Inspection Reports for Delmar Gardens of Smyrna
404 KING SPRINGS VILLAGE PKWY, SMYRNA, GA, 30082
Back to Facility ProfileInspection Report Summary
The most recent inspection on February 18, 2025, found no deficiencies and confirmed correction of all prior issues. Earlier inspections, particularly the December 2024 survey, cited multiple deficiencies related mainly to medication management, infection control, resident dignity, care planning, and unsafe use of bed rails. Complaint investigations were mostly substantiated but did not result in additional deficiencies, and enforcement actions such as fines or license suspensions were not listed in the available reports. Prior Life Safety Code surveys noted electrical safety and fire protection deficiencies, which were recurring themes over several years. The facility appears to have addressed many prior deficiencies by the latest inspection, indicating improvement in compliance over time.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
9.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
96% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
104 residents
Based on a February 2025 inspection.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 18, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Delmar Gardens of Smyrna following a regulatory inspection.
Findings
The report contains initial comments but does not specify any detailed deficiencies or findings.
Inspection Report
Re-Inspection
Census: 104
Deficiencies: 0
Date: Feb 18, 2025
Visit Reason
A revisit survey was conducted on 2/18/2025 in conjunction with the investigation of Complaint Intake Number GA00253801.
Complaint Details
Complaint Intake Number GA00253801 was investigated and substantiated with no deficiencies cited.
Findings
All deficiencies cited as a result of the 12/19/2024 recertification survey were found to be corrected. The complaint investigation was substantiated with no deficiencies cited.
Inspection Report
Abbreviated Survey
Census: 104
Deficiencies: 0
Date: Feb 18, 2025
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00253801.
Complaint Details
Complaint GA00253801 was substantiated with no deficiencies.
Findings
The complaint GA00253801 was substantiated with no deficiencies found during the survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 3, 2025
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.
Findings
All previously cited survey tags have been corrected as noted by the surveyor during the follow-up visit.
Inspection Report
Routine
Census: 90
Deficiencies: 8
Date: Dec 19, 2024
Visit Reason
A State Licensure survey was conducted at Delmar Gardens of Smyrna from December 17, 2024, through December 19, 2024, to assess compliance with state health regulations and facility licensure requirements.
Findings
The survey revealed multiple deficiencies including failure to promptly notify responsible parties of resident condition changes, failure to maintain resident dignity, improper medication management, inadequate infection control practices, failure to accommodate physician orders for resident care, incomplete care plans, and unsafe use of bed rails without proper consent or orders.
Deficiencies (8)
Failure to promptly notify the responsible party of a resident's change in condition related to a deep tissue injury.
Failure to maintain dignity by not providing a dignity bag for a resident with an indwelling urinary catheter.
Psychotropic medications were ordered as needed (PRN) for more than 14 days without clinical indication.
Failure to follow infection control procedures including uncovered clean linen during transport, failure to follow transmission-based precautions, improper storage of CPAP mask, inadequate hand hygiene, and failure to clean shared medical equipment between uses.
Unauthorized medications were stored at the bedside without assessment or physician order for self-administration.
Failure to provide reasonable accommodation for a resident to elevate feet as ordered by physician due to lack of appropriate wheelchair equipment.
Failure to develop a comprehensive person-centered care plan for a resident receiving antipsychotic, antidepressant, and antianxiety medications.
Use of bilateral half-side bed rails without necessary consent, physician's order, or completed assessment.
Report Facts
Facility census: 90
Residents reviewed for change in condition: 19
Residents reviewed for use of unnecessary medications: 7
Residents sampled: 28
Residents reviewed for bed rail use: 6
Morse Fall Scale score: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN HH | Licensed Practical Nurse | Confirmed urinary catheter drainage bag was uncovered and visible from hallway |
| LPN BB | Licensed Practical Nurse | Observed failing to clean blood pressure equipment and sanitize hands during medication pass |
| LPN EE | Licensed Practical Nurse | Confirmed unauthorized medication was stored at resident bedside |
| RN JJ | Registered Nurse | Confirmed resident's feet were not elevated as ordered due to lack of appropriate wheelchair |
| Unit Manager II | Unit Manager Licensed Practical Nurse | Confirmed order to keep resident's feet elevated and acknowledged compliance issues |
| Director of Nursing | Director of Nursing | Provided multiple confirmations regarding expectations for notification, infection control, medication administration, and care plan compliance |
| MDS Coordinator | MDS Coordinator | Verified involvement in care plan development and confirmed missing care plan areas for medications |
| Housekeeper MM | Housekeeper | Observed transporting clean linen uncovered and confirmed it should be covered |
| Housekeeping Director | Housekeeping Director | Expected clean laundry to be covered during transport |
| Infection Preventionist | Infection Preventionist | Expected clean linen and laundry to be covered during transport |
Inspection Report
Routine
Census: 90
Deficiencies: 12
Date: Dec 19, 2024
Visit Reason
A standard survey was conducted at Delmar Gardens of Smyrna from December 17, 2024, through December 19, 2024, including investigation of multiple complaint intake numbers.
Complaint Details
Complaint Intake Numbers GA00247351, GA00247352, GA00248903, and GA00249051 were investigated during the standard survey.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with multiple deficiencies including failure to maintain resident dignity, improper medication storage, inadequate accommodation of resident needs, failure to notify responsible parties of condition changes, inaccurate Minimum Data Set assessments, incomplete care plans, failure to provide adequate ADL care, lack of communication with dialysis center, improper use of bed rails, psychotropic medication order issues, and infection control lapses.
Deficiencies (12)
Failure to maintain dignity by not providing a dignity bag for a resident with an indwelling urinary catheter.
Unauthorized medications stored at bedside for a resident not assessed for self-administration.
Failure to provide wheelchair to accommodate physician's order to elevate feet at all times.
Failure to promptly notify responsible party of resident's change in condition related to deep tissue injury.
Failure to provide accurate Minimum Data Set assessment data for two residents.
Failure to develop baseline care plan for enteral tube feeding within 48 hours of admission.
Failure to develop comprehensive person-centered care plan for use of unnecessary medications.
Failure to provide adequate shaving care resulting in excessive facial hair.
Failure to ensure communication between facility and dialysis center was documented after each dialysis session.
Failure to ensure consent, physician's order, and assessment for use of bilateral half-side rails on bed.
Failure to ensure psychotropic medications were not ordered PRN for more than 14 days without clinical indication.
Failure to follow infection control procedures including uncovered clean linen during transport, lack of Transmission Based Precautions for MRSA resident, improper storage of CPAP mask, improper hand hygiene during medication pass, and failure to clean shared medical equipment between residents.
Report Facts
Deficiencies cited: 12
Resident census: 90
BIMS score: 14
BIMS score: 9
BIMS score: 12
Morse Fall Scale score: 40
PRN psychotropic medication duration: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN HH | Licensed Practical Nurse | Confirmed urinary catheter drainage bag was uncovered and visible. |
| Director of Nursing | Director of Nursing | Provided expectations on urinary catheter care, medication administration, notification of condition changes, and infection control. |
| LPN EE | Licensed Practical Nurse | Confirmed unauthorized medication at bedside and dialysis communication form issues. |
| RN JJ | Registered Nurse | Confirmed resident's physician order for elevating feet and lack of appropriate wheelchair. |
| Unit Manager LPN II | Unit Manager Licensed Practical Nurse | Confirmed inconsistent compliance with elevating resident's feet. |
| Resident Representative | Reported not being informed of resident's condition change. | |
| MDS Coordinator | MDS Coordinator | Confirmed inaccuracies in Minimum Data Set assessments. |
| Certified Nursing Assistant DD | Certified Nursing Assistant | Provided shaving assistance and confirmed excessive facial hair. |
| Housekeeper MM | Housekeeper | Observed transporting clean linen uncovered. |
| Infection Preventionist | Infection Preventionist | Provided expectations on linen transport and Transmission Based Precautions. |
| LPN BB | Licensed Practical Nurse | Observed failing to clean blood pressure equipment and hand hygiene during medication pass. |
Inspection Report
Routine
Census: 90
Deficiencies: 8
Date: Dec 19, 2024
Visit Reason
A State Licensure survey was conducted at Delmar Gardens of Smyrna from December 17, 2024, through December 19, 2024, to assess compliance with state health regulations.
Findings
The survey revealed multiple deficiencies including failure to promptly notify responsible parties of resident condition changes, failure to maintain resident dignity, improper medication orders, inadequate infection control practices, unauthorized medication storage, failure to accommodate resident needs, incomplete care plans, and improper use of bed rails without required consent or orders.
Deficiencies (8)
Failure to promptly notify the responsible party of a resident's change in condition related to a deep tissue injury.
Failure to maintain dignity by not providing a dignity bag for a resident with an indwelling urinary catheter.
Psychotropic medications were ordered as needed (PRN) for more than 14 days without clinical indication.
Failure to follow infection control procedures including uncovered clean linen during transport, failure to follow transmission-based precautions, improper storage of CPAP mask, failure to perform proper hand hygiene, and failure to clean shared medical equipment between residents.
Unauthorized medications stored at the bedside without physician order or assessment for self-administration.
Failure to provide reasonable accommodation for a resident's physician order to elevate feet at all times due to lack of appropriate wheelchair equipment.
Failure to develop a comprehensive person-centered care plan for a resident receiving antipsychotic, antidepressant, and antianxiety medications.
Use of bilateral half-side bed rails without necessary consent, physician's order, or completed assessment.
Report Facts
Facility census: 90
Residents reviewed for change in condition: 19
Residents reviewed for use of unnecessary medications: 7
Residents reviewed for infection control: 5
Residents sampled for medication storage: 28
Residents sampled for accommodation of needs: 28
Residents reviewed for care plan completeness: 7
Residents reviewed for bed rail use: 6
Morse Fall Scale score: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN HH | Licensed Practical Nurse | Confirmed urinary catheter drainage bag was uncovered and visible from hallway |
| LPN BB | Licensed Practical Nurse | Observed failing to clean blood pressure equipment and sanitize hands during medication pass |
| LPN EE | Licensed Practical Nurse | Confirmed unauthorized medication was stored at resident bedside |
| RN JJ | Registered Nurse | Confirmed resident's feet were not elevated as ordered due to lack of appropriate wheelchair |
| Unit Manager II | Unit Manager Licensed Practical Nurse | Confirmed inconsistent compliance with elevating resident's feet and lack of proper wheelchair |
| Director of Nursing | Director of Nursing | Provided multiple confirmations regarding expectations for notification, infection control, medication administration, and equipment use |
| MDS Coordinator | MDS Coordinator | Confirmed lack of care plan areas for medications and consent requirements for bed rails |
| Housekeeper MM | Housekeeper | Observed and confirmed clean linen laundry cart was uncovered during transport |
| Housekeeping Director | Housekeeping Director | Expected clean laundry to be covered during transport |
| Infection Preventionist | Infection Preventionist | Expected clean linen and laundry to be covered during transport |
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 12
Date: Dec 19, 2024
Visit Reason
A Standard survey was conducted from December 17-19, 2024, including investigations of Complaint Intake Numbers GA00247351, GA00247352, GA00248903, and GA00249051. The survey assessed compliance with Medicare/Medicaid regulations for long term care facilities.
Complaint Details
The survey included investigations of Complaint Intake Numbers GA00247351, GA00247352, GA00248903, and GA00249051.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements, including failure to maintain resident dignity, improper medication storage, failure to accommodate physician orders, lack of timely notification of condition changes, inaccurate Minimum Data Set assessments, incomplete care plans, inadequate ADL care, failure in dialysis communication, improper use of bed rails, psychotropic medication order issues, and multiple infection control deficiencies.
Deficiencies (12)
Failure to maintain dignity by not providing a dignity bag for a resident with an indwelling urinary catheter.
Unauthorized medications stored at bedside for a resident without assessment or physician order for self-administration.
Failure to provide a wheelchair to accommodate physician's order to elevate resident's feet at all times.
Failure to promptly notify responsible party of resident's change in condition related to a deep tissue injury.
Failure to provide accurate Minimum Data Set assessment data for two residents.
Failure to develop baseline care plan for enteral tube feeding within 48 hours of admission.
Failure to develop comprehensive person-centered care plan for use of unnecessary medications.
Failure to provide adequate shaving care resulting in excessive facial hair for a resident.
Failure to ensure documented communication between facility and dialysis center after each dialysis session.
Failure to ensure consent, physician's order, and assessment for use of bilateral half-side rails on bed.
Failure to ensure psychotropic medications ordered as needed were limited to 14 days unless clinically indicated.
Multiple infection control failures including uncovered clean linen during transport, failure to follow transmission based precautions for MRSA resident, improper storage of CPAP mask, failure to perform hand hygiene during medication pass, and failure to clean shared medical equipment between residents.
Report Facts
Resident census: 90
BIMS score: 14
BIMS score: 9
BIMS score: 12
Morse Fall Scale score: 40
Medication doses: 0.5
Medication doses: 50
Medication doses: 15
Medication doses: 10
Medication doses: 50
Medication doses: 0.5
Medication doses: 800
Medication doses: 160
Medication doses: 5
Medication doses: 50
Medication doses: 100
Medication doses: 25
Enteral feeding rate: 50
CPAP pressure setting: 8
CPAP pressure setting: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| HH | Licensed Practical Nurse (LPN) | Confirmed urinary catheter drainage bag was uncovered and visible. |
| EE | Licensed Practical Nurse (LPN) | Confirmed unauthorized medication at bedside and CPAP mask storage issues. |
| JJ | Registered Nurse (RN) | Confirmed resident's physician order to elevate feet and lack of appropriate wheelchair. |
| II | Unit Manager Licensed Practical Nurse (LPN) | Confirmed inconsistent compliance with elevating resident's feet. |
| DD | Certified Nursing Assistant (CNA) | Provided shaving assistance and confirmed excessive facial hair. |
| MM | Housekeeper | Observed transporting clean linen uncovered. |
| BB | Licensed Practical Nurse (LPN) | Observed failing to clean blood pressure equipment and hand hygiene during medication pass. |
| FF | Certified Nursing Assistant (CNA) | Observed providing care to MRSA resident without gown. |
Inspection Report
Life Safety
Census: 90
Capacity: 120
Deficiencies: 2
Date: Dec 17, 2024
Visit Reason
The Life Safety Code Survey was 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 with the Life Safety Code requirements, specifically related to utilities involving gas and electric equipment. Deficiencies included an uncovered 4x4 electrical box in the fire alarm/sprinkler riser room and a multiple outlet power supply on the floor in the kitchen manager's office, posing a risk of personal electrical shock.
Deficiencies (2)
Uncovered 4x4 electrical box (j-box) on the ceiling in the fire alarm/sprinkler riser room not covered to prevent shock.
Multiple outlet power supply (MOPS) found on the floor in the kitchen manager's office.
Report Facts
Certified beds: 120
Census: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings of electrical hazards during facility tour |
Inspection Report
Life Safety
Census: 90
Capacity: 120
Deficiencies: 2
Date: Dec 17, 2024
Visit Reason
A Life Safety Code Survey was 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 with the Life Safety Code requirements, specifically failing to assure against personal electrical shock due to uncovered electrical boxes and improperly placed power supplies in one of four smoke compartments.
Deficiencies (2)
A 4x4 electrical box (j-box) on the ceiling in the fire alarm/sprinkler riser room was not covered to prevent shock.
A multiple outlet power supply (MOPS) was found on the floor in the kitchen manager's office, posing a shock hazard.
Report Facts
Census: 90
Total Capacity: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M confirmed findings during the tour |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 18, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00249662.
Complaint Details
Complaint GA00249662 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 0
Date: Apr 12, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00242086.
Complaint Details
Complaint GA00242086 was substantiated with no deficiency cited.
Findings
The complaint GA00242086 was substantiated with no deficiency cited.
Inspection Report
Abbreviated Survey
Census: 92
Deficiencies: 0
Date: Feb 28, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint numbers GA00241698, GA00242336, and GA00242078.
Complaint Details
Complaint numbers GA00241698 and GA00242336 were unsubstantiated without federal deficiency cited. Complaint number GA00242078 was substantiated without deficiency cited.
Findings
Complaint numbers GA00241698 and GA00242336 were found to be unsubstantiated without federal deficiency cited. Complaint number GA00242078 was substantiated without deficiency cited.
Report Facts
Complaint numbers investigated: 3
Inspection Report
Deficiencies: 0
Date: Oct 11, 2023
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Delmar Gardens of Smyrna, indicating a regulatory inspection was conducted.
Findings
The report contains no detailed findings or deficiencies; the summary statement of deficiencies section is blank.
Inspection Report
Re-Inspection
Census: 83
Deficiencies: 0
Date: Oct 11, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the August 10, 2023 Standard Survey.
Findings
All deficiencies cited in the August 10, 2023 Standard Survey were found to be corrected during the revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 3, 2023
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Aug 10, 2023
Visit Reason
A Licensure Survey was conducted from August 8, 2023 through August 10, 2023 to assess compliance with licensure requirements and care standards at Delmar Gardens of Smyrna.
Findings
The facility failed to follow the care plan related to fall prevention for one resident and ensure Activities of Daily Living (ADL) care was provided for two residents, including nail care and shower assistance. Additionally, the facility failed to properly label and date opened food items and did not dry clean dishes appropriately, affecting most residents.
Deficiencies (6)
Failure to follow care plan related to fall prevention interventions for one resident (R#77), including absence of 'Call Don't Fall' signage.
Failure to provide nail care for a dependent diabetic resident (R#31), with fingernails observed long and uncut.
Failure to provide adequate shower assistance for a dependent resident (R#68), who reported insufficient help during showers.
Failure to ensure opened food items in refrigerator and dry storage were properly labeled and dated.
Failure to dry clean dishes appropriately, with items stacked wet due to lack of drying space.
Failure to properly clean kitchen equipment including fryer and oven.
Report Facts
Residents sampled: 32
Residents affected by food labeling deficiency: 98
Fall risk score: 65
Number of falls: 14
BIMS score: 9
BIMS score: 14
Shower dates: 7
Shower refusals: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CC | Licensed Practical Nurse (LPN) | Confirmed absence of 'Call Don't Fall' signage in resident R#77's room and responsibility for diabetic nail care |
| KK | Certified Nursing Assistant (CNA) | Stated nail care should be completed with showers on scheduled days |
| JJ | Restorative Nursing Assistant | Explained nail care responsibilities for diabetic residents |
| AA | Dietary Cook | Verified food labeling deficiencies and stacking of wet dishes due to lack of drying space |
| BB | Dietary Aide | Admitted stacking dishes wet without proper drying due to space constraints |
| Dietary Manager | Observed unlabeled food containers and unclean kitchen equipment; stated expectations for cleaning and labeling | |
| Administrator | Stated expectations for dietary staff to label and date opened food items and maintain cleaning schedules | |
| Director of Nursing (DON) | Discussed fall prevention interventions and expectations for nail care and ADL assistance |
Inspection Report
Annual Inspection
Census: 100
Deficiencies: 8
Date: Aug 10, 2023
Visit Reason
A recertification survey was conducted at Delmar Gardens of Smyrna from August 8, 2023 through August 10, 2023, including investigation of Complaint Intake Numbers GA00231860 and GA00233215.
Complaint Details
The complaint investigation involved allegations of verbal abuse by a Certified Nursing Assistant (CNA NN) toward resident #53. The facility failed to report the abuse timely to the State Agency and failed to conduct a thorough investigation, resulting in actual harm. The resident reported ongoing fear for her safety. The abusive CNA was suspended after the investigation.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including unsafe water temperatures in resident rooms, unlabeled and unbagged elimination containers, failure to timely report and investigate verbal abuse allegations, failure to follow fall prevention care plans, inadequate ADL care for residents, improper oxygen equipment storage and use, and improper food labeling and kitchen sanitation.
Deficiencies (8)
Water temperatures in 11 of 66 resident rooms exceeded the regulatory maximum of 110 degrees Fahrenheit, reaching up to 116 degrees.
Unlabeled and unbagged bedpans, urinals, specimen pans, wash basins, and dirty bedside commode lids found in three resident rooms.
Failure to report an allegation of verbal abuse to the State Agency within the required two hours for one resident.
Failure to thoroughly investigate and follow-up on an allegation of verbal abuse, resulting in actual harm to a resident.
Failure to follow fall prevention care plan interventions for one resident at high risk for falls, including absence of 'Call Don't Fall' signage in the resident's room.
Failure to provide adequate Activities of Daily Living (ADL) care for two residents, including failure to clip nails for a diabetic resident and inadequate shower assistance.
Failure to follow physician orders and properly store oxygen equipment for one resident, including tubing not changed weekly and lack of humidification when required.
Failure to properly label and date opened food items in the refrigerator and dry storage, and failure to properly dry clean dishes and maintain kitchen equipment cleanliness.
Report Facts
Resident census: 100
Water temperature: 116
Fall risk score: 65
Number of falls: 13
Oxygen liters: 4
Oxygen liters ordered: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA NN | Certified Nursing Assistant | Named in verbal abuse allegation against resident #53 |
| LPN CC | Licensed Practical Nurse, Unit Manager | Involved in reporting and investigation of abuse allegation and care for residents #53 and #77 |
| Administrator | Facility Administrator involved in abuse reporting and investigation | |
| Director of Nursing | DON | Involved in abuse reporting, investigation, and care plan oversight |
| Dietary Cook AA | Dietary Cook | Verified unlabeled food items and improper dish drying |
| Dietary Manager | Dietary Manager | Oversaw kitchen sanitation and food labeling |
| CNA KK | Certified Nursing Assistant | Provided information on nail care practices |
| CNA JJ | Restorative Nursing Assistant | Provided information on nail care practices |
| CNA II | Certified Nursing Assistant | Reported on shower assistance for resident #68 |
Inspection Report
Life Safety
Census: 102
Capacity: 120
Deficiencies: 3
Date: Aug 9, 2023
Visit Reason
The inspection 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 with fire safety requirements, including missing K-class extinguisher signage in the kitchen, overdue 5-year sprinkler system inspection, improperly installed sprinkler components, loaded sprinkler heads in the laundry, and a penetration through a smoke barrier allowing smoke passage between compartments.
Deficiencies (3)
Missing required instructional fire safety signage (K-class extinguisher placard) in the kitchen above the unit.
Fire sprinkler system not maintained at optimum readiness, including overdue 5-year inspection, escutcheon plate not flush with ceiling tiles near dishwasher, and loaded sprinkler heads in laundry.
Smoke barrier penetration above a door allowing passage of smoke between compartments.
Report Facts
Census: 102
Total licensed beds: 120
Smoke Compartments affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observation |
Inspection Report
Deficiencies: 1
Date: Sep 12, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the CDC's NHSN during a required seven-day reporting period from 09/05/2022 to 09/11/2022, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete COVID-19 information 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: 95
Deficiencies: 0
Date: Apr 8, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the Recertification survey of 2/3/2022.
Findings
All deficiencies cited in the prior Recertification survey were found to be corrected during this revisit survey.
Inspection Report
Re-Inspection
Census: 95
Deficiencies: 0
Date: Apr 8, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the Recertification survey of 2022-02-03.
Findings
All deficiencies cited in the prior Recertification survey were found to be corrected during this revisit survey.
Inspection Report
Renewal
Deficiencies: 1
Date: Feb 3, 2022
Visit Reason
A Licensure Survey was conducted from February 1, 2022 through February 3, 2022 to assess compliance with licensure requirements.
Findings
The facility failed to assess one resident (R#28) of 23 sampled residents for the ability to safely self-administer over-the-counter medications, and there was no physician order or care plan supporting self-administration. Medications were observed left at the resident's bedside without proper assessment or authorization.
Deficiencies (1)
Failure to assess resident R#28 for safe self-administration of over-the-counter medications.
Report Facts
Sampled residents: 23
Resident ID: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse EE | Licensed Practical Nurse | Completed nurse progress note dated 12/14/2021 noting resident holding medication at bedside |
| Administrator | Interviewed regarding lack of education provided to nursing staff on self-administration policy | |
| Director of Nursing | Director of Nursing | Confirmed no assessment or physician order for resident self-administration |
| LPN AA | Licensed Practical Nurse | Interviewed about awareness of facility policy and medication administration practices |
| LPN BB | Agency Nurse | Interviewed about medication administration practices and prohibition of leaving medications at bedside |
Inspection Report
Life Safety
Census: 88
Capacity: 120
Deficiencies: 0
Date: Feb 2, 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 substantial compliance with the Emergency Preparedness Program requirements and Life Safety Code standards.
Inspection Report
Routine
Census: 88
Deficiencies: 1
Date: Feb 1, 2022
Visit Reason
A standard survey was conducted at Delmar Gardens of Smyrna from February 1, 2022, through February 3, 2022, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance due to failure to assess one resident (R#28) for the ability to safely self-administer over-the-counter medications, lacking a care plan and physician order for self-administration, and medications were left at the resident's bedside without proper authorization.
Deficiencies (1)
Failure to assess one resident (R#28) for the ability to safely self-administer over-the-counter medications.
Report Facts
Resident census: 88
Sampled residents: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse EE | Licensed Practical Nurse | Completed nurse progress note dated 12/14/2021 noting resident holding medication cup |
| Administrator | Interviewed regarding lack of education on self-administration policy | |
| Director of Nursing | Director of Nursing | Confirmed no assessment or physician order for resident self-administration |
| LPN AA | Licensed Practical Nurse | Interviewed about facility policy and medication administration practices |
| LPN BB | Licensed Practical Nurse | Agency nurse interviewed about medication administration practices |
Inspection Report
Abbreviated Survey
Census: 84
Deficiencies: 0
Date: Feb 18, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey in conjunction with an Abbreviated/Partial Extended Survey investigating complaint #GA00210521 was conducted from February 16 to February 18, 2021.
Complaint Details
Complaint #GA00210521 was unsubstantiated.
Findings
The complaint #GA00210521 was unsubstantiated, no regulatory violations were cited, and the facility was found to be in compliance with infection control regulations and COVID-19 preparedness practices.
Report Facts
Total census: 84
Inspection Report
Routine
Census: 99
Deficiencies: 0
Date: Jan 21, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with federal regulations and recommended practices related to COVID-19 preparedness and infection control.
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: 99
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 19, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was initiated on October 19, 2020, to investigate complaint #GA00209042.
Complaint Details
Complaint #GA00209042 was investigated and found to be unsubstantiated.
Findings
The complaint #GA00209042 was unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 21, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00203508 and #GA00203532.
Complaint Details
Complaints #GA00203532 and #GA00203508 were substantiated with no regulatory violations.
Findings
Complaints #GA00203532 and #GA00203508 were substantiated with no regulatory violations found.
Inspection Report
Routine
Census: 80
Deficiencies: 0
Date: Jul 16, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted at Delmar Gardens-Smyrna on July 16, 2020 to assess compliance with relevant CMS and CDC regulations.
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 recommended practices to prepare for COVID-19.
Report Facts
Total census: 80
Inspection Report
Routine
Census: 82
Deficiencies: 0
Date: Jun 18, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) to assess compliance with COVID-19 related regulations and preparedness.
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, including implementation of CMS and CDC recommended practices for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Feb 5, 2020
Visit Reason
An abbreviated survey was conducted to investigate complaint numbers GA00200089 and GA00202463.
Complaint Details
The complaints GA00200089 and GA00202463 were investigated and found to be unsubstantiated.
Findings
The complaints investigated during the abbreviated survey were found to be unsubstantiated.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 29, 2019
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited deficiencies had been corrected during the follow-up visit.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 11, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00 197251.
Complaint Details
Complaint GA00 197251 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Re-Inspection
Census: 97
Deficiencies: 0
Date: Jul 10, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 5/23/19 Standard Survey.
Findings
All deficiencies cited as a result of the 5/23/19 Standard Survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jul 8, 2019
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey tags.
Findings
The facility failed to assure against additional fire initiation devices, specifically a portable space heater was found in the Director of Nursing office without documentation that heating elements do not exceed 212 degrees Fahrenheit, placing 40 residents at risk in the event of fire.
Deficiencies (1)
Portable space heater found in the Director of Nursing office without documentation that heating elements do not exceed 212 degrees Fahrenheit, violating NFPA 101 requirements.
Report Facts
Residents at risk: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M confirmed findings at time of discovery |
Inspection Report
Life Safety
Census: 106
Capacity: 120
Deficiencies: 7
Date: May 20, 2019
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with fire safety regulations and related NFPA standards for participation in Medicare/Medicaid.
Findings
The facility was found not in substantial compliance with fire safety requirements, including issues with fire protection equipment, fire alarm system access and maintenance, sprinkler system readiness, smoke barrier doors, electrical safety, and the presence of prohibited portable space heaters.
Deficiencies (7)
Rubber cap on one extinguishing system nozzle was detached, possibly blocking extinguishing agent.
Facility failed to maintain emergency access to all fire protection notification devices; a fire alarm pull station was blocked.
Fire alarm system was in 'Trouble' status indicating failure to maintain optimum readiness.
Loaded sprinkler heads identified in the laundry area.
Fire door on C-hall did not latch in the closed position as required.
Facility failed to protect against shock hazards; multiple outlet power supplies found on the floor and electrical panel obstructed.
Portable space heater located behind desk in Director of Nursing office without documentation of temperature compliance.
Report Facts
Residents at risk due to blocked fire alarm pull station: 40
Staff at risk due to extinguishing system nozzle issue: 6
Residents at risk due to fire door not latching: 60
Residents at risk due to electrical shock hazard: 40
Loaded sprinkler heads identified: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed multiple findings during facility tour |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 16, 2018
Visit Reason
A complaint survey was conducted on 7/16/18 to investigate complaints #GA00188484 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint #GA00188484 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 11, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the April 12, 2018 Annual Survey.
Findings
All deficiencies cited as a result of the April 12, 2018 Annual Survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 30, 2018
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The follow-up survey noted that all previously cited deficiencies had been corrected.
Inspection Report
Routine
Census: 108
Deficiencies: 5
Date: Apr 12, 2018
Visit Reason
A standard survey was conducted at Delmar Gardens of Smyrna from April 9, 2018 through April 12, 2018 to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including timely response to call lights, advance directive documentation, baseline and comprehensive care plan development, and food safety practices.
Deficiencies (5)
Failure to ensure residents' call lights were answered in a timely manner, resulting in resident grievances and incidents of toileting accidents.
Failure to have a process to ensure Resident's Advance Directives were complete, accurate, and communicated to staff for 4 of 25 sampled residents.
Failure to complete baseline care plans and provide summaries to residents or representatives for 7 of 7 sampled new admissions.
Failure to develop and implement a comprehensive care plan for one of nine residents reviewed for new admission status.
Failure to store and prepare food in accordance with professional food service safety standards, including unlabeled and undated opened food items and cross contamination risk from use of contaminated oven mitt.
Report Facts
Resident census: 108
Sample size: 25
Minutes waited for call light response: 44
Minutes waited for call light response: 60
Minutes waited for call light response: 15
Number of unlabeled/undated food items: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| JJ | Licensed Practical Nurse | Named in interview regarding Resident #64's code status and advance directive documentation |
| FF | Social Services Director | Named in interview regarding resident council issues and advance directive process |
| II | Staff Development Nurse | Named in interview regarding call light in-service training |
| BB | Certified Nursing Assistant | Named in interview regarding typical call light response times |
| EE | Licensed Practical Nurse | Named in interview regarding Resident #101's resuscitation status |
| HH | Admissions Coordinator | Named in interview regarding advance directive checklist completion |
| GG | MDS Coordinator | Named in interview regarding baseline and comprehensive care plan development |
| CC | Lead Cook | Named in observations and interview regarding food storage and labeling deficiencies |
| DD | Prep Cook | Named in observation and interview regarding cross contamination with oven mitt |
| LL | Registered Nurse | Named in interview regarding comprehensive care plan completion |
Inspection Report
Routine
Deficiencies: 1
Date: Apr 12, 2018
Visit Reason
The inspection was conducted to assess compliance with nursing care requirements, specifically reviewing the comprehensive care plan for resident #230.
Findings
The facility failed to have a comprehensive care plan completed for resident #230 until after the surveyor intervened. The MDS Coordinator was new and the care plan was overlooked and not completed until 4/11/18.
Deficiencies (1)
Failure to provide nursing care according to the patient's needs and care plan, evidenced by the lack of a comprehensive care plan for resident #230.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LL | Registered Nurse | Confirmed no comprehensive care plan in resident's chart. |
| GG | MDS Coordinator | Confirmed care plan was not completed until after surveyor intervention. |
| DON | Director of Nursing | Discussed care plan status and MDS Coordinator's newness. |
Inspection Report
Life Safety
Census: 108
Capacity: 120
Deficiencies: 3
Date: Apr 9, 2018
Visit Reason
The Life Safety Code Survey was conducted to assess compliance with 42 CFR Subpart 483.70(a) and NFPA 101 Life Safety Code 2012 edition requirements for fire safety and related standards.
Findings
The facility was found not in substantial compliance with fire safety requirements, including loaded sprinkler heads in patient rooms, resident room doors that would not latch properly to resist smoke passage, and electrical hazards such as a power strip on the floor at the nurses station. These deficiencies could place staff and residents at risk in the event of fire or electrical hazards.
Deficiencies (3)
Sprinkler heads in patient rooms 9211 and 9103 were found to be loaded, compromising fire protection readiness.
Resident room doors in rooms 9121 and 9127 would not close to latch, failing to resist passage of smoke.
A multiple outlet power strip was located on the floor under the desk in the ANNEX nurses station, posing an electrical shock hazard.
Report Facts
Census: 108
Total Capacity: 120
Staff and residents at risk: 60
Staff and residents at risk: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M confirmed findings during the facility tour and at time of discovery |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 7, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The survey noted that all previously cited deficiencies had been corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 4, 2017
Visit Reason
A follow-up to the Recertification survey of June 16, 2017 was conducted to verify correction of previous 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: 104
Capacity: 120
Deficiencies: 5
Date: Jun 13, 2017
Visit Reason
The inspection 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 with fire safety requirements, including issues with the sprinkler system, corridor doors not closing or latching properly, smoke barrier integrity breaches, and electrical hazards. These deficiencies posed risks to residents and staff in the event of fire or electrical shock.
Deficiencies (5)
Missing sprinkler escutcheon plate in the kitchen that could delay extinguishing capability of the system.
Resident doors would not close and completely latch, and gaps around doors allowed smoke passage.
Fire/smoke wall above smoke door had an obvious penetration that would not limit smoke passage.
Corridor smoke doors would not fully close and latch on alarm release.
Electrical hazards including a voided circuit in electrical panel, missing outlet cover, multiple outlet power strips plugged into each other, and blocked electrical panel box.
Report Facts
Census: 104
Total Capacity: 120
Staff at risk: 10
Residents at risk: 40
Staff at risk: 10
Residents at risk: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 10, 2017
Visit Reason
The inspection was conducted as a complaint investigation survey to investigate complaint GA00175900.
Complaint Details
Complaint investigation survey conducted; no health deficiencies were cited.
Findings
No health deficiencies were cited during the complaint investigation survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 25, 2017
Visit Reason
The inspection was conducted as a Complaint Survey to investigate complaints #GA00172539 and #GA00172830 and to determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Investigation of complaints #GA00172539 and #GA00172830 during the Complaint Survey.
Findings
The survey identified deficiencies related to compliance with 42 CFR, Part 483, Subpart B for Long Term Care Requirements at Delmar Gardens of Smyrna.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 23, 2017
Visit Reason
The visit was conducted as a Complaint Survey to investigate complaints #GA00167839 and #GA00170215 and included a re-entry to determine compliance with Federal and State Long Term Care regulations.
Complaint Details
The survey was conducted to investigate complaints #GA00167839 and #GA00170215. No deficiencies were found, indicating the complaints were not substantiated.
Findings
No deficiencies were cited during the complaint survey and re-entry inspection.
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