Life Care Center of Gwinnett

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policies titled, BiPAP/CPAP Administration and Associate Conduct and Dress Code, the facility failed to ensure infection control was maintained, to ensure CPAP was appropriately stored when not in use, to label and properly store distilled water for one of 14 residents (R) (R44) reviewed for respiratory therapy, and failed to ensure dietary staff wore a beard covering. The deficient practice had the potential of food contamination by beard hair in the kitchen and to place R44 at increased risk of cross contamination, respiratory complications and adverse clinical outcomes.

Inspectors wroteBased on observations, resident and staff interviews, and review of the facility policy titled, Resident Rights, the facility failed to post notice of the availability of the State survey results so that facility residents (R), including four of 38 sampled R's (C1, C2, C3, C4) and/or visitors were aware of its location.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.