Inspection Reports for
Delmar Gardens of Gwinnett Senior Living
3100 Club Dr, Lawrenceville, GA 30044, GA, 30044
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
4.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
16% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 12, 2025
Visit Reason
The purpose of this visit was to investigate intake# GA50005166 and conduct the compliance inspection.
Complaint Details
Investigation of intake# GA50005166; no rule violations were found.
Findings
No rule violations were cited as a result of this visit.
Inspection Report
Routine
Deficiencies: 5
Date: Aug 14, 2025
Visit Reason
The inspection was conducted to evaluate compliance with care plan adherence, physician orders, respiratory care, staffing requirements, and overall resident treatment and safety in the nursing facility.
Findings
The facility failed to follow care plans and physician orders for oxygen therapy and PICC line dressing changes for sampled residents, failed to provide a registered nurse on duty for required hours on multiple days, and did not ensure proper respiratory care and safety interventions such as mattress orders were followed. Deficiencies had potential for minimal harm or actual harm to residents.
Deficiencies (5)
Failed to follow the care plan for oxygen therapy for one resident (R4), oxygen flow was set higher than ordered.
Failed to develop and implement a comprehensive care plan for PICC line dressing and failed to change PICC line dressing as ordered for one resident (R55).
Failed to ensure physician orders were followed for two residents (R55 and R6), including PICC line dressing changes, flushing protocols, and mattress interventions.
Failed to provide safe and appropriate respiratory care by not delivering oxygen per physician order for one resident (R4).
Failed to have a registered nurse on duty for at least eight consecutive hours a day, seven days a week on multiple days in February and March 2025.
Report Facts
Residents sampled: 33
Oxygen flow rate ordered: 4
Oxygen flow rate observed: 5
PICC line dressing change frequency: 7
Heparin flush volume: 5
Heparin flush volume used: 0
Registered nurse hours missing: 4
Registered nurse hours worked: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Licensed Practical Nurse (LPN) | Named in PICC line dressing and flushing deficiencies for resident R55 |
| CC | Registered Nurse (RN), Unit Manager | Named in PICC line dressing deficiencies and staffing issues |
| AA | Certified Medication Aide (CMA) | Confirmed incorrect oxygen flow rate for resident R4 |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding care plan adherence, PICC line dressing, oxygen therapy, and staffing deficiencies |
| Social Services (SS) | Social Services | Interviewed regarding mattress change for resident R6 |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 5, 2025
Visit Reason
The purpose of this visit was to investigate intake number #GA50000155. The onsite visit was made on 2/5/25.
Complaint Details
Investigation of intake number #GA50000155 with no rule violations found.
Findings
The investigation was completed on 2/26/25 with no rule violations found as a result of this survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 11, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00250412 with an onsite visit made on 10/11/24.
Complaint Details
Investigation of intake #GA00250412 was completed with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Routine
Census: 58
Deficiencies: 8
Date: Apr 16, 2024
Visit Reason
The inspection was conducted as a routine regulatory oversight visit to assess compliance with federal and state regulations related to resident care, medication management, social services, food safety, and facility maintenance.
Findings
The facility was found deficient in multiple areas including failure to conduct required Level II PASARR evaluations, incomplete care plans for anticoagulant monitoring, inadequate social services for vision and hearing care, failure to monitor anticoagulant side effects, improper medication labeling and storage, food safety violations including improper food labeling and unclean kitchen equipment, dumpster maintenance issues, and broken kitchen equipment.
Deficiencies (8)
Failed to ensure a Level II PASARR was conducted for one of two sampled residents following a mental illness diagnosis.
Failed to follow individualized care plan for monitoring side effects of anticoagulant drug use for two residents.
Failed to provide adequate assistance and support from social service with receiving vision and hearing care for three of five sampled residents.
Failed to document monitoring and side effects of anticoagulant use for two of five sampled residents.
Failed to ensure medications were dated appropriately when opened and failed to discard expired medical supplies in medication carts.
Failed to ensure opened food items were properly dated and labeled, failed to ensure oven and ice machines were clean, dietary staff not wearing appropriate hair covering, and pureed food recipe not followed.
Failed to ensure one dumpster had a plug in place and the surrounding area was free of trash and debris.
Failed to ensure the flat top oven door would close efficiently to prepare cooked meals.
Report Facts
Residents affected: 58
Residents affected: 25
Residents affected: 5
Residents affected: 2
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MM | Licensed Practical Nurse | Provided support to medication techs and described monitoring responsibilities for anticoagulant medications |
| LL | Certified Nursing Assistant/Certified Medication Aide | Unaware of monitoring requirements for residents on blood thinners |
| NN | Licensed Practical Nurse | Described monitoring practices and documentation for resident behaviors and anticoagulant side effects |
| DON | Director of Nursing | Confirmed expectations for anticoagulant monitoring and medication labeling; discussed medication storage and expired medication handling |
| OO | Pharmacy Nurse Consultant | Conducts quarterly medication cart audits and provides in-service training on expired medications and labeling |
| EE | Utility Worker | Observed not wearing hairnet during kitchen tour |
| FF | Lead Dining Server | Described food container date checking practices |
| HH | Described food labeling and disposal practices; reported flat top stove usage and condition | |
| MD | Maintenance Director | Discussed dumpster maintenance and oven repair |
| GG | Reported flat top stove had been broken for weeks |
Inspection Report
Routine
Census: 58
Deficiencies: 8
Date: Apr 16, 2024
Visit Reason
The inspection was conducted as a routine regulatory oversight visit to assess compliance with healthcare facility regulations, including medication management, care planning, social services, food safety, and equipment maintenance.
Findings
The facility was found deficient in multiple areas including failure to conduct required Level II PASARR evaluations, incomplete care plans for anticoagulant monitoring, inadequate social services for vision and hearing care, failure to monitor anticoagulant side effects, improper medication labeling and storage, food safety violations including improper food labeling and unclean equipment, and failure to maintain essential kitchen equipment.
Deficiencies (8)
Failed to ensure a Level II PASARR was conducted for one resident following a mental illness diagnosis.
Failed to develop and implement complete care plans for monitoring side effects of anticoagulant drug use for two residents.
Failed to provide adequate social services for vision and hearing care for three residents.
Failed to document monitoring and side effects of anticoagulant use for two residents.
Failed to ensure medications were dated appropriately when opened and failed to discard expired medical supplies in medication carts.
Failed to ensure opened food items were properly dated and labeled; oven and ice machines were unclean; dietary staff lacked appropriate hair covering; pureed food recipe was not followed.
Failed to dispose of garbage and refuse properly; one dumpster was unplugged and surrounded by trash and debris.
Failed to ensure the flat top oven was working properly; oven door was broken and did not close efficiently.
Report Facts
Residents affected: 58
Residents affected: 25
Residents affected: 5
Residents affected: 2
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MM | Licensed Practical Nurse | Provided support to medication techs and described monitoring responsibilities for anticoagulant medications |
| LL | Certified Nursing Assistant/Certified Medication Aide | Unaware of monitoring requirements for residents on blood thinners |
| NN | Licensed Practical Nurse | Described monitoring practices and documentation for resident behaviors and anticoagulant side effects |
| DON | Director of Nursing | Provided expectations for anticoagulant monitoring and medication labeling; confirmed deficiencies |
| OO | Pharmacy Nurse Consultant | Conducts quarterly medication cart audits and provides in-service training on expired medications and labeling |
| EE | Utility Worker | Observed without hairnet in dietary area |
| FF | Lead Dining Server | Described food container date checking practices |
| HH | Described food labeling and disposal practices; reported on flat top stove usage | |
| MD | Maintenance Director | Verified dumpster condition and discussed oven repair |
| GG | Reported flat top stove had been broken for weeks | |
| Chef | Described oven door issue and food preparation practices | |
| Administrator | Discussed facility systems for problem resolution and staff education |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 18, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00244335 with an onsite visit made to the facility on 3/18/24.
Complaint Details
Investigation of intake #GA00244335 found no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 26, 2023
Visit Reason
The purpose of this survey was to investigate complaint #GA00234761 during an onsite visit on 5/26/2023.
Complaint Details
Investigation of complaint #GA00234761 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 9, 2023
Visit Reason
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.
Complaint Details
Investigation of complaint intakes GA00232042 and GA00232767; no violations found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 26, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00228922 with an onsite visit made on 1/26/23.
Complaint Details
Investigation of intake #GA00228922; no rule violations were found.
Findings
The investigation was completed on 1/26/23 and no rule violations were cited.
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Dec 4, 2022
Visit Reason
The inspection was conducted based on complaints and concerns regarding failure to complete background checks for nursing staff, incomplete care plans for respiratory and oxygen therapy, lack of stop dates for psychotropic medications, and unsanitary kitchen conditions.
Complaint Details
The visit was complaint-related due to concerns about background checks for nursing staff, incomplete care plans, psychotropic medication management, and kitchen sanitation. The complaint was substantiated with findings of deficiencies in these areas.
Findings
The facility failed to complete criminal background checks for four nursing staff, did not develop a comprehensive care plan for respiratory and oxygen therapy for one resident, failed to ensure a 14-day stop date for PRN psychotropic medication for one resident, and did not maintain a clean and sanitary kitchen with proper food labeling and cleaning procedures.
Deficiencies (4)
Failed to complete a background check screening process for four nursing staff of 10 total staff reviewed.
Failed to develop a person-centered comprehensive care plan for respiratory and oxygen therapy for one of 21 residents (R#58).
Failed to ensure a stop date was implemented, not to exceed 14 days, for psychotropic medications for one of five residents (R#31).
Failed to maintain a clean and sanitary kitchen, including failure to label and date opened food items, failure to clean meat slicer and floor stand mixer, and improper use of the three compartment sink for sanitizing.
Report Facts
Nursing staff without background checks: 4
Residents reviewed for care plan deficiency: 21
Residents reviewed for psychotropic medication: 5
Residents affected by kitchen sanitation deficiency: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DD | Licensed Practical Nurse | Named in background check deficiency for being hired without a completed background check. |
| EE | Registered Nurse | Named in background check deficiency for being hired without a completed background check. |
| FF | Licensed Practical Nurse | Named in background check deficiency for being hired without a completed background check. |
| GG | Human Resources | Interviewed regarding background check procedures. |
| AA | Certified Nursing Assistant | Interviewed regarding care and monitoring of resident R#58. |
| BB | Licensed Practical Nurse | Interviewed regarding care and monitoring of resident R#58. |
| CC | Minimum Data Set Coordinator | Acknowledged lack of care plan for resident R#58. |
| DON | Director of Nursing | Interviewed regarding background checks and psychotropic medication stop dates. |
| DD | Director of Dietary | Interviewed regarding kitchen sanitation and food labeling. |
| ADD | Assistant Director of Dietary | Interviewed regarding kitchen sanitation and dishwashing procedures. |
| RD | Registered Dietitian | Provided documentation for sanitizing procedures. |
Inspection Report
Routine
Deficiencies: 0
Date: Sep 28, 2021
Visit Reason
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.
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jan 27, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00210694, which was opened on 2021-01-18 and completed on 2021-01-27.
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.
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.
Deficiencies (4)
Facility's resident care plan failed to address specific behaviors with interventions for Resident #1 who was a fall risk.
Facility failed to review and share Resident #1's written care plan with direct care staff.
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.
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.
Report Facts
Date of fall: Dec 19, 2020
Date of hospital admission: Dec 20, 2020
Date of surgery: Dec 21, 2020
Staff 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. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 26, 2020
Visit Reason
The purpose of this inspection was to investigate intake #GA00208741.
Complaint Details
Investigation began 2020-10-16 and was completed 2020-10-26. No rule violation cited.
Findings
No rule violation was cited as a result of this inspection.
Inspection Report
Monitoring
Deficiencies: 0
Date: Apr 6, 2020
Visit Reason
The purpose of this review is to monitor COVID-19 cases and assess infection control process.
Findings
No specific findings or deficiencies are detailed in the report.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 5, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00202952.
Complaint Details
Investigation of intake #GA00202952 found no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 9, 2019
Visit Reason
The purpose of this visit was to investigate intake #GA00198927, with the investigation starting on 2019-08-28 and completing on 2019-09-13.
Complaint Details
Investigation of intake #GA00198927 was conducted and completed with no violations cited.
Findings
No violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 3, 2019
Visit Reason
The purpose of this visit was to investigate complaint GA00195802.
Complaint Details
Complaint GA00195802 was investigated and found to have no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Mar 15, 2019
Visit Reason
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.
Deficiencies (1)
Failure to update the Medication Assistance Record (MAR) each time medication was offered or taken for Resident #9 and Resident #4.
Report Facts
Medication Administration Record missing initials: 5
Medication Administration Record missing initials: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff L interviewed regarding MAR update procedures |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 18, 2019
Visit Reason
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.
Complaint Details
Investigation of complaint # GA00193334 conducted with onsite visit on 12/19/18 and 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.
Inspection Report
Routine
Deficiencies: 3
Date: Sep 19, 2018
Visit Reason
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.
Deficiencies (3)
Facility failed to ensure that heated water did not exceed 120 degrees Fahrenheit.
Community failed to update the Medication Assistance Record (MAR) each time medication was offered or taken for 2 of 8 sampled residents.
Facility failed to properly dispose of unused medications for 1 of 8 sampled residents, including expired Ranitidine medications.
Report Facts
Hot water temperature: 135
Hot water temperatures: 138
Hot water temperatures: 121
Hot water temperatures: 124
Hot water temperatures: 133
Hot water temperatures: 136
Hot water temperatures: 129
Hot water temperatures: 122
Hot water temperatures: 134
Expired medication dates: 2
Sampled residents with MAR issues: 2
Sampled 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. |
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