The most recent inspection on September 12, 2025, found no deficiencies. Earlier inspections also generally found no rule violations, with multiple complaint investigations resulting in no cited issues. Prior reports identified deficiencies related mainly to medication documentation and resident care planning, including a substantiated complaint in January 2021 involving inadequate fall risk interventions and neglect after a resident’s fall. No fines, immediate jeopardy findings, or enforcement actions were listed in the available reports. The inspection history shows improvement over time, with recent inspections free of cited deficiencies.
Deficiencies (last 7 years)
Deficiencies (over 7 years)1.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
The purpose of this visit was to investigate intake GA00232042 and GA00232767 with an onsite visit made on 3/9/23. The investigation started on 3/6/23 and was completed on 3/16/23.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation of complaint intakes GA00232042 and GA00232767; no violations found.
The purpose of this visit was to conduct a compliance inspection at Delmar Gardens of Gwinnett.
Findings
An onsite visit was made on 2021-09-28 and the inspection was completed on 2021-09-30. No rule violations were cited as a result of this investigation.
The purpose of this visit was to investigate intake #GA00210694, which was opened on 2021-01-18 and completed on 2021-01-27.
Findings
The facility failed to adequately address fall risk interventions and care planning for Resident #1, who suffered a fall resulting in a displaced left femur fracture. The care plan was incomplete, direct care staff were not familiar with the care plan, and the resident was left in pain overnight without proper assessment, indicating neglect.
Complaint Details
Investigation of intake #GA00210694 regarding Resident #1's fall and subsequent injury. The complaint was substantiated based on findings of neglect and inadequate care.
Severity Breakdown
SS= D: 4
Deficiencies (4)
Description
Severity
Facility's resident care plan failed to address specific behaviors with interventions for Resident #1 who was a fall risk.
SS= D
Facility failed to review and share Resident #1's written care plan with direct care staff.
SS= D
Facility failed to ensure each resident received adequate and appropriate care in compliance with state law and regulations, specifically Resident #1 was not assessed properly after a fall.
SS= D
Facility failed to ensure Resident #1's right to be free from neglect; Resident #1 was left in pain overnight after a fall before staff called 911.
SS= D
Report Facts
Date of fall: Dec 19, 2020Date of hospital admission: Dec 20, 2020Date of surgery: Dec 21, 2020Staff shift hours: 830
Employees Mentioned
Name
Title
Context
Staff C
Named in findings related to failure to assess Resident #1 after fall and failure to review care plan.
Staff D
Named in findings related to assisting Resident #1 after fall and failure to complete assessment.
BB
Interviewed regarding Resident #1's injury and EMS arrival.
Staff B
Interviewed regarding Resident #1's complaint of hip pain and transfer to hospital.
The purpose of this visit was to conduct a follow-up to the (9/18/18) compliance inspection.
Findings
The facility failed to update the Medication Assistance Record (MAR) each time the medication was offered or taken for 2 of 4 sampled residents, specifically Resident #9 and Resident #4, as evidenced by multiple empty cells without staff initials on the MARs.
Severity Breakdown
E: 1
Deficiencies (1)
Description
Severity
Failure to update the Medication Assistance Record (MAR) each time medication was offered or taken for Resident #9 and Resident #4.
E
Report Facts
Medication Administration Record missing initials: 5Medication Administration Record missing initials: 5
Employees Mentioned
Name
Title
Context
Staff L interviewed regarding MAR update procedures
The purpose of this visit was to investigate complaint # GA00193334. An onsite visit was made to the facility on 12/19/18, and the investigation was completed on 1/18/19.
Findings
The document is a statement of deficiencies and plan of correction related to the complaint investigation. No specific findings or deficiencies are detailed in the provided text.
Complaint Details
Investigation of complaint # GA00193334 conducted with onsite visit on 12/19/18 and completed on 1/18/19.
The purpose of this visit was to conduct a compliance inspection of the assisted living community.
Findings
The inspection found that the facility failed to ensure hot water temperatures did not exceed 120 degrees Fahrenheit, failed to maintain accurate Medication Assistance Records (MAR) for residents, and failed to properly dispose of expired medications.
Severity Breakdown
J: 1D: 2
Deficiencies (3)
Description
Severity
Facility failed to ensure that heated water did not exceed 120 degrees Fahrenheit.
J
Community failed to update the Medication Assistance Record (MAR) each time medication was offered or taken for 2 of 8 sampled residents.
D
Facility failed to properly dispose of unused medications for 1 of 8 sampled residents, including expired Ranitidine medications.
D
Report Facts
Hot water temperature: 135Hot water temperatures: 138Hot water temperatures: 121Hot water temperatures: 124Hot water temperatures: 133Hot water temperatures: 136Hot water temperatures: 129Hot water temperatures: 122Hot water temperatures: 134Expired medication dates: 2Sampled residents with MAR issues: 2Sampled residents with medication disposal issues: 1
Employees Mentioned
Name
Title
Context
Staff A
Present during hot water temperature measurement and stated hot water temperature would be lowered.
Staff H
Present during hot water temperature measurement.
Staff I
Interviewed regarding MAR initials and expired medication disposal; stated staff failed to initial MARs and was unaware of expired medications.
Loading inspection reports...
Need Help?
Let us help you or a loved one find the perfect senior home.