Inspection Reports for Delmar Gardens of Gwinnett
3100 CLUB DRIVE, LAWRENCEVILLE, GA, 30044
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 7, 2024, did not identify any deficiencies. Earlier inspections in April 2024 cited multiple deficiencies related to medication management, social services support for vision and hearing care, anticoagulant monitoring, kitchen safety, and food safety practices. Complaint investigations around that time included one substantiated complaint without resulting deficiencies and one unsubstantiated complaint. Prior reports noted issues with Life Safety Code compliance, including sprinkler system maintenance and door locking mechanisms, as well as failures to report complete COVID-19 data in early 2023 and late 2022. The facility appears to have addressed many prior deficiencies successfully, as indicated by the clean results in the most recent inspections.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
3.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
22% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
56 residents
Based on a June 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Deficiencies: 0
Date: Jun 7, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for Delmar Gardens of Gwinnett, indicating a regulatory inspection was conducted.
Findings
The report contains an initial comment section but does not provide specific findings or deficiencies in the provided page.
Inspection Report
Follow-Up
Census: 56
Deficiencies: 0
Date: Jun 6, 2024
Visit Reason
A Health revisit survey was conducted to verify correction of deficiencies cited in the Recertification Survey concluded on April 16, 2024.
Findings
All deficiencies cited in the prior Recertification Survey were found to be corrected during this revisit survey.
Inspection Report
Life Safety
Deficiencies: 0
Date: Jun 3, 2024
Visit Reason
A Life Safety Code Revisit Survey was conducted to verify correction of previously cited Life Safety Code deficiencies.
Findings
The survey found that all previously cited Life Safety Code deficiencies had been corrected.
Inspection Report
Annual Inspection
Census: 58
Deficiencies: 5
Date: Apr 16, 2024
Visit Reason
The inspection was conducted as a State Licensure survey at Delmar Gardens of Gwinnett from April 13, 2024 through April 16, 2024, to determine compliance with the State Long Term Care Requirements.
Findings
The facility was cited for multiple deficiencies including failure to provide adequate social services for vision and hearing care, improper medication management including failure to date opened medications, failure to follow individualized care plans for anticoagulant monitoring, safety issues with kitchen equipment such as a broken oven door, and food safety violations including improper labeling and dating of food items and unclean kitchen equipment.
Deficiencies (5)
Failure to provide adequate assistance and support from social service with receiving vision care and audiologist assistance for residents.
Medications were not dated appropriately when opened and expired medical supplies were not discarded timely in medication carts.
Failure to follow individualized care plans for monitoring side effects of anticoagulant drug use for two residents.
Failure to ensure the flat top oven was working properly; oven door would not close efficiently.
Failure to ensure opened food items were properly dated and labeled in cooler, freezer, and dry food pantry; unclean oven and ice machines; dietary staff not consistently wearing hair coverings; recipe for pureed food not followed; dumpster not properly maintained.
Report Facts
Sample size: 25
Residents affected: 58
Residents reviewed for social service deficiency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LL | Certified Medication Aide (CMA) | Mentioned in medication dating deficiency observation and interview |
| JJ | Certified Medication Aide (CMA) | Mentioned in medication cart check and interview regarding medication dating |
| NN | Licensed Practical Nurse (LPN) | Mentioned in medication cart check and interview regarding medication dating |
| OO | Pharmacy Nurse Consultant | Provided quarterly medication cart audits and reports |
| MDS Nurse | Responsible for assessments and care plans related to anticoagulant monitoring | |
| DON | Director of Nursing | Interviewed regarding medication management and care plan expectations |
| Chef | Mentioned in relation to kitchen oven issues and food labeling | |
| MD | Maintenance Director | Mentioned in relation to oven repair and dumpster maintenance |
| Administrator | Interviewed regarding facility practices and quality assurance | |
| SSD | Social Service Director | Interviewed regarding vision services and social service deficiencies |
| MDS Coordinator | Responsible for completing Section B of MDS and vision assessments | |
| FF | Lead Dining Server | Interviewed regarding food labeling practices |
| HH | Cook | Interviewed regarding food labeling and kitchen practices |
| EE | Utility Worker | Observed not wearing hairnet in kitchen |
Inspection Report
Routine
Census: 58
Deficiencies: 8
Date: Apr 16, 2024
Visit Reason
A standard survey was conducted from April 13 through April 16, 2024, including investigation of two complaint intakes, one unsubstantiated and one substantiated without deficiencies.
Complaint Details
Complaint Intake Number GA00236181 was unsubstantiated and GA00233014 was substantiated without deficiencies.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to conduct Level II PASARR evaluations, inadequate monitoring of anticoagulant medication side effects, failure to provide adequate social services for vision and hearing, improper medication labeling and storage, unsanitary food storage and preparation practices, and maintenance issues with kitchen equipment and dumpsters.
Deficiencies (8)
Failure to ensure a Level II PASARR was conducted for one resident following a mental illness diagnosis.
Failure to follow individualized care plans for monitoring side effects of anticoagulant drug use for two residents.
Failure to provide adequate assistance and support from social services for vision and hearing care for three residents.
Failure to document monitoring and side effects of anticoagulant use for two residents.
Failure to ensure medications were dated appropriately when opened and failure to discard expired medical supplies.
Failure to ensure opened food items were properly dated and labeled, unsanitary conditions in kitchen including dirty oven and ice machines, dietary staff not wearing appropriate hair coverings, and failure to follow pureed food recipe.
Failure to ensure one dumpster had a plug in place and the surrounding area was free of trash and debris.
Failure to ensure the flat top oven was working properly; oven door was broken and did not close efficiently.
Report Facts
Residents present: 58
Sample size: 25
Medication carts: 3
Residents affected: 58
Inspection Report
Life Safety
Census: 59
Capacity: 75
Deficiencies: 2
Date: Apr 13, 2024
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance due to deficiencies including a sprinkler system yellow tagged for dry heads not tested or replaced, and two mag locks hanging out of the wall next to rooms 101 and 115 affecting smoke compartments.
Deficiencies (2)
Sprinkler system yellow tagged due to dry heads not being tested or replaced affecting the entire facility.
Two mag locks hanging out of the wall next to rooms 101 and 115 affecting two of four smoke compartments.
Report Facts
Census: 59
Certified beds: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observation |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 18, 2023
Visit Reason
The facility was reviewed for failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility did not report complete COVID-19 data to the NHSN between 12/11/2023 and 12/17/2023 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 23, 2023
Visit Reason
The inspection was conducted due to the facility's failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility did not report complete COVID-19 data to the NHSN between 01/16/2023 and 01/22/2023 as required by CMS and CDC regulations, potentially causing more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Re-Inspection
Census: 51
Deficiencies: 0
Date: Jan 18, 2023
Visit Reason
A Revisit Survey was conducted at Delmar Gardens of Gwinnett to verify correction of deficiencies cited in the Recertification Survey concluded on December 4, 2022.
Findings
All deficiencies cited as a result of the Recertification Survey were found to be corrected during this revisit survey.
Inspection Report
Re-Inspection
Census: 51
Deficiencies: 0
Date: Jan 18, 2023
Visit Reason
A Revisit Survey was conducted to verify correction of deficiencies cited during the Recertification Survey concluded on December 4, 2022.
Findings
All deficiencies cited as a result of the Recertification Survey were found to be corrected during this revisit survey.
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 4
Date: Dec 4, 2022
Visit Reason
A standard survey was conducted from December 2 through December 4, 2022, in conjunction with Complaint Intake Number GA#00225875 to investigate facility compliance with Medicare/Medicaid regulations.
Complaint Details
Complaint Intake Number GA#00225875 was investigated in conjunction with the standard survey.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to complete background checks for nursing staff, lack of a comprehensive care plan for respiratory and oxygen therapy for one resident, improper ordering of psychotropic medications, and food safety violations including unlabeled and undated opened food items and improper sanitization procedures.
Deficiencies (4)
Failed to complete background check screening process for four nursing staff of 10 reviewed.
Failed to develop a person-centered comprehensive care plan for respiratory and oxygen therapy for one resident (R#58).
Failed to ensure psychotropic medications including antianxiety medications were not ordered as needed (PRN) for more than 14 days unless clinically indicated for one resident (R#31).
Failed to label and date opened food items; failed to have the meat slicer and floor stand mixer clean, free from food debris; failed to properly use the three compartment sink to prevent food borne illness.
Report Facts
Resident census: 58
Number of nursing staff reviewed: 10
Number of nursing staff without background check: 4
Resident sample size: 21
Resident sample size for medication review: 5
Oxygen flow rate: 2
BIMS score: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DD | Licensed Practical Nurse | Named in background check deficiency and dietary interviews |
| EE | Registered Nurse | Named in background check deficiency |
| FF | Licensed Practical Nurse | Named in background check deficiency |
| GG | Human Resources | Interviewed regarding background check process |
| AA | Certified Nursing Assistant | Interviewed regarding care of resident #58 |
| BB | Licensed Practical Nurse | Interviewed regarding care of resident #58 |
| CC | Minimum Data Set Coordinator | Acknowledged lack of care plan for resident #58 |
| DON | Director of Nursing | Named in background check and medication order deficiencies |
| DD | Director of Dietary | Interviewed regarding food safety deficiencies |
| ADD | Assistant Director of Dietary | Interviewed regarding food safety deficiencies |
| RD | Registered Dietitian | Interviewed regarding sanitizing procedures |
Inspection Report
Life Safety
Census: 47
Capacity: 67
Deficiencies: 0
Date: Dec 4, 2022
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found to be in compliance with the Emergency Preparedness Program requirements under 42 CFR § 483.73 and the Life Safety Code requirements at 42 CFR Subpart 483.90(a).
Inspection Report
Routine
Deficiencies: 1
Date: Dec 2, 2022
Visit Reason
A State Licensure survey was conducted from December 2, 2022 through December 4, 2022, to determine compliance with State Long Term Care Requirements.
Findings
The facility failed to develop a person-centered comprehensive care plan for respiratory and oxygen therapy for one resident (R#58) of 21 sampled residents. The resident had physician orders for oxygen therapy and related interventions, but the care plan did not reflect these respiratory needs.
Deficiencies (1)
Failure to develop a person-centered comprehensive care plan for respiratory and oxygen therapy for one resident (R#58).
Report Facts
Sampled residents: 21
Oxygen flow rate: 2
Head of bed elevation: 30
Oxygen saturation: 95
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA | Certified Nursing Assistant (CNA) | Interviewed regarding resident R#58's respiratory status and oxygen therapy |
| BB | Licensed Practical Nurse (LPN) | Interviewed regarding monitoring and administration of oxygen therapy for resident R#58 |
| CC | Minimum Data Set Coordinator (MDS) | Acknowledged lack of care plan for respiratory issues for resident R#58 |
Inspection Report
Routine
Census: 50
Deficiencies: 0
Date: Feb 18, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted to assess the facility's compliance with relevant federal regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing CMS and CDC recommended practices for COVID-19.
Report Facts
Total census: 50
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 27, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA#205201.
Complaint Details
Complaint GA#205201 was investigated and found to be unsubstantiated.
Findings
The complaint GA#205201 was found to be unsubstantiated during the survey conducted on 08/27/2020.
Inspection Report
Routine
Census: 42
Deficiencies: 0
Date: Jun 24, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted on June 23-24, 2020 by Ascellon on behalf of the Georgia Department of Community Health (DCH).
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 infection control regulations, implementing CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Re-Inspection
Census: 61
Deficiencies: 0
Date: Nov 26, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies found in the prior October 3, 2019 survey.
Findings
All deficiencies resulting from the October 3, 2019 survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 22, 2019
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The survey noted that all previously cited deficiencies had been corrected.
Inspection Report
Life Safety
Census: 58
Capacity: 67
Deficiencies: 8
Date: Oct 2, 2019
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and related NFPA standards.
Findings
The facility was found not in substantial compliance with life safety requirements, including issues with egress door locking systems, fire alarm system initiation, smoke detector placement, sprinkler system maintenance, rated ceiling penetrations, electrical system maintenance, HVAC servicing, fire door inspection, and generator maintenance.
Deficiencies (8)
Facility sleeping room corridor egress doors have two different locking systems and one does not override the other; no means for staff to release mag locks other than fire alarm activation.
Facility failed to properly maintain smoke detectors; detectors located in airflow streams of HVAC supplies in Riser Room and Copier Room.
Facility failed to properly maintain fire sprinkler system; no data plate on riser, improperly adjusted sprinkler heads in multiple locations.
Facility failed to properly maintain rated ceilings; several improperly protected penetrations in rated ceiling of Riser Room/Storage.
Facility failed to properly maintain electrical system; open junction box with exposed wiring and missing knockout in junction box at rear of riser.
Facility failed to properly maintain HVAC equipment; HVAC equipment has not been serviced by a qualified person.
Facility failed to properly maintain fire rated doors; no established program for inspection and maintenance of fire doors.
Facility failed to properly maintain generator; missing required monthly load test records for the most recent 12 months.
Report Facts
Census: 58
Total Capacity: 67
Deficiencies cited: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed findings during facility tour and record review |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 26, 2018
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Delmar Gardens of Gwinnett following a survey completed on 09/26/2018.
Findings
The document contains no detailed deficiencies or findings; it only includes the initial comments section without any specific deficiencies or corrective actions listed.
Inspection Report
Life Safety
Census: 59
Capacity: 67
Deficiencies: 0
Date: Jul 26, 2018
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found to be in substantial compliance with the Emergency Preparedness Plan requirements and the Life Safety Code standards as per the 2012 NFPA edition.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 11, 2017
Visit Reason
A follow-up to the Recertification survey of July 7, 2017 was conducted to verify correction of previously identified deficiencies.
Findings
The follow-up survey revealed that all deficiencies were corrected and the facility was in substantial compliance as of July 22, 2017.
Inspection Report
Life Safety
Census: 60
Capacity: 67
Deficiencies: 0
Date: Jul 7, 2017
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found in substantial compliance with the Life Safety Code requirements and related standards during the survey.
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