LAWRENCEVILLE, GA - Federal inspectors documented multiple infection control violations at Life Care Center of Lawrenceville during a January 2025 survey, including improperly stored respiratory equipment for a vulnerable patient and failure to follow basic hand hygiene protocols during medical procedures.
The January 30, 2025 inspection revealed systematic failures to maintain sanitary conditions that placed residents at increased risk for infections and cross-contamination, according to the Centers for Medicare & Medicaid Services report.
Respiratory Equipment Found on Floor
Inspectors discovered critical lapses in the storage of respiratory therapy supplies for a resident with multiple serious lung conditions. The patient, identified as R47 in the report, had been admitted with chronic pulmonary edema, acute and chronic respiratory failure with low oxygen levels, post-COVID-19 complications, heart failure, and stroke.
R47 received nebulizer treatments four times daily with Ipratropium-Albuterol solution to manage chronic obstructive pulmonary disease and shortness of breath. These treatments require specialized equipment including nebulizer masks and tubing that must be kept sanitary between uses.
On January 28, 2025, at approximately 12:04 pm, inspectors observed the resident's nebulizer mask and tubing lying on the nightstand in a tangled condition, with portions touching the floor. The equipment was unbagged and not in use at the time.
The following day, inspectors returned to the same room at 9:00 am and found the respiratory supplies in identical condition - tangled on the nightstand, unbagged, and exposed to environmental contamination.
When questioned by inspectors at noon on January 29, Registered Nurse AA opened the nightstand drawer and revealed a labeled storage bag specifically designated for the respiratory supplies. The nurse placed the nebulizer mask in the bag and acknowledged the equipment should have been stored there when not in use.
Medical Significance of Proper Equipment Storage
Respiratory therapy equipment comes into direct contact with a patient's airways and breathing passages. When left exposed to environmental contaminants, these devices can harbor bacteria, viruses, and other pathogens that directly enter the respiratory system during treatment.
For patients with compromised lung function, the risks are particularly severe. Contaminated nebulizer equipment can introduce infectious agents into already damaged airways, potentially causing pneumonia, bronchitis, or exacerbation of underlying respiratory conditions.
Floor surfaces in healthcare facilities contain particularly high concentrations of microorganisms. Equipment that touches the floor and then contacts a patient's airway creates a direct pathway for pathogens to enter the body.
The facility's own policy, titled "Oxygen Administration (Safety, Storage, Maintenance)" and revised October 11, 2024, explicitly requires staff to "store oxygen and respiratory supplies in bag labeled with resident's name when not in use."
Hand Hygiene Violations During Medical Procedures
Inspectors documented a separate infection control failure during medication administration rounds on January 29, 2025. At 11:35 am, they observed Registered Nurse AA performing a blood sugar check on a resident.
The nurse approached the medication cart and gathered necessary supplies without washing or sanitizing her hands. She then entered the resident's room and proceeded with the glucose check, again without performing hand hygiene. Additionally, the nurse failed to clean and disinfect the glucose meter before using it on the resident.
When questioned, the nurse stated that someone had removed the hand sanitizer from her medication cart and she had forgotten to perform hand hygiene. She acknowledged she should have sanitized her hands before preparing supplies, upon entering the room, and should have cleaned the glucose meter before use.
Glucose meters represent shared medical equipment used on multiple residents throughout a shift. Each device contacts residents' blood and, without proper cleaning between uses, can transmit bloodborne pathogens including hepatitis B, hepatitis C, and other infectious agents.
Facility Standards and Expectations
The facility's Hand Hygiene policy, revised June 3, 2024, clearly outlines requirements for staff members. The policy mandates hand hygiene "even if gloves are used" in specific situations including before and after contact with residents, after contact with objects and surfaces in the resident's environment, and after removing personal protective equipment.
RN FF, the Staff Development Coordinator and Interim Infection Control Preventionist, confirmed during a January 29 interview at 3:00 pm that she expected staff to perform hand hygiene before and after any contact with each resident. She specified that staff should either use alcohol-based hand sanitizer or, after three consecutive sanitizer uses, wash hands with soap and water.
Regarding respiratory equipment, RN FF stated she expected oxygen supplies and respiratory masks to be kept in labeled bags when not in use.
Corporate Oversight Confirms Expectations
On January 30, 2025, at 9:20 am, inspectors interviewed two corporate nurses, Registered Nurse EE and Registered Nurse DD. Both confirmed they expected staff to keep oxygen supplies and respiratory masks in labeled bags when not in use.
The corporate nurses also stated expectations that staff perform hand hygiene using either soap and water or alcohol-based hand sanitizer before and after contact with each resident, and clean glucose meters before and after each use.
Pattern of Multiple Infection Control Failures
The inspection documented that 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."
This indicates the violations were not isolated incidents but represented systematic problems in infection control practice across the facility. The inspection report noted these deficient practices "increased the risk to spread infection, equipment contamination, and other health complications."
The facility received a citation for F880, which addresses requirements to "provide and implement an infection prevention and control program." Inspectors classified the violation as causing "minimal harm or potential for actual harm" affecting "some" residents. The sample size for the inspection included 24 residents.
Industry Standards for Infection Prevention
Healthcare-associated infections represent a significant risk in long-term care facilities. The Centers for Disease Control and Prevention estimates that between 1 and 3 million serious infections occur in nursing homes annually.
Hand hygiene remains the single most important measure for preventing transmission of healthcare-associated pathogens. Studies have demonstrated that proper hand hygiene can reduce infection rates by 30 to 50 percent in healthcare settings.
Proper cleaning and disinfection of shared medical devices between patients is considered a fundamental infection control practice. The failure to clean glucose meters between uses has been directly linked to hepatitis B outbreaks in multiple healthcare facilities.
Conclusion
The violations documented at Life Care Center of Lawrenceville represent failures to follow basic infection control protocols that protect vulnerable residents from preventable infections. The facility's own policies outlined appropriate procedures, yet staff failed to implement them during routine care activities.
Federal regulations require nursing homes to maintain infection prevention and control programs that provide a sanitary environment to prevent the development and transmission of communicable diseases and infections. The January 2025 inspection found the facility fell short of these requirements.
For complete details of the inspection findings and the facility's plan of correction, the full CMS-2567 report is available through the Centers for Medicare & Medicaid Services.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Life Care Ctr of Lawrenceville from 2025-01-30 including all violations, facility responses, and corrective action plans.
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