies and Plan of Correction following an inspection of the facility.

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.

A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.

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

An abbreviated survey was conducted to verify removal of Immediate Jeopardy related to a COVID-19 outbreak and to investigate Complaint Number GA00238040.

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.

Complaint Number GA00238040 was investigated and substantiated without deficiencies.

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.

The complaint was substantiated without deficiency cited.

Complaint Number GA00238040 was investigated and substantiated without any deficiency cited.

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.

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.

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.

A State Monitoring visit was conducted at Life Care of Lawrenceville related to an ongoing immediate jeopardy.

No additional concerns were identified during the monitoring visit.

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.

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.

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.

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.

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.

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.

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.

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.

The document is a statement of deficiencies and plan of correction for the Life Care Center of Lawrenceville following a state inspection.

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.

A revisit survey was conducted to verify correction of deficiencies cited during the standard survey on 2022-02-03.

All deficiencies cited in the prior standard survey were found to be corrected as of 2022-03-18.

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.

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.

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).

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.

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.

Complaint Intake numbers GA00218921, GA00215413 and GA00214755 were investigated with no deficiencies cited. Complaint Intake number GA00214740 was investigated and deficiency F686 was cited.

The visit was conducted as a Life Safety Code Survey to assess compliance with fire safety regulations and emergency preparedness requirements.

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.

An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00203618, GA00206111, GA00207423, and GA00209646.

The complaints investigated were unsubstantiated and no deficiencies were cited during this survey.

Complaints GA00203618, GA00206111, GA00207423, and GA00209646 were investigated and found to be unsubstantiated.

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.

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.

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.

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.

An abbreviated survey was conducted to investigate complaint number GA00200293.

The complaint was unsubstantiated and no deficiencies were cited during the survey.

Complaint number GA00200293 was investigated and found to be unsubstantiated with no deficiencies cited.

A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.

The survey noted that all previously cited deficiencies had been corrected.

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.

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.

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.

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.

An abbreviated survey was conducted to investigate complaint GA00187863 at Life Care Center of Lawrenceville.

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.

Investigation of complaint GA00187863; facility found in substantial compliance.

A complaint survey was conducted to investigate complaint #GA00186595 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.

No deficiencies were cited during the complaint investigation survey.

Complaint #GA00186595 was investigated and found to have no deficiencies.

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.

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.

A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.

The facility was found in substantial compliance with the Life Safety Code requirements, including the Emergency Preparedness plan review which met Appendix Z standards.

The inspection was conducted to investigate complaint #GA00175697 to determine compliance with Federal and State Long Term Care regulations.

No deficiencies were cited during the complaint survey at Life Care Center Lawrenceville.

Complaint #GA00175697 was investigated and found to have no deficiencies.

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.

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.

A revisit survey was conducted from 4/19/17 through 4/21/17 to verify correction of previously cited deficiencies.

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.

A revisit survey was conducted from 4/19/17 through 4/21/17 to verify correction of previously cited deficiencies.

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.

This follow-up inspection was conducted to verify correction of previously cited deficiencies from the prior survey dated 2/6/2017.

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.

Revisit survey conducted in conjunction with an Abbreviated survey to investigate noncompliance and immediate jeopardy related to resident care and pressure ulcers.

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.

An abbreviated complaint investigation and a revisit survey were conducted due to noncompliance with Medicare/Medicaid regulations, including immediate jeopardy related to complaint GA00169281.

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.

The abbreviated complaint investigation was conducted in conjunction with a revisit survey due to complaints GA00169880 and GA00169281, with immediate jeopardy related to GA00169281.

A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.

The survey noted that all previously cited deficiencies had been corrected.

A follow-up survey was conducted to verify correction of previously cited deficiencies at the facility.

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.