Life Care Ctr Of Lawrenceville

F-F656

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 8 115659 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115659 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Life Care Ctr of Lawrenceville 210 Collins Industrial Way Lawrenceville, GA 30045

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 50940 potential for actual harm Based on observations, interviews, review of the facility's policies titled Oxygen Administration (Safety, Residents Affected - Some 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 6/3/2024, revealed the Policy section included 2. Associates perform hand hygiene (even if gloves are used) in the following situations: a) Before and after contact with the resident; c) After contact with objects and surfaces in the resident's environment) After removing personal protective equipment.

1. Review of Resident R47's Electronic Medical Records (EMR) revealed, Resident R47 was admitted to the facility with diagnoses including, but not limited to chronic pulmonary edema, acute and chronic respiratory failure with hypoxia, post Covid 19, heart failure, and stroke.

Review of the Physician Orders for Resident R47 revealed an order dated 1/2/2025 for Ipratropium-Albuterol Solution (nebulizer to treat chronic obstructive pulmonary disease) 0.5-2.5 (3) MG (milligram) /3ML (milliliters) 3 ml inhale orally via nebulizer four times a day for shortness of breath (SOB).

During an observation on 1/28/2025 at 12:04 pm in the resident's room, Resident R47's respiratory supplies (nebulizer mask and tubing) were laying on the nightstand tangled and touching the floor. The respiratory supplies were unbagged and not in use.

During an observation on 1/29/2025 at 9:00 am, Resident R47's nebulizer mask and tubing were laying on the nightstand tangled, unbagged, and not in use.

Observation and Interview on 1/29/2025 at 12:00 pm in Resident R47's room with RN AA revealed, the nebulizer masks and tubing were unbagged while not in use. She opened the nightstand drawer, revealing a labeled bag designated for the respiratory supplies. RN AA placed the nebulizer mask in the bag and confirmed that

it should have been stored in the bag when not in use.

In an interview on 1/29/2025 at 3:20 pm with the Staff Development Coordinator, Intern Infection Control Preventionist (ICP), RN FF, she stated that she expected oxygen supplies and respiratory masks to be kept

in a labeled bag when not in use.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 8 115659 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115659 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Life Care Ctr of Lawrenceville 210 Collins Industrial Way Lawrenceville, GA 30045

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Interview on 1/30/2025 at 9:20 am with the facility's corporate nurses, Registered Nurse (RN) EE and RN DD revealed, that they expected staff to keep oxygen supplies and respiratory masks in labeled bags when not Level of Harm - Minimal harm or in use. potential for actual harm 2. Observation and Interview during medication pass on 1/29/2025 at 11:35 am revealed, RN AA was Residents Affected - Some observed performing a blood sugar check on a resident. RN AA approached the medication cart and gathered the necessary supplies; however, she did not wash or sanitize her hands before collecting the supplies or upon entering the room nor did she clean and disinfect the glucose glucometer before use. RN AA revealed, someone had removed the sanitizer from her cart, and she had forgotten to do so when questioned about not sanitizing or washing her hands before preparing for the glucose check or upon entering the room. RN AA confirmed she should have sanitized her hands in both instances and cleaned the glucometer before use.

During an interview on 1/29/2025 at 3:00 pm with RN FF Staff Development Coordinator/Interim Infection Control Preventionist (SDC/ICP) revealed that she expects her staff to perform hand hygiene before and

after any contact with each resident. RN FF SDC/ICP revealed, staff members should either sanitize with an alcohol-based hand sanitizer or, after three consecutive uses, wash their hands with soap and water.

During the interview on 1/30/2025 at 9:20 am with RN EE and RN DD stated, that they expected staff to perform hand hygiene using either soap and water or an alcohol-based hand sanitizer before and after contact with each resident and to clean the glucometer before and after use.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 8 115659

F-F695

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 8 115659 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115659 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Life Care Ctr of Lawrenceville 210 Collins Industrial Way Lawrenceville, GA 30045

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47947

Residents Affected - Some 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 temperature for bathing.

Observations on 1/28/2025 from 1:15 pm to 1:20 pm of water temperature checks on 226 - 232 corridor with

the Assistant of Maintenance Director (AMD) using the facility's digital thermometer revealed, water temperature measurements in room [ROOM NUMBER] at 127.8 degrees F, room [ROOM NUMBER] at 127. 2 degrees F, room [ROOM NUMBER] at 127 degrees F and room [ROOM NUMBER] at 126.7 degrees F. No other residents' rooms were affected.

Interview on 1/28/2025 at 1:25 pm with the AMD revealed, that maintenance department conducted weekly water temperatures in 10 rooms, in rotation.

Interview on 1/28/2025 at 1:30 pm with the Administrator and Maintenance Director (MD) to inform them about the hot water test result. The Administrator stated that the MD would adjust the temperature promptly.

Follow-up Observation on 1/28/2025 at 5:40 pm of water temperature checks revealed, room [ROOM NUMBER] at 106.3 degrees F, room [ROOM NUMBER] at 105.9 degrees F, room [ROOM NUMBER] at 105. 9 degrees F, and room [ROOM NUMBER] at 105.6 degrees F.

Review of facility water temperature log revealed that water temperature checks were completed on 1/2/2025, 1/8/2025, 1/16/2025, and 1/23/2025 with temperatures ranges between 106 degrees F and 106.9 degrees F.

Review of the facility's records revealed, no residents sustained burns injuries related to hot water temperatures.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 8 115659 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115659 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Life Care Ctr of Lawrenceville 210 Collins Industrial Way Lawrenceville, GA 30045

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Interview on 1/28/2025 at 5:50 pm with the Maintenance Director (MD) confirmed, that when he went to adjust the water temperature, the water heater thermostat was showing 130 degrees Fahrenheit. The MD Level of Harm - Minimal harm or revealed that he had conducted weekly check of the thermostat to ensure the water temperature remained potential for actual harm under 110 degrees however he was unsure why the temperature had gone up.

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 8 115659 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115659 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Life Care Ctr of Lawrenceville 210 Collins Industrial Way Lawrenceville, GA 30045

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50944 potential for actual harm Based on observations, staff and resident interviews, record review, and review of the facility's policy titled, Residents Affected - Few Oxygen Administration (Safety, Storage, Maintenance),the facility failed to ensure that one out of 19 residents (R) Resident R41 receiving oxygen therapy was administered the therapy in accordance with the physician orders. This deficient practice had the potential to put Resident 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 Resident 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 chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease.

Review of the most recent Minimum Data Set (MDS) dated [DATE REDACTED] for Resident R41, revealed a Brief Interview for Mental Status (BIMS) was coded as 8, indicating the resident had moderate impaired cognition.

Review of Physician orders revealed, oxygen therapy-nasal cannula (N/C) at rate of 1(one) liter, date initiated 1/7/2025.

Observation on 1/28/2025 at 12:57 pm revealed, Resident R41's wall mounted oxygen flow meter rate set on 1.5 (one and a half) liters via (by way) N/C.

Observation on 1/29/2025 at 11:00 am revealed, Resident R41's wall mounted oxygen flow meter rate set on 2 (two) liters via N/C.

Observation on 1/30/205 at 1:37 pm revealed, Resident R41's wall mounted oxygen flow meter rate set on 2 (two) liters via N/C.

Observation and interview on 1/30/2025 at 3:40 pm with Licensed Practical Nurse (LPN) TT confirmed that resident's oxygen tank setting was on two liters. LPN TT checked resident's physician orders and confirmed that oxygen flow meter rate should be set on one liter.

Cross Reference