Inspection Reports for
Delmar Gardens of Smyrna
404 King Springs Village Pkwy, Smyrna, GA 30082, GA, 30082
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
5.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
12% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 6, 2025
Visit Reason
The inspection was conducted due to complaints regarding misappropriation of a resident's property and failure to timely report suspected sexual abuse between residents.
Complaint Details
The complaint involved misappropriation of a resident's bank card and failure to immediately report nonconsensual sexual abuse between two residents. The sexual abuse was substantiated, and the facility delayed reporting to the state beyond the required timeframe.
Findings
The facility failed to protect a resident from misappropriation of her bank card and failed to immediately report suspected sexual abuse between two residents. Investigations were inconclusive regarding the theft, and the sexual abuse was reported late to the state. Psychosocial monitoring and assessments were implemented following the abuse incident.
Deficiencies (2)
F 0602: The facility failed to protect a resident from misappropriation of property when a resident's bank card was stolen from her handbag stored in her closet. The investigation was inconclusive, and the card was later found in another resident's room.
F 0609: The facility failed to timely report suspected sexual abuse between two residents, delaying notification to the state beyond the required 2-hour window. Psychosocial monitoring and full body assessments were conducted following the incident.
Report Facts
Residents Affected: 1
Residents Affected: 2
BIMS score: 15
BIMS score: 9
BIMS score: 3
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 8, 2025
Visit Reason
The purpose of this visit was to complete a follow-up inspection to the initial inspection conducted on 2025-01-16.
Findings
The inspection started on 2025-05-07 and was completed on 2025-05-08. No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 19, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50001536.
Complaint Details
Investigation of intake #GA50001536; no violations were found.
Findings
No violations were cited as a result of this survey.
Inspection Report
Routine
Deficiencies: 2
Date: Jan 16, 2025
Visit Reason
The inspection was conducted to assess compliance with physical design, environment, and safety requirements in the memory care unit of the assisted living facility.
Findings
The facility failed to provide secured outdoor spaces in the memory care unit and lacked an effective automated device or system to alert staff of unauthorized exits or entrances. Staff indicated plans to install an automated alarm system.
Deficiencies (2)
Failure to provide secured outdoor spaces in a specialized memory care unit.
Failure to have an effective automated device or system to alert staff of unauthorized exit or entrance in the memory care unit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding deficiencies and plans for correction. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 27, 2024
Visit Reason
The visit was conducted to investigate intake numbers #GA00251492 and #GA00249336.
Complaint Details
Investigation of two complaint intakes (#GA00251492 and #GA00249336) with no rule violations found.
Findings
The investigation was completed with no rule violations cited as a result.
Inspection Report
Annual Inspection
Deficiencies: 12
Date: Dec 19, 2024
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements and evaluate the quality of care and services provided at Delmar Gardens of Smyrna.
Findings
The facility was found deficient in multiple areas including resident dignity, medication self-administration, accommodation of resident needs, notification of condition changes, accuracy of assessments, care planning, activities of daily living assistance, dialysis communication, bed rail use, psychotropic medication management, and infection control practices. Deficiencies were generally of minimal harm with potential to affect resident quality of life and safety.
Deficiencies (12)
F 0550: The facility failed to maintain dignity by ensuring a urinary catheter drainage bag was covered in a privacy bag for one resident, leaving it visible from the hallway.
F 0554: The facility failed to prevent unauthorized medications from being stored at the bedside for one resident without assessment or physician order for self-administration.
F 0558: The facility failed to reasonably accommodate a resident's physician order to keep feet elevated at all times due to lack of appropriate wheelchair equipment.
F 0580: The facility failed to promptly notify the resident's responsible party of a change in condition related to a deep tissue injury for one resident.
F 0641: The facility failed to provide accurate Minimum Data Set (MDS) assessment data for two residents, affecting the assessment of their care needs.
F 0655: The facility failed to develop a baseline care plan for enteral tube feeding within 48 hours of admission for one resident.
F 0656: The facility failed to develop a comprehensive person-centered care plan for one resident receiving unnecessary medications.
F 0677: The facility failed to provide adequate shaving assistance to one resident, resulting in excessive facial hair and unmet personal hygiene needs.
F 0698: The facility failed to document communication between the facility and dialysis center after each dialysis session for one resident receiving dialysis.
F 0700: The facility failed to obtain consent, physician's order, and assessment for the use of bilateral half-side bed rails for one resident at fall risk.
F 0758: The facility failed to limit PRN psychotropic medication orders to 14 days or provide clinical indication for continued use for one resident.
F 0880: The facility failed to ensure infection control practices including covering clean linen during transport, following transmission-based precautions for MRSA, proper storage of CPAP masks, hand hygiene during medication pass, and cleaning shared medical equipment between residents.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Facility census: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN HH | Licensed Practical Nurse | Confirmed urinary catheter bag uncovered |
| LPN EE | Licensed Practical Nurse | Confirmed unauthorized medication at bedside and dialysis communication issues |
| RN JJ | Registered Nurse | Confirmed wheelchair accommodation issue |
| Unit Manager LPN II | Unit Manager Licensed Practical Nurse | Confirmed wheelchair accommodation and notification issues |
| Director of Nursing | Director of Nursing | Provided multiple statements on expectations for catheter care, medication administration, care planning, dialysis communication, bed rail use, psychotropic medication orders, and infection control |
| CNA DD | Certified Nursing Assistant | Reported shaving assistance and facial hair observations |
| Housekeeper MM | Housekeeper | Observed transporting uncovered clean linen |
| Housekeeping Director | Housekeeping Director | Stated expectation for covering clean linen during transport |
| Infection Preventionist | Infection Preventionist | Confirmed expectations for linen transport, transmission-based precautions, and CPAP mask cleaning |
| LPN BB | Licensed Practical Nurse | Observed failing to clean blood pressure equipment and perform hand hygiene during medication pass |
| MDS Coordinator | MDS Coordinator | Confirmed inaccurate MDS assessments and consent requirements for bed rails |
Inspection Report
Annual Inspection
Deficiencies: 12
Date: Dec 19, 2024
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with regulatory requirements and evaluate the quality of care and services provided at the nursing home.
Findings
The facility was found deficient in multiple areas including residents' rights and dignity, medication management, care planning, infection control, use of assistive devices, and communication with dialysis centers. Deficiencies were generally of minimal harm but affected several residents and had potential to impact quality of life and safety.
Deficiencies (12)
F 0550: The facility failed to maintain dignity by ensuring a urinary catheter drainage bag was covered for one resident, leaving it visible and uncovered in the hallway.
F 0554: The facility failed to prevent unauthorized medications from being stored at a resident's bedside without assessment or physician order for self-administration.
F 0558: The facility failed to reasonably accommodate a resident's needs by not providing a wheelchair to elevate both feet as ordered by the physician.
F 0580: The facility failed to promptly notify the resident's responsible party of a change in condition related to a deep tissue injury.
F 0641: The facility failed to provide accurate Minimum Data Set (MDS) assessment data for two residents, affecting care planning.
F 0655: The facility failed to develop a baseline care plan for enteral tube feeding within 48 hours of admission for one resident.
F 0656: The facility failed to develop a comprehensive person-centered care plan for a resident using unnecessary medications.
F 0677: The facility failed to provide adequate shaving assistance, resulting in excessive facial hair for one resident.
F 0698: The facility failed to document communication between the facility and dialysis center after each dialysis session for one resident.
F 0700: The facility failed to obtain consent, physician's order, and assessment for the use of bilateral half-side bed rails for one resident.
F 0758: The facility failed to limit PRN psychotropic medication orders to 14 days unless clinically indicated for one resident.
F 0880: The facility failed to ensure infection control procedures including covering clean linen during transport, following transmission-based precautions, proper storage of CPAP masks, hand hygiene during medication pass, and cleaning shared medical equipment.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Facility census: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN HH | Licensed Practical Nurse | Confirmed urinary catheter bag uncovered |
| LPN EE | Licensed Practical Nurse | Confirmed unauthorized medication at bedside and dialysis communication issues |
| RN JJ | Registered Nurse | Confirmed wheelchair accommodation failure |
| Unit Manager LPN II | Unit Manager Licensed Practical Nurse | Confirmed wheelchair accommodation failure and notification failure |
| CNA DD | Certified Nursing Assistant | Reported failure to provide shaving assistance |
| LPN BB | Licensed Practical Nurse | Observed failing hand hygiene and cleaning shared equipment |
| CNA FF | Certified Nursing Assistant | Observed not following transmission based precautions |
| Housekeeper MM | Housekeeper | Observed transporting clean linen uncovered |
| Infection Preventionist | Infection Preventionist | Confirmed infection control deficiencies |
| MDS Coordinator | MDS Coordinator | Confirmed inaccurate MDS assessments and consent requirements |
| Director of Nursing | Director of Nursing | Provided multiple statements on expectations and deficiencies |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Aug 10, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with health and safety regulations, including resident care, abuse reporting, fall prevention, respiratory care, and food safety.
Findings
The facility was found deficient in multiple areas including unsafe water temperatures in resident rooms, failure to timely report and investigate verbal abuse allegations, incomplete implementation of fall prevention care plans, inadequate assistance with activities of daily living, improper respiratory care including oxygen equipment management, and food safety violations related to labeling and cleaning.
Deficiencies (7)
F 0584: Water temperatures in 11 of 66 resident rooms exceeded the safe limit of 110 degrees Fahrenheit, reaching up to 116 degrees, posing a scalding risk. Additionally, multiple elimination containers were found unlabeled, unbagged, and improperly stored in shared bathrooms.
F 0609: The facility failed to report an allegation of verbal abuse by a Certified Nursing Assistant against a resident within the required two hours, delaying notification to the State Agency.
F 0610: The facility failed to thoroughly investigate and follow-up on a verbal abuse allegation, resulting in actual harm to the resident who remained fearful for her safety.
F 0656: The facility failed to follow the care plan for fall prevention for one resident, including absence of 'Call Don't Fall' signage in the resident's room despite a high fall risk score and history of multiple falls.
F 0677: The facility failed to provide adequate Activities of Daily Living care for two residents, including failure to clip fingernails for a diabetic resident and insufficient shower assistance for another resident.
F 0695: The facility failed to follow physician orders and properly store oxygen equipment for one resident, including use of oxygen without required humidification and tubing not changed weekly as ordered.
F 0812: The facility failed to ensure opened food items were properly labeled and dated, and failed to dry clean dishes appropriately, with observed moisture between stacked items and unclean kitchen equipment.
Report Facts
Resident rooms with unsafe water temperature: 11
Residents sampled: 32
Fall risk score: 65
Residents affected by food safety deficiency: 98
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA NN | Certified Nursing Assistant | Named in verbal abuse allegation against resident #53 |
| LPN CC | Licensed Practical Nurse and Unit Manager | Involved in abuse reporting and oxygen care for resident #77 |
| Dietary AA | Dietary Staff | Verified food labeling and dish drying deficiencies |
| Dietary Manager | Dietary Manager | Confirmed food safety and cleaning deficiencies |
| Administrator | Facility Administrator | Interviewed regarding abuse reporting and dietary expectations |
| Director of Nursing | Director of Nursing | Interviewed regarding abuse reporting, fall prevention, and respiratory care |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Aug 10, 2023
Visit Reason
The inspection was conducted as a routine annual survey to assess compliance with regulatory requirements and investigate specific complaints and concerns related to resident safety, care, and facility conditions.
Findings
The facility was found deficient in multiple areas including unsafe water temperatures in resident rooms, failure to timely report and investigate verbal abuse allegations, inadequate fall prevention care plan implementation, insufficient assistance with activities of daily living, improper respiratory care including oxygen equipment management, and poor food storage and kitchen sanitation practices.
Deficiencies (7)
F 0584: The facility failed to maintain safe water temperatures not exceeding 110 degrees Fahrenheit in 11 of 66 resident rooms, with temperatures measured up to 116 degrees F. Additionally, bedpans and urinal containers were found unlabeled, unbagged, and improperly stored in shared bathrooms.
F 0609: The facility failed to timely report an allegation of verbal abuse by a Certified Nursing Assistant against one resident within the required two hours, with reports delayed up to seven days.
F 0610: The facility failed to thoroughly investigate and follow up on the verbal abuse allegation, resulting in actual harm to the resident who remained fearful for her safety.
F 0656: The facility failed to implement fall prevention interventions as required by the care plan for one resident at high risk for falls, including absence of 'Call Don't Fall' signage in the resident's room.
F 0677: The facility failed to provide adequate activities of daily living care for two residents, including failure to clip fingernails for a diabetic resident and insufficient shower assistance for another resident.
F 0695: The facility failed to follow physician orders for oxygen therapy and properly store oxygen equipment for one resident, including use of oxygen without required humidification and tubing not changed weekly.
F 0812: The facility failed to ensure opened food items in the refrigerator and dry storage were properly labeled and dated, and failed to properly dry clean dishes and maintain kitchen equipment sanitation.
Report Facts
Resident rooms with unsafe water temperature: 11
Residents sampled: 32
Residents affected by food storage deficiency: 98
Fall risk score: 65
Oxygen tubing date: Jul 31, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA NN | Certified Nursing Assistant | Named in verbal abuse allegation against resident #53. |
| LPN CC | Licensed Practical Nurse and Unit Manager | Involved in reporting and investigation of abuse allegation and oxygen therapy management. |
| Dietary AA | Dietary Staff | Verified food labeling and kitchen sanitation deficiencies. |
| Dietary Aide BB | Dietary Aide | Admitted to stacking dishes wet due to lack of drying space. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 29, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00222376 and conduct the compliance inspection.
Complaint Details
Investigation of intake #GA00222376; no rule violations found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 3, 2022
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to assess a resident for the ability to safely self-administer over-the-counter medications.
Complaint Details
The complaint investigation found the facility failed to assess and obtain physician orders for resident self-administration of medications. The issue was substantiated with observations, record reviews, and staff interviews confirming policy noncompliance.
Findings
The facility failed to perform an assessment or obtain a physician's order for a resident to self-administer medications. Medications were found left at the resident's bedside without proper authorization, and staff confirmed lack of education and adherence to the self-administration policy.
Deficiencies (1)
F 0554: The facility failed to assess one resident for the ability to safely self-administer over-the-counter medications and did not have a physician's order for self-administration. Medications were left at the resident's bedside without proper authorization, violating facility policy.
Report Facts
Residents sampled: 23
Resident affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse EE | Licensed Practical Nurse | Named in nurse progress note regarding medication left at bedside |
| LPN AA | Licensed Practical Nurse | Interviewed about facility policy and medication administration |
| LPN BB | Agency Nurse | Interviewed about medication administration practices |
| Director of Nursing | Director of Nursing | Confirmed lack of assessment and physician order for self-administration |
| Administrator | Administrator | Interviewed about staff education on self-administration policy |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 20, 2021
Visit Reason
The purpose of this visit was to investigate self-reported intake GA 00209595.
Complaint Details
Visit was complaint-related to investigate self-reported intake GA 00209595. Resident #1 became agitated when Staff B removed spoiled food from the resident's refrigerator, leading to physical contact and the resident losing balance. Staff B was terminated for refusal to stop removing food when asked.
Findings
The facility failed to ensure that one resident was treated with dignity, kindness, consideration, and respect, and was given privacy in the provision of assisted living care. Staff B was terminated due to refusal to stop removing spoiled food from Resident #1's refrigerator despite the resident's request to stop.
Deficiencies (1)
Facility failed to ensure each resident was treated with dignity, kindness, consideration and respect and given privacy in assisted living care for 1 of 1 residents sampled (Resident #1).
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Named in finding related to removal of spoiled food from Resident #1's refrigerator and subsequent termination. | |
| Staff A | Interviewed regarding the incident involving Staff B and Resident #1. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 27, 2020
Visit Reason
The purpose of this inspection was to investigate complaint intakes #GA00208899, #GA00208885, and #GA00208658.
Complaint Details
The investigation began on 2020-10-16 and was completed on 2020-10-27. The complainant was contacted on 2020-10-16 at 2:30 p.m.
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 processes.
Findings
The report focuses on monitoring COVID-19 cases and evaluating the facility's infection control processes.
Inspection Report
Routine
Deficiencies: 0
Date: Mar 27, 2019
Visit Reason
The purpose of this visit was to conduct a compliance inspection.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Original Licensing
Deficiencies: 0
Date: Nov 9, 2017
Visit Reason
The purpose of this visit was to conduct the initial inspection of the facility.
Findings
No rule violations were cited as a result of this inspection.
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