Life Care Center of Gwinnett

Based on observations, staff interviews, and review of the facility policy titled, Food Safety, the facility failed to label, date, and discard expired food items in the refrigerator, freezer, and dry food storage. This deficient practice created the potential for 86 of 87 residents who received meals from the kitchen to contract food borne illnesses. Findings Include:A review of facility's policy titled, Food Safety, revised May 26, 2026, revealed under Policy: Food is stored and maintained in a clean, safe, and sanitary manner following federal, state, and local guidelines to minimize contamination and bacterial growth. The policy further states under Dry Storage: 2. Opened packages of food are sealed tightly to prevent contamination of the food item and use by date will be used when applicable. Under Procedure: 2. Pre-packaged food is placed in a leak-proof, non-absorbent, sanitary (NSF) container, with a tight-fitting lid. The container is labeled with the name of the contents and date (when the item is transferred to the new container). Use by Date is noted on the label of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, record review, and review of the facility's policy titled, Indwelling Urinary Catheter (Foley) Management, the facility failed to provide the resident with appropriate catheter tubing management and securement for one of two residents (R) (R2) reviewed for catheter care. This deficient practice had the potential to cause urine backflow, bacterial infection, and excessive tension on the catheter, which could lead to urethral tears or catheter dislodgment. Findings include:Review of the facility's policy titled, Indwelling Urinary Catheter (Foley) Management, revised September 4, 2025, revealed under General Urinary Catheter Maintenance Guidelines: . 2. b. Keep the collecting bag below the level of the bladder at all times. Do not rest the drainage bag on the floor. Under Additional Care Practices Related To Catheterization: . 5. Keeping [sic] the catheter anchored to prevent excessive tension on the catheter, which can lead to urethral tears or dislodging the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, record review, and review of the facility's policy titled, Infusion Therapy-Intravenous (IV Fluids), the facility failed to properly date and initial one midline dressing for one of two residents (R) (R46) reviewed for IV therapy. This deficient practice had the potential to cause confusion about when to change the dressing next and to lead to infection. Findings include: Review of the facility's policy titled, Infusion Therapy-Intravenous (IV Fluids), revised May 5, 2026, revealed under Procedure: .2. The facility will utilize the [NAME] (manual of Nursing Practice is a comprehensive, evidence-based guide for nursing students and practicing nurses, offering practical guidance across all major areas of patient care) procedures: . IV therapy.Review of the electronic medical record (EMR) revealed resident R46 was admitted to the facility with pertinent diagnoses, including, but not limited to, moderate protein-calorie malnutrition, dependence on supplemental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and review of the facility's policy titled, Bed Rails - Safe and Effective Use of Bed Rails, the facility failed to develop a baseline care plan specific to the use of side rails for three of nine Residents (R) (R290, R14, and R287) reviewed for physical restraints. In addition, the facility failed to develop a baseline care that identified the use of an indwelling urinary catheter for one of one resident (R236) reviewed for indwelling urinary catheter. The failure created the potential for the residents to have unmet care needs, safety needs, and to not meet their highest levels of functional abilities. Findings include: Review of the facility's policy titled, Bed Rails - Safe and Effective Use of Bed Rails revised 9/6/2024 indicated, Procedure: A person-centered care plan will be developed within 48 hours of admission to address the bed rail(s), if indicated. The interdisciplinary team will review and revise the care plan, if indicated, upon completion of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and review of the facility's policy titled, Bed Rails - Safe and Effective Use of Bed Rails, the facility failed to develop a comprehensive care plan specific to the use of side rails for six of nine Residents (R) (R58, R290, R14, R25, R48, and R52) reviewed for physical restraints. The failure created the potential for the residents to have unmet care needs, safety needs, and to not meet their highest levels of functional abilities. Findings include: Review of the facility's policy titled, Bed Rails - Safe and Effective Use of Bed Rails revised 9/6/2024 indicated, Procedure: A person-centered care plan will be developed within 48 hours of admission to address the bed rail(s), if indicated. The interdisciplinary team will review and revise the care plan, if indicated, upon completion of the comprehensive, significant change and quarterly MDS for the need to continue the use of bed rail(s). 1. Review of the admission Record located under the Profile tab in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility's policy titled, Bed Rails - Safe and Effective Use of Bed Rails, the facility failed to complete initial and quarterly assessments for the use and safety of side rails for six of nine Residents (R) (R290, R14, R25, R48, R49, R287) reviewed for physical restraints. This failure had the potential for the residents to be injured or restrict movement of residents. Findings include: Review of the facility's policy titled, Bed Rails - Safe and Effective Use of Bed Rails revised 9/6/2024 indicated, Assess the resident for risk of entrapment from bed rails prior to installation. Procedure: Residents will be assessed upon admission, readmission, or upon initiation utilizing the Evaluation for use of bed rails assessment. If bed rails are determined to be appropriate for use with a resident, a reassessment of rail(s) use will be assessed at a minimum of quarterly and potentially with a change of condition utilizing the Evaluation for use of bed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interview, the facility failed to maintain a safe, clean homelike environment for two of 14 rooms on the B Hall. Specifically, the facility failed to maintain clean air filters in the Packaged Terminal Air Conditioners (PTACs) in rooms [ROOM NUMBERS]. In addition, room [ROOM NUMBER] contained a stained and broken blade on the window blind. The facility sample was 34 residents. Findings include: Observation of the B Hall on 9/11/2023 beginning at 5:00 pm revealed PTAC filters in rooms [ROOM NUMBERS] that were covered in dust. In addition, the window blind in room [ROOM NUMBER] was stained and had a broken blade. Observation on the B Hall with the Housekeeping Supervisor (HS) on 9/13/2023 beginning at 3:25 pm, revealed the PTAC filters in rooms [ROOM NUMBERS] remained covered in dust. Interview conducted during this time with the HS confirmed the PTAC filters were dusty and stated they should be cleaned at least monthly. He stated that was the responsibility of the Maintenance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and review of the facility policy titled, Pre-admission Screening and Resident Review (PASARR), the facility failed to submit an application for a Level II PASARR for evaluation and determination of specialized services for one of three sampled residents (R) (R#30). The deficient practice increased the potential for R30 not to receive treatment and/or care according to the resident's needs. Findings include: Review of the facility policy titled, Pre-admission Screening and Resident Review (PASARR) revised 10/6/2022 revealed: 4) A positive level I screen necessitates an in-depth evaluation of the individual by the state designated authority, known as PASARR Level II, which must be conducted prior to admission to a nursing facility. 13) Any resident with a newly evident or possible serious mental disorder, Intellectual Disorder (ID) or a related condition must be referred, by the facility to the appropriate state designated mental health or intellectual disability…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews, the facility failed to develop a care plan for a diagnosis of Post Traumatic Stress Disorder-chronic (PTSD), for one Resident (R) R62 of 25 sampled residents. The deficient practice increased the potential for R62 not to receive treatment and/or care according to the resident's needs. Findings include: Review of the facility policy titled Comprehensive Care Plans and Revisions review date 8/22/2023 revealed the policy statement The facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed or individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about his or her care. Procedure states: 1. The facility should monitor the resident over time to help identify changes in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and review of the facility policies titled, Administration of Medications, and Receipt of Interim/Stat/Emergency Deliveries the facility failed to maintain professional nursing standards of quality. Specifically, one (1) Licensed Practical Nurses (LPN) and 1 Registered Nurse (RN) administered R#401 narcotic medication, using another resident's medication. The sample size was 34. Findings include: Review of facility policy titled, Administration of Medications, revised [DATE], under subtitle Procedure revealed: B. Staff who are responsible for mediation administration will adhere to the 10 Rights of Medication Administration. 2. Right Resident. Use two identifiers. Ask the resident his or her full name and compare it to the name on the medication or treatment administration record (MAR/TAR) and compare the resident's photo to the resident. Review of facility's policy titled Receipt of Interim/Stat/Emergency Deliveries revised [DATE], under subtitle Procedure revealed: 4.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, staff interviews and review of facility policy titled, 3.8 Psychotropic Medication Use the facility failed to limit as needed (PRN) psychotropic medications to no more than 14 days with documentation in the medical record for use after the 14-day time frame for one of five Residents (R) (R49) reviewed for unnecessary drugs. This failure had the potential to create unnecessary adverse side effects or adverse neurological effects. Findings include: Review of the facility policy titled, 3.8 Psychotropic Medication Use last revised October 24, 2022, under subsection, Procedures revealed: 8. PRN psychotropic medications should be ordered for no more than 14 days. Each resident who is taking a PRN psychotropic drug will have his or her prescription reviewed by the physician or prescribing practitioner every 14 days and by a pharmacist every month. 9. For psychotropic medications, excluding antipsychotics, that the attending physician believes a PRN order for longer than 14 days is appropriate, the physician can extend the prescription beyond 14 days for the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.