Inspection Reports for Northside Gwinnett Extended Care Center
650 Professional Dr, Lawrenceville, GA 30046, GA, 30046
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 12, 2020 found the facility in compliance with COVID-19 emergency preparedness and infection control regulations, with no deficiencies cited. Earlier inspections showed a mixed record, including multiple Life Safety Code surveys that identified fire safety and maintenance issues such as problems with fire sprinkler systems, fire doors, and oxygen cylinder storage. Complaint investigations were generally unsubstantiated, except for one in 2018 that found failures in injury reporting and Minimum Data Set assessments. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s record shows improvement in infection control and licensing compliance, though fire safety deficiencies have recurred over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
12% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
43 residents
Based on a June 2020 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Routine
Census: 43
Deficiencies: 0
Date: Jun 12, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) from June 11, 2020 through June 12, 2020 to assess compliance with COVID-19 related regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 26, 2020
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The survey noted that all previously cited survey tags have been corrected.
Inspection Report
Original Licensing
Deficiencies: 0
Date: Jan 9, 2020
Visit Reason
The inspection was conducted as a Licensure survey to assess compliance for facility licensing.
Findings
No deficiencies were identified during the Licensure survey.
Inspection Report
Life Safety
Census: 79
Capacity: 89
Deficiencies: 4
Date: Jan 7, 2020
Visit Reason
The inspection was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance with fire safety requirements, including failure to properly maintain the fire sprinkler system, electrical system, fire rated doors, and oxygen cylinder storage. Specific issues included loaded sprinkler heads, use of extension cords as permanent wiring, unrepaired fire doors, and oxygen cylinders exposed to direct sunlight.
Deficiencies (4)
Loaded fire sprinkler heads found in Employee Brake Room, Refreshment Room Subacute Area, and Clean Utility.
Extension cords used as permanent wiring in Sleeping Rooms 111A, 109B, Rooms G013, G039, and under Kitchen hood behind cooking equipment.
Failure to repair damaged fire doors (0570, 0571, 0574, 0575, 0579) identified in a previous report dated 9/14/19.
Oxygen cylinders and manifold cylinders in outdoor storage area not protected from temperatures above 130 degrees and exposed to direct sunlight.
Report Facts
Census: 79
Total Capacity: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and interviews |
Inspection Report
Routine
Census: 82
Deficiencies: 0
Date: Jan 9, 2019
Visit Reason
A standard survey was conducted at Northside Gwinnett Extended Care Center from January 6, 2019 through January 9, 2019 to assess compliance with Medicare/Medicaid regulations.
Findings
The standard survey revealed that the facility was in compliance with the Healthcare portion of the Medicare/Medicaid regulations at 42 Code of Federal Regulations Part 483, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 0
Date: Jan 8, 2019
Visit Reason
An unannounced visit was made to investigate Complaint Intake Number GA00191587, including observations, staff and resident interviews, record reviews, and review of relevant facility documents.
Complaint Details
Complaint Intake Number GA00191587 was investigated and found to be unsubstantiated.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B. The complaint investigation was determined to be unsubstantiated.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 25, 2018
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Northside Gwinnett Extended Care Center following a survey completed on 09/25/2018.
Findings
The document contains no detailed deficiencies or findings; it only includes an initial comments section without specific content.
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 4
Date: Aug 2, 2018
Visit Reason
A standard survey was conducted from July 30, 2018 through August 2, 2018, including investigation of Complaint Intake Number GA00189147, to assess compliance with Medicare/Medicaid regulations.
Complaint Details
Complaint Intake Number GA00189147 was investigated in conjunction with the standard survey. The complaint involved failure to investigate and report an injury of unknown origin for Resident #220.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, including failure to investigate and report an injury of unknown origin for one resident, failure to complete required Minimum Data Set (MDS) assessments including admission, annual, and quarterly assessments, and failure to timely transmit MDS data to CMS systems.
Deficiencies (4)
Failure to investigate and report an injury of unknown origin for one resident (R#220).
Failure to complete admission and annual Minimum Data Set (MDS) assessments for multiple residents.
Failure to complete and sign quarterly Minimum Data Set (MDS) assessments every 90 days for three residents.
Failure to submit Minimum Data Set (MDS) assessments to CMS systems within seven days after completion for five residents.
Report Facts
Resident census: 79
Sample size: 42
Residents with incomplete admission or annual MDS: 5
Residents with incomplete quarterly MDS: 3
Residents with MDS not transmitted timely: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CC | Licensed Practical Nurse (LPN) | Interviewed regarding Resident #220's injury and fracture |
| AA | MDS Nurse | Interviewed regarding MDS completion and transmission issues |
| Director of Nursing (DON) | Interviewed regarding failure to investigate Resident #220's injury | |
| Administrator | Interviewed regarding injury investigations and MDS issues |
Inspection Report
Life Safety
Census: 80
Capacity: 89
Deficiencies: 0
Date: Aug 1, 2018
Visit Reason
A Life Safety Code survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found to be in substantial compliance with the Emergency Preparedness Plan requirements and Life Safety Code standards.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 13, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The survey noted that all previously cited deficiencies had been corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 5, 2017
Visit Reason
A follow-up to the Recertification survey of August 10, 2017 was conducted to verify correction of previously identified deficiencies.
Findings
The follow-up survey revealed that all deficiencies were corrected and the facility was in substantial compliance as of September 24, 2017.
Inspection Report
Life Safety
Census: 79
Capacity: 89
Deficiencies: 9
Date: Aug 8, 2017
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with life safety requirements, including failures in maintaining self-closing doors, emergency lighting, fire alarm system installation and testing, sprinkler system installation, smoke barrier integrity, evacuation plan completeness, electrical system emergency lighting, and oxygen storage safety.
Deficiencies (9)
Doors with self-closing devices were not maintained properly; doors to pantries and Activity Room lacked required smoke detectors within five feet.
Emergency lighting was not properly maintained in electrical rooms; no 90-minute annual test conducted in past 12 months.
Fire alarm system was not properly maintained; missing Record of Completion and incomplete inspection documentation; visual notification devices improperly mounted; smoke detectors in HVAC air flow stream.
Fire alarm system testing and maintenance deficient; no sensitivity test of smoke detectors in over 2 years.
Fire sprinkler system improperly installed; sprinkler head closer than 4 inches to wall; hydraulic nameplate not permanently marked or made of required materials.
Smoke barriers had unprotected and improperly protected penetrations with unknown sealing materials.
Facility fire evacuation and relocation plan incomplete; missing element requiring call to 911 for all alarms.
Electrical systems emergency lighting deficient; no emergency lighting in pharmacy and medication rooms.
Oxygen storage area improperly maintained; full and empty cylinders stored together without separation.
Report Facts
Census: 79
Total Capacity: 89
Deficiencies cited: 9
Emergency light test duration: 90
Fire alarm inspection date: Oct 14, 2016
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