Life Care Center of Gwinnett

In the surveyor’s words

From the most serious findings on record at Life Care Center of Gwinnett, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jun 18, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF655Apr 10, 2025

  52126 Based 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. […]

• No harm, potential for more than minimal, patternF656Apr 10, 2025

  Based 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. Findings include: Review of the facility's policy titled, Bed Rails - Safe and Effective Use of Bed Rails revised 9/6/2024 indicated, Procedure: A person-centered care plan will be developed within 48 hours of admission to address the bed rail(s), if indicated. […]

• No harm, potential for more than minimal, patternF700Apr 10, 2025

  Based 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. Findings include: Review of the facility's policy titled, Bed Rails - Safe and Effective Use of Bed Rails revised 9/6/2024 indicated, Assess the resident for risk of entrapment from bed rails prior to installation. Procedure: Residents will be assessed upon admission, readmission, or upon initiation utilizing the Evaluation for use of bed rails assessment. […]

• No harm, potential for more than minimal, isolatedF690Jun 18, 2026

  Based 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. Findings include:Review of the facility's policy titled, Indwelling Urinary Catheter (Foley) Management, revised September 4, 2025, revealed under General Urinary Catheter Maintenance Guidelines: . 2. b. Keep the collecting bag below the level of the bladder at all times. […]