Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Life Care Ctr Of Lawrenceville during CMS and state inspections, most recent first.
Food safety and sanitation were not maintained in the kitchen, dry storage, walk-in freezer, and ice machine. Surveyors found expired food in dry storage, multiple unlabeled or undated food items in the freezer, and a brown-black slime-like substance in the ice machine. Staff interviews showed inconsistent responsibility for cleaning and labeling, and the DM confirmed the lack of cleanliness and that some food items were not properly dated.
A resident with protein calorie malnutrition and a terminal prognosis was admitted on hospice with corresponding physician orders and a care plan, but hospice services were not coded on either the admission or quarterly MDS assessments. The MDS Coordinator and two MDS LPNs confirmed that, despite the resident receiving hospice care, Section O of both MDS assessments incorrectly indicated the resident was not on hospice, which the Administrator and DON acknowledged resulted in inaccurate MDS data.
A resident with COPD, chronic respiratory failure with hypoxia, and other cardiopulmonary conditions did not receive proper respiratory care when the O2 concentrator humidification bottle was empty, the tubing was not dated, and the concentrator filter had heavy dust buildup. The resident said it was hard to breathe, and staff later confirmed the equipment had not been checked that day and was not maintained as required.
A resident with severe cognitive impairment and multiple medical conditions had expressed a preference for DNR status, but the facility failed to update the medical record and care plan to reflect this change. Despite discussions and signed documents by the resident and family, staff did not ensure the POLST form was properly completed and signed by a physician, resulting in the resident remaining listed as full code. Facility staff interviews revealed confusion and lack of clarity in the process for documenting and communicating changes in advance directives.
The facility failed to maintain safe water temperatures in four resident rooms, with temperatures recorded above 110 degrees Fahrenheit, reaching as high as 127.8 degrees Fahrenheit. Despite weekly checks, the water heater thermostat was set at 130 degrees Fahrenheit, posing a potential risk to residents. No burn injuries were reported.
A facility failed to maintain sanitary conditions for storing respiratory supplies and did not follow proper hand hygiene practices. A resident's nebulizer mask and tubing were improperly stored, and a nurse failed to sanitize hands and equipment during a medication pass. These actions were against the facility's infection control policies.
A facility failed to conduct a PASARR Level II assessment for a resident with bipolar disorder, depression, and anxiety, despite the use of psychotropic medications. Staff interviews revealed a lack of training and understanding of PASARR requirements, with responsibilities unclear among the Social Services Assistant, Admissions Director, Business Office Manager, and Health Information Management Director. The Administrator expected the Business Office Manager to ensure PASARR Level II completion, but this was not fulfilled.
A facility failed to develop a comprehensive care plan for a resident requiring oxygen therapy, despite physician orders. The resident, with a history of respiratory failure and chronic conditions, did not have a care plan addressing the prescribed oxygen therapy, confirmed by staff interviews. This oversight risked the resident's medical needs and quality of life.
A resident with multiple health conditions, including respiratory failure and impaired cognition, was not administered oxygen therapy according to physician orders. The prescribed oxygen flow rate was one liter per minute, but observations showed it was set higher on multiple occasions. An LPN confirmed the discrepancy, which could have posed risks to the resident's health.
Food Storage and Ice Machine Sanitation Lapses
Penalty
Summary
Food safety and sanitation practices were not maintained in the kitchen, dry storage area, walk-in freezer, and ice machine. During the initial tour with the Dietary Manager, surveyors found expired food in dry storage, including boxes of cookies, honey thickened flavored water, and alfredo sauce mix past their expiration dates. In the walk-in freezer, multiple five-gallon bags of pre-packaged food products were observed without proper labels or dates, including cut carrots, sliced pepperoni, catfish, vegetable sausage, pork, roast beef, beef, and a box of mixed meats that included several items with an expiration date. The facility policy required pre-packaged food to be stored in sanitary containers with labels showing the contents and date, and use-by dates when applicable. Surveyors also observed a brown-black slime-like substance in the ice machine during the kitchen tour, and the Dietary Manager confirmed the lack of cleanliness. The DM stated the ice machine was cleaned quarterly, but the cleaning log showed only two cleaning dates, and a maintenance record showed a service date with a later next-service date noted. Staff interviews revealed inconsistent responsibility for cleaning and labeling tasks: one staff member said he could not label pepperoni because the label device was malfunctioning while he was passing breakfast trays, another said he had not cleaned the ice maker in about a year, and another said the night shift was usually responsible for the ice machine but no one had been assigned lately. Staff also reported not noticing the expired dry storage items and not focusing on dates when stocking food.
Failure to Accurately Code Hospice Services on MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate completion of the Minimum Data Set (MDS) for a resident receiving hospice services. The facility’s policy on Certification of Accuracy of the MDS requires that appropriate health professionals correctly document residents’ medical, functional, and psychosocial problems using the Resident Assessment Instrument. The resident in question was admitted with diagnoses including protein calorie malnutrition and had a care plan dated 01/09/2026 indicating a terminal prognosis and admission to hospice, with a goal to honor advance directives and provide comfort with dignity. Physician’s orders dated 12/09/2025 also included an order to admit the resident to hospice. Despite this, review of the admission MDS and a subsequent quarterly MDS showed that hospice services were not coded in Section O (Special Treatments, Procedures and Programs), even though both assessments documented a Brief Interview for Mental Status (BIMS) score of five, indicating severely impaired cognition. Interviews with the MDS Coordinator and two MDS LPNs confirmed that the resident had been on hospice since admission and that both the admission and quarterly MDS assessments were incorrectly coded as not on hospice. The MDS Coordinator acknowledged that the MDS should present an accurate clinical picture for a given period and stated that this was a clerical error, resulting in CMS not receiving correct hospice coding for the resident. The Administrator and DON stated their expectation that MDS assessments accurately reflect residents’ services and confirmed that failure to code hospice in the MDS results in an inaccurate reflection of the data.
Oxygen Equipment Not Maintained for a Resident on Supplemental O2
Penalty
Summary
Safe and appropriate respiratory care was not provided for one resident receiving oxygen therapy. The resident had diagnoses including acute and chronic respiratory failure with hypoxia, COPD, hypertensive heart disease with heart failure, dependence on supplemental oxygen, and obstructive sleep apnea. The resident’s MDS showed a BIMS score of 15 and indicated oxygen therapy/non-invasive mechanical ventilator use. The care plan identified COPD and included an intervention to identify and eliminate sources of respiratory irritation such as cigarette smoke, pollen, and perfumes. During observation, the resident’s oxygen concentrator had an empty humidification bottle, no date on the oxygen tubing, and a concentrator filter with heavy gray-like dust buildup. The resident stated that this was why it was hard to breathe and asked for someone to fix it. Later observations confirmed the humidification bottle was still empty, the tubing remained undated, and the concentrator filter still had significant dust buildup. Staff interviews revealed the nurse had not inspected the resident’s oxygen tubing, humidification, or concentrator that day, and the DON and ADON confirmed the equipment issues and that the resident’s oxygen equipment had not been checked before the deficiency was identified.
Failure to Update and Communicate Resident's Change in Code Status
Penalty
Summary
The facility failed to ensure that a resident's change in code status from full code to do not resuscitate (DNR) was properly communicated and updated in the medical record. According to facility policy, a DNR order must be documented as a medical order by a physician or authorized practitioner, and any changes to advance directives require immediate notification and documentation. However, review of the resident's care plan and physician orders indicated the resident remained listed as full code, despite discussions and documentation indicating a preference for DNR status. The resident in question had severe cognitive impairment and required extensive assistance with activities of daily living. Interviews revealed that the resident and family had discussed and signed DNR documents during the admission process, but staff failed to update the medical record accordingly. The Admissions Director explained that if the Physician Order for Life-Sustaining Treatment (POLST) form was unsigned, the default status was full code, and the process for obtaining physician signatures was unclear and not consistently followed. The Social Services Director confirmed that the POLST form was not properly dated or signed, and there was confusion about the process and documentation requirements. Further interviews with staff, including the Administrative Assistant and Administrator, highlighted gaps in communication and documentation regarding advance directives. The facility's process required collaboration between Admissions, Social Services, and physicians, but there was no clear timeframe or accountability for ensuring timely updates to the resident's code status. As a result, the resident's expressed wishes regarding resuscitation were not honored in the medical record, contrary to facility policy and regulatory requirements.
Unsafe Water Temperatures in Resident Rooms
Penalty
Summary
The facility failed to maintain safe water temperatures in four resident rooms, with temperatures recorded above 110 degrees Fahrenheit, reaching as high as 127.8 degrees Fahrenheit. This was discovered during a survey conducted on January 28, 2025, where water temperature checks were performed in the 226 - 232 corridor. The Assistant of Maintenance Director (AMD) used a digital thermometer to measure the water temperatures, which were found to be significantly higher than the recommended safe temperature for bathing, which is 100 degrees Fahrenheit. The facility's document, [Name of Company] TELS: Instructions, advises keeping domestic water temperatures below 120 degrees Fahrenheit to prevent burns, with many states having stricter standards. Interviews with the AMD and the Maintenance Director (MD) revealed that the maintenance department conducted weekly water temperature checks in 10 rooms on a rotational basis. Despite these checks, the water heater thermostat was found to be set at 130 degrees Fahrenheit, which the MD was unaware of. The facility's water temperature logs showed that previous checks in January 2025 recorded temperatures within the safe range of 106 to 106.9 degrees Fahrenheit. No residents sustained burn injuries related to the hot water temperatures, but the elevated temperatures posed a potential risk to residents in the affected rooms.
Infection Control Deficiencies in Respiratory Supplies and Hand Hygiene
Penalty
Summary
The facility failed to maintain sanitary conditions for storing respiratory supplies for one of the residents receiving respiratory treatments. Specifically, the nebulizer mask and tubing for a resident with chronic pulmonary edema, acute and chronic respiratory failure, and other conditions were observed to be improperly stored. The supplies were found tangled and touching the floor, unbagged, and not in use, despite the facility's policy requiring them to be stored in a labeled bag when not in use. This was confirmed by both the RN and the Staff Development Coordinator, who acknowledged that the supplies should have been stored correctly. Additionally, during a medication pass observation, a nurse failed to perform proper hand hygiene and did not sanitize shared medical equipment between residents' use. The nurse did not wash or sanitize her hands before collecting supplies or entering the resident's room, nor did she clean the glucose glucometer before use. The nurse admitted to forgetting to sanitize her hands and clean the equipment, which was expected by the facility's infection control policies. Interviews with the Staff Development Coordinator and corporate nurses confirmed the expectation for staff to perform hand hygiene and clean equipment before and after resident contact.
Failure to Conduct PASARR Level II Assessment
Penalty
Summary
The facility failed to ensure that a resident, identified as R13, was evaluated by the state-designated authority for a PASARR Level II assessment. This deficiency was identified through staff interviews, record reviews, and a review of the facility's policy on Pre-admission Screening and Resident Review (PASARR). R13 was admitted with diagnoses including bipolar disorder, depression, and anxiety, which were not recognized as primary diagnoses in the PASARR Level I assessment. Consequently, no PASARR Level II assessment was conducted, despite the resident's use of antipsychotic, antidepressant, and antianxiety medications. Interviews with various staff members, including the Social Services Assistant, Admissions Director, Business Office Manager, and Health Information Management Director, revealed a lack of understanding and training regarding the PASARR Level II requirements. The Social Services Assistant was not trained on who should have a PASARR Level II, and the Admissions Director indicated that PASARR Level II assessments were typically completed at the local hospital for short stays. The Business Office Manager acknowledged the need for a PASARR Level II but lacked the clinical background to complete it. The Health Information Management Director and Assistant were unaware of their department's responsibility in completing PASARR Level II assessments. The Administrator expected the Business Office Manager to ensure PASARR Level II completion, but this expectation was not met, leading to the deficiency.
Failure to Develop Comprehensive Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to develop a person-centered, comprehensive care plan for a resident (R41) who required oxygen therapy. Despite having physician orders dated 1/7/2025 for oxygen therapy via nasal cannula at a rate of one liter, the care plan initiated on the same date did not include any provisions for this therapy. This oversight was confirmed during an interview with the Regional Coordinator of Clinical Services and the Unit Care Coordinator, who acknowledged that a care plan should have been developed upon admission but was not. The resident's medical history included acute and chronic respiratory failure, hypertensive heart and chronic kidney disease, and other conditions. The absence of a care plan for the prescribed oxygen therapy had the potential to place the resident at risk for medical complications, unmet needs, and a diminished quality of life. The facility's policy on Comprehensive Care Plans and Revisions, dated 9/11/2024, mandates the timely development and revision of care plans by an interdisciplinary team, which was not adhered to in this case.
Oxygen Therapy Not Administered Per Physician Orders
Penalty
Summary
The facility failed to administer oxygen therapy to a resident, identified as R41, in accordance with the physician's orders. The resident was admitted with multiple diagnoses, including acute and chronic respiratory failure, hypertensive heart and chronic kidney disease, and had moderate impaired cognition as indicated by a BIMS score of 8. The physician's orders specified that the resident should receive oxygen therapy via nasal cannula at a rate of one liter per minute, initiated on January 7, 2025. However, observations on three separate occasions revealed discrepancies in the oxygen flow meter settings. On January 28, 2025, the flow meter was set at 1.5 liters, and on January 29 and 30, 2025, it was set at two liters. An interview with LPN TT on January 30, 2025, confirmed that the oxygen tank setting was incorrect and should have been set at one liter as per the physician's orders. This failure to adhere to the prescribed oxygen flow rate had the potential to put the resident at risk for medical complications.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lawrenceville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mesun Health And Rehabilitation Center | 3.6 mi | ★★★★★ | 9 | 0 |
| Salude - The Art Of Recovery | 4.8 mi | ★★★★★ | 0 | 0 |
| D Scott Hudgens Center For Skilled Nursing, The | 5.3 mi | ★★★★★ | 2 | 0 |
| Delmar Gardens Of Gwinnett | 5.8 mi | ★★★★★ | 4 | 0 |
| Life Care Center Of Gwinnett | 7.8 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.