Inspection Reports for Life Care Ctr of Lawrenceville (2)
210 COLLINS INDUSTRIAL WAY, LAWRENCEVILLE, GA, 30045
Back to Facility ProfileInspection Report Summary
The most recent inspection on February 3, 2022, identified deficiencies related to advance directives documentation, pressure ulcer care, pain management, and infection control practices including COVID-19 precautions and glucometer disinfection. Earlier inspections showed similar issues, particularly with wound care, pain management, and infection control, indicating a consistent pattern of these types of deficiencies. Complaint investigations mostly resulted in no deficiencies except for one substantiated complaint concerning wound care and pain management. No fines, immediate jeopardy findings, or enforcement actions were listed in the available reports. The inspection history suggests ongoing challenges in these areas without clear improvement or worsening trends.
Deficiencies (last 1 years)
Deficiencies (over 1 years)
16 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
227% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Annual Inspection
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 complaint investigations of multiple complaint intake numbers.
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 related to advance directives, pressure ulcer care, pain management, and infection control. Deficiencies included failure to ensure resident wishes for advance directives were documented and followed, incomplete wound assessments and inadequate nutritional monitoring for wound healing, insufficient pain assessment documentation and management, and failure to follow COVID-19 transmission-based precautions and proper glucometer disinfection.
Deficiencies (4)
Failed to ensure resident wishes were correctly entered into orders to reflect preferred code status and failed to obtain and file copies of advance directives or provide education materials for 4 of 6 residents reviewed.
Failed to ensure a resident with pressure ulcers received care and services to promote healing and that wound care staff performed complete evaluations including depth measurements and nutritional monitoring for one resident.
Failed to develop an interdisciplinary and resident-centered plan of care to manage chronic pain and failed to document pain specifics and reassess effectiveness for one resident.
Failed to ensure staff followed transmission-based precautions for COVID-19 for two newly admitted residents on quarantine and failed to ensure multiuse glucometers were cleaned and disinfected according to manufacturer instructions and facility policy on two medication carts.
Report Facts
Resident census: 68
Pressure ulcer wound size: 4
Pressure ulcer wound size: 7.5
Pressure ulcer wound size: 3.3
Pressure ulcer wound size: 1.4
Weight loss: 27
Pain score: 3
Pain score: 5
Pain score: 6
Pain score: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| R29 | Resident | Named in advance directive deficiency related to code status and education |
| R38 | Resident | Named in advance directive deficiency related to code status and education |
| R23 | Resident | Named in advance directive deficiency related to code status and education |
| R19 | Resident | Named in advance directive deficiency related to code status and education |
| RN10 | Registered Nurse | Acknowledged incomplete wound documentation |
| RD | Registered Dietician | Acknowledged nutritional monitoring deficiencies for wound healing |
| MD1 | Medical Doctor | Attending physician for resident with wounds and pain management issues |
| LPN7 | Licensed Practical Nurse | Observed cleaning glucometer and acknowledged insufficient cleaning |
| LPN3 | Licensed Practical Nurse | Observed cleaning glucometer and acknowledged insufficient cleaning |
| ICP | Infection Control Preventionist | Provided training on glucometer cleaning |
| DON | Director of Nursing | Acknowledged policy and training deficiencies |
| OT8 | Occupational Therapist | Observed not wearing gown during quarantine resident therapy session |
| COTA5 | Certified Occupational Therapy Aide | Observed not wearing gown during quarantine resident care |
| LPN7 | Licensed Practical Nurse | Did not document pain level or source for resident |
| ADOR | Assistant Director of Rehabilitation Services | Described resident therapy and pain limitations |
| PTA12 | Physical Therapy Assistant | Described resident pain limiting therapy participation |
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 related standards at Lifeway Center of Lawrenceville.
Findings
The facility was found in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR Subpart 483.90(a) and the NFPA 101 Life Safety Code 2012 edition. The Miranda Hallway, housing 12 beds isolated due to COVID-19 patients, was not surveyed, but all other life safety provisions of the partition were compliant.
Report Facts
Beds in Miranda Hallway: 12
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 4
Date: Feb 3, 2022
Visit Reason
The inspection was a State Licensure survey conducted from 01/31/2022 through 02/03/2022, including investigation of multiple complaint intakes (GA00218921, GA00215413, GA00214755, and GA00214740). The visit aimed to assess compliance with licensure and complaint allegations.
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 due to failure to provide adequate wound care and pain management for a resident with pressure ulcers, failure to follow COVID-19 transmission-based precautions for newly admitted residents on quarantine, and failure to properly clean and disinfect multiuse glucometers according to manufacturer and facility policy.
Deficiencies (4)
Failure to ensure a resident with pressure ulcers received appropriate wound care and evaluations, including incomplete wound depth documentation and lack of 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 two of three 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
Wound healing time estimate: 58
Weight loss percentage: 9.8
COVID-19 county positivity rate: 27.88
Pain score counts: 93
Pain score distribution: 5
Pain score distribution: 1
Pain score distribution: 1
Pain score distribution: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse 10 | Registered Nurse | Acknowledged incomplete wound depth documentation for Resident 36. |
| Director of Nursing | Director of Nursing (DON) | Acknowledged wounds had depth and nursing staff should document all wound characteristics; also acknowledged staff are required to evaluate pain using numeric scale and reevaluate effectiveness. |
| Registered Dietician | Registered Dietician (RD) | 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 (MD) | Acknowledged wounds were unavoidable and nutritional status important for wound healing; stated resident abuses opiates and pain management is problematic. |
| Licensed Practical Nurse 7 | Licensed Practical Nurse (LPN) | Observed cleaning glucometer with one wipe; acknowledged not documenting resident pain level on 01/31/22. |
| Assistant Director of Rehabilitation Services | Assistant Director of Rehabilitation Services (ADOR) | Described therapy scheduling and resident's refusal to get out of bed due to pain. |
| Physical Therapy Assistant 12 | Physical Therapy Assistant (PTA) | Acknowledged resident has not participated in therapy since 01/25/22 due to pain. |
| Infection Control Preventionist | Infection Control Preventionist (ICP) | Acknowledged training staff to clean glucometers with one wipe and drying time of two minutes. |
| Licensed Practical Nurse 3 | Licensed Practical Nurse (LPN) | Observed cleaning glucometer with one wipe and acknowledged glucometer dried within one minute. |
| Occupational Therapist 8 | Occupational Therapist (OT) | Observed not wearing gown during therapy session with resident on quarantine; acknowledged should have worn gown after reading posted signs. |
| Certified Occupational Therapy Aide 5 | Certified Occupational Therapy Aide (COTA) | Observed entering resident room without gown and gloves despite posted contact precautions; acknowledged not wearing gown because no isolation set up. |
Inspection Report
Annual Inspection
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 and a standard survey to assess 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 ensure resident advance directives were properly documented and honored, inadequate pressure ulcer care and wound assessment, insufficient pain management documentation and care, and lapses in infection control practices including COVID-19 precautions and glucometer disinfection.
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 a resident with pressure ulcers received care and services to promote healing and that wound care staff performed complete evaluations including depth measurements.
Failure to develop an interdisciplinary and resident-centered pain management plan and inadequate documentation of pain assessments and interventions.
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 and facility policy.
Report Facts
Resident census: 68
Pressure ulcer wound measurements: 4
Pressure ulcer wound measurements: 7.5
Pressure ulcer wound measurements: 2
Pressure ulcer wound measurements: 3
Weight loss: 27
Pain score counts: 5
Pain score counts: 1
Pain score counts: 1
Pain score counts: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| R29 | Resident | Named in advance directive deficiency related to failure to obtain and document advance directives and code status. |
| R38 | Resident | Named in advance directive deficiency related to failure to update code status and document 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 document living will and advance directives in medical record. |
| R36 | Resident | Named in pressure ulcer care deficiency, pain management deficiency, and nutritional care deficiency. |
| Social Services Director | Interviewed regarding advance directive education and documentation. | |
| Admission Director | Interviewed regarding advance directive collection and documentation. | |
| Director of Nursing | Interviewed regarding advance directive policy, pain management, and wound care documentation. | |
| Registered Dietician | Interviewed regarding nutritional assessment and wound healing. | |
| Wound Medical Doctor | Interviewed regarding wound assessment and treatment. | |
| Licensed Practical Nurse 7 | Observed and interviewed regarding glucometer cleaning and pain medication administration. | |
| Licensed Practical Nurse 3 | Observed and interviewed regarding glucometer cleaning. | |
| Occupational Therapist 8 | Observed and interviewed regarding COVID-19 PPE use during therapy session. | |
| Certified Occupational Therapy Aide 5 | Observed and interviewed regarding COVID-19 PPE use during resident care. | |
| Assistant Director of Rehabilitation Services | Interviewed regarding therapy services and resident participation. | |
| Physical Therapy Assistant 12 | Interviewed regarding therapy and pain management. | |
| Medical Doctor 1 | Interviewed regarding pain management and wound care. | |
| Infection Control Preventionist | Interviewed regarding glucometer cleaning and infection control policies. |
Inspection Report
Life Safety
Census: 66
Capacity: 125
Deficiencies: 0
Date: Feb 3, 2022
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with fire safety requirements and related standards at the facility.
Findings
The facility was found in compliance with the Life Safety Code requirements for participation in Medicare/Medicaid. The Miranda Hallway, housing 12 beds isolated due to COVID-19 patients, was not surveyed, but all other life safety provisions of the partition were found in compliance.
Report Facts
Beds in Miranda Hallway: 12
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 4
Date: Feb 3, 2022
Visit Reason
A State Licensure survey was conducted including investigation of multiple complaint intake numbers related to the facility's compliance with care and infection control standards.
Complaint Details
Complaint Intake numbers GA00218921, GA00215413 and GA00214755 were investigated with no deficiencies cited. Complaint Intake number GA00214740 was investigated and deficiencies were cited related to wound care and pain management.
Findings
The facility was found not in substantial compliance due to failure to provide adequate wound care and pain management for a resident with pressure ulcers, failure to follow COVID-19 transmission-based precautions for newly admitted residents on quarantine, and failure to properly clean and disinfect multiuse glucometers according to policy and manufacturer instructions.
Deficiencies (4)
Failure to ensure a resident with pressure ulcers received appropriate wound care and evaluations, including incomplete wound depth documentation and lack of 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 two of three 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
Estimated healing time: 58
Weight loss: 27
Pain scores: 93
Pain score level 3: 5
Pain score level 5: 1
Pain score level 6: 1
Pain score level 0: 86
Medication administration opportunities: 44
ProSource consumption 0%: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse 10 | Registered Nurse | Acknowledged incomplete wound depth documentation for Resident 36 |
| Director of Nursing | Director of Nursing | Acknowledged wounds had depth and nursing staff should document all wound characteristics; also acknowledged nursing staff are required to evaluate pain using numeric scale and facility policy |
| Registered Dietician | Registered Dietician | Acknowledged resident's poor nutritional intake and suboptimal monitoring; did not obtain prealbumin level; described informal interdisciplinary communication due to COVID outbreak |
| Medical Doctor 1 | Attending Medical Doctor | Acknowledged wounds were unavoidable, poor nutritional status, and problematic pain management with resident abusing opiates |
| LPN 7 | Licensed Practical Nurse | Documented muscle spasm medication effectiveness but did not document pain level or source of discomfort for Resident 36 |
| Assistant Director of Rehabilitation Services | Assistant Director of Rehabilitation Services | Reported therapy schedule and resident's refusal to get out of bed due to pain |
| Physical Therapy Assistant 12 | Physical Therapy Assistant | Reported resident usually given tramadol prior to therapy and resident has not participated in therapy due to pain |
| Occupational Therapist 8 | Occupational Therapist | Observed not wearing gown during therapy session with resident on quarantine despite posted signage |
| Certified Occupational Therapy Aide 5 | Certified Occupational Therapy Aide | Observed entering resident room without gloves and gown despite posted signage |
| LPN 3 | Licensed Practical Nurse | Observed cleaning glucometer with one wipe and not allowing full wet time per manufacturer instructions |
| Infection Control Preventionist | Infection Control Preventionist | Acknowledged training staff to clean glucometers with one wipe and drying within two minutes |
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