Life Care Ctr Of Lawrenceville

Based on observations, staff interviews, and review of the facility's policy titled, Food Safety and Sanitation, the facility failed to ensure food safety protocols and maintain sanitary conditions for the ice machine, the disposal of expired and opened food in the walk-in refrigerator freezer, and failed to properly label or date food in the dry storage and walk in freezer. The deficient practices had the potential to place 84 residents who received an oral diet from the kitchen at risk of contracting a foodborne illness. Findings Include:Review of the facility's policy titled Food Safety and Sanitation reviewed dated 05/01/2025, documented in Procedure . 2. Pre-packaged food is placed in a leak-proof, pest proof, non-absorbent, sanitary (NSF-National Sanitation Foundation certification) container with a tight-fitting lid. The container is labeled with the name of the contents and date (when the item is transferred to new container). Use by Date is noted on the label or product when applicable. Documented in Food Service/Meal Service .12c. Ice machines must be of a type that…

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's policy titled, Certification of Accuracy of the (Minimum Data Set) MDS, the facility failed to ensure the MDS accurately reflected the status of one of one sampled resident (R) (R28) reviewed for hospice.Findings include:Review of the facility's policy titled Certification of Accuracy of the MDS reviewed 08/29/2025 documented under Definitions: Accuracy of Assessment - means that the appropriate, health professionals correctly document the resident's medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the appropriate Resident Assessment Instrument (RAI) (e.g. comprehensive, quarterly, significant change in status).Review of the Electronic Medical Record (EMR) revealed R28 was admitted to the facility on [DATE] with a diagnosis including but not limited to protein calorie malnutrition.Review of the Admissions MDS dated [DATE]…

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, staff interviews and review of the facility policy titled, Oxygen Administration (Infection Control, Safety, and Storage), the facility failed to provide respiratory care consistent with professional standards of practice by ensuring humidification was provided and the oxygen concentrator and filter were clean for one of 20 residents (R) (R81) receiving oxygen (O2) or respiratory therapy. The deficient practice increased the risk of infection for R81. Findings include:Review of the facility policy titled Oxygen Administration (Infection Control, Safety, and Storage) revised date 03/03/2026, revealed in section Infection Control 1. Change oxygen supplies (e.g. cannula, tubing, humidifier) weekly and when visibly soiled. Equipment should be labeled with resident name and dated when setup or changed out.4b. External filters should be checked daily and all dust should be removed. Review of the electronic medical record (EMR) for R81 revealed she was admitted to the facility with…

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, resident and staff interviews, and review of the facility policies titled, Cardiopulmonary Resuscitation (CPR) Policy and Advance Directives and Advance Care Planning, the facility failed to communicate and ensure preference for the change in code status from full code to do not resuscitate (DNR) was updated in the medical record for one of three sampled residents (R) (R1). The deficient practice had the potential to deny the residents and/or representatives the opportunity to direct health care in the event that they were to become unable to make decisions or communicate health care preferences. Findings include: Review of the facility policy titled Cardiopulmonary Resuscitation (CPR) Policy last revision date of [DATE] documented under Definitions: Do Not Resuscitate (DNR) Order – refers to a medical order issued by a physician or other authorized non-physician practitioner that directs healthcare providers not to administer CPR in the event of cardiac or respiratory arrest. Existence…

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 interviews, record review and review the facility document titled, [Name of Company] TELS (The Equipment Lifecycle System): Instructions, the facility failed to keep the residents free of accident hazards as evidenced by water temperatures above 110 degrees Fahrenheit (F) in four out of 68 resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]). The deficient practices had the potential to cause injury to residents residing in these rooms. Findings include: Review of the facility document titled, [Name of Company] TELS: Instructions, under the section titled Steps revealed, 1. For burn prevention, federal guidelines advise that you keep domestic water temperatures below 120 degrees Fahrenheit, although this temperature can still cause burns if exposure reaches five minutes. Many states have even stricter standards that set maximum temperatures lower than 120 degrees Fahrenheit, although 100 degrees Fahrenheit is considered a safe water…

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 observations, interviews, review of the facility's policies titled Oxygen Administration (Safety, Storage, Maintenance), Cleaning and Disinfection of Non-Critical Patient Care Equipment, and Hand Hygiene, the facility failed to maintain sanitary conditions for storing respiratory supplies for one of 19 residents that received respiratory treatments. In addition, the facility failed to sanitize shared medical equipment between residents' use during two of four medication pass observations and follow proper hand hygiene practices when providing residents' care during one of four medication pass observation. The deficient practices increased the risk to spread infection, equipment contamination, and other health complications. The sample size was 24 residents. Findings include: Review of the facility's policy titled Oxygen Administration (Safety, Storage, Maintenance) revised on 10/11/2024 revealed the Policy section included 4: Store oxygen and respiratory supplies in bag labeled with resident's name when not in use. Review of the facility's policy titled Hand Hygiene revised…

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's policy titled, Pre-admission Screening and Resident Review (PASARR), the facility failed to ensure that one of one resident (R) (R13) reviewed for PASARR was evaluated by the state designated authority for a PASARR Level II. This deficient practice had the potential to affect the appropriate level of care and services provided for R13. Findings include: Review of the facility's policy titled Pre-admission Screening and Resident Review (PASARR), with dated 9/26/2024 under Policy revealed, The facility will ensure that potential admissions are to be screened for possible serious mental disorders or intellectual disabilities and related conditions. This initial pre-screening is referred to as PASARR Level I and is completed prior to admission to a nursing facility. A negative Level I screen permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. A positive Level…

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 observations, staff and resident interviews, record review, and review of the facility's policy titled, Comprehensive Care Plans and Revisions, the facility failed to develop a person-centered, comprehensive care plan related to providing oxygen therapy as ordered for one of 19 Residents (R) (R41) reviewed for oxygen administration. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs and a diminished quality of life. Findings include: Review of the facility policy titled Comprehensive Care Plans and Revisions, dated 9/11/2024 under the section Policy revealed, 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 of individuals who have knowledge of the resident and his/her needs . Review of the clinical electronic record for R41 revealed, diagnoses that included but not limited to acute and chronic respiratory failure, unspecified whether with hypoxia or…

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, Oxygen Administration (Safety, Storage, Maintenance),the facility failed to ensure that one out of 19 residents (R) R41 receiving oxygen therapy was administered the therapy in accordance with the physician orders. This deficient practice had the potential to put R41 at risk for medical complications, respiratory depression, and potentially life-threatening complications. Findings include: Review of the facility's policy titled Oxygen Administration (Safety, Storage, Maintenance), dated 10/11/2024, under the section Procedure - Oxygen Administration, outlines the following procedures: 1. Oxygen order should be written for specific liter flow required by the resident. Review of the clinical electronic record for R41 revealed, she was admitted with diagnoses that included but not limited to acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, hypertensive heart and…

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, interviews, and record review, the facility failed to ensure an accurate comprehensive assessment for dental status for one of 62 sampled residents (R) (R#26). Findings included: Review of the electronic medical record (EMR) revealed that R#26 was admitted to the facility on [DATE] with diagnose including but not limited to hypertensive heart disease with heart failure, paroxysmal atrial fibrillation, dementia, bipolar disorder, diabetes, Bell's Palsy, hyperlipidemia, hypothyroidism, oral phase dysphagia, need for assistance with personal care, and anxiety disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] and a review of the Quarterly MDS assessment of 5/8/2023 revealed a Brief Interview for Mental Status (BIMS) score of five, indicating severe cognitive impairment. Section L revealed no dental concerns (obvious or likely cavity or broken natural teeth was not checked). Continued review of the EMR revealed that there were no dental assessments from a dental…

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, and review of the policy titled Wound Care Management Program, the facility failed to ensure care was provided in accordance with professional standards of practice related to maintaining skin integrity under geri-sleeves and clean geri-sleeves and boot heel protector for one resident (R) (R#23). The sample size was 63 Residents. Findings include: Review of the facility policy Wound Care Management Program reviewed 3/3/2023 revealed the skin care program is interdisciplinary and implemented using a team approach. Members of the team include the following: Nursing (nursing and Certified Nursing Assistants (CNA), Rehab, the resident, the resident's physician, and or the Medical Director, Registered Dietician, Others as deemed appropriate. Communication is vital and should occur daily at the stand-up meeting, and in Grand Grounds, then weekly at the Resident at Risk (RAR) meeting, and monthly at the Quality Assurance and Performance Improvement (QAPI)…

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, interviews, and review of the facility policy titled Oxygen Administration/Safety/Storage/Maintenance, the facility failed to follow Physician Orders for one resident (R) (R#35) to change Oxygen tubing, nebulizer circuit, and to clean concentrator filter weekly for one of eight residents (R) (R#35) receiving respiratory care. Findings include: Review of the policy titled Oxygen Administration/Safety/Storage/Maintenance revised 8/2/2021, revealed the policy was that oxygen will be administered in accordance with physician orders and current standards of practice. Infection Control number 1. Change oxygen supplies weekly and when visibly soiled. Equipment should be dated when setup or changed out. 3. Store oxygen and respiratory supplies in bag labeled with residents' name when not in use. 4. Clean exterior of concentrator weekly with an Environmental Protection Agency (EPA) registered hospital disinfectant. b. External filter should be checked daily, and all dust should be…

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.