Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Delmar Gardens Of Gwinnett during CMS and state inspections, most recent first.
The facility failed to provide RN coverage for at least 8 consecutive hours a day on multiple days. PBJ staffing data, timecards, daily staffing schedules, and two-week staffing grids showed no RN hours on several dates, and one RN only worked 6 hours on one day. The DON confirmed there were no RNs on the listed days and that four nurses were hired through the portal to cover the shifts, but none reported.
Failure to follow the care plan was identified for one resident with COPD, asthma, and chronic respiratory failure whose O2 via NC was ordered at 4 LPM continuous but was observed set at 5 LPM on two occasions. A second resident receiving IV therapy through a PICC line had a care plan addressing MDRO/MRSA precautions and line care, but the PICC dressing date was found to be outdated, and the DON stated nurses were expected to change PICC dressings every 7 days.
The facility failed to follow physician orders for two residents. One resident with a PICC line for IV antibiotics had a dressing change schedule and heparin flush order that were not followed as written, and staff stated they were unaware of the tubing and flush policy. Another resident had an order for a deep perimeter defining mattress, but the mattress was changed to a regular mattress after discussion with the resident and family, and staff were unsure about the order requirements.
Incorrect Oxygen Flow Rate: A resident with COPD, asthma, chronic respiratory failure, and moderate cognitive impairment was ordered O2 by NC at 4 LPM continuous, but surveyors observed the concentrator set at 5 LPM on multiple occasions. A CMA confirmed the flow rate was incorrect and stated it should have been checked each shift by nursing staff; the DON stated she believed the roommate was manipulating the resident’s oxygen levels.
The facility failed to properly date and label opened food items in the cooler, freezer, and dry food pantry, and did not maintain cleanliness in the kitchen. Observations revealed undated food items, a dirty oven and ice machine, and a utility worker not wearing a hairnet. Staff interviews indicated inconsistencies in labeling and dating food items, with some staff unsure about the process. The Chef and Dietary Manager were unable to read codes on food containers, leading to expired items being stored.
The facility failed to ensure one of two dumpsters had a plug in place and that the surrounding area was free of trash and debris. Trash, including soiled diapers, was observed on the ground behind the dumpster. The Dietary Manager and Maintenance Director confirmed the issue, and the Administrator indicated that staff should have a system in place to address such problems.
The facility failed to ensure the flat top oven in the kitchen was working properly, affecting all 58 residents who received an oral diet. The oven door was broken, and no maintenance work order was submitted for repair. Kitchen staff used the broken oven for storage, and the issue was verbally reported but not documented, leading to the deficiency.
The facility failed to ensure a Level II PASARR was conducted for a resident following a mental illness diagnosis. The resident's care plan noted the use of antipsychotic and antidepressant medications, but the Level I PASARR assessment did not indicate any mental illness, and thus, a Level II evaluation was not triggered. Interviews revealed that there was no process in place to review the Level I PASARR for accuracy.
The facility failed to follow individualized care plans for monitoring side effects of anticoagulant drug use for two residents. Despite having care plans that included monitoring for adverse effects such as abnormal bruising or bleeding, the facility did not adhere to these plans.
The facility failed to provide adequate vision and hearing care for three residents, including those with macular degeneration and diabetes. Despite residents expressing concerns and the facility's policy on maintaining hearing and vision abilities, there were no documented care plans, and the facility did not offer in-house optometry services.
The facility failed to document monitoring and side effects of anticoagulant use for two residents receiving Coumadin and Eliquis. Staff interviews revealed a lack of awareness and understanding of the need to monitor for side effects, and the monitoring orders were not entered into the system, resulting in no documentation on the MAR.
The facility failed to ensure medications were dated appropriately when opened and to discard expired medical supplies in one of three medication carts. Observations revealed multiple medications without open or discard dates, and expired oral supplements were found in the storage room. Staff interviews indicated awareness of the requirements but inconsistent adherence to procedures.
No RN Coverage on Multiple Days
Penalty
Summary
The facility failed to provide the services of an RN for at least eight consecutive hours a day, seven days a week on three days in February 2025 and one day in March 2025. Review of the PBJ Staffing Data Report showed the facility triggered for No RN Hours on 2/1/2025, 2/15/2025, 2/16/2025, and 3/1/2025. Payroll employee timecards showed RN CC worked 6.0 hours on 2/15/2025 and 0.00 hours on 2/1/2025, 2/16/2025, and 3/1/2025. The daily staffing schedules for 2/1/2025, 2/16/2025, and 3/1/2025 showed no RNs scheduled for 1st, 2nd, or 3rd shift, and the facility two-week staffing grids for the same periods showed no RN hours. During interview, the DON stated the facility used an on-call nurse 24/7 and expected a nurse to come into the facility, but confirmed there were no RNs on the listed days and that four nurses were hired through the portal to cover the shifts, none of whom showed up.
Failure to Follow Oxygen Orders and Incomplete PICC Line Care Planning
Penalty
Summary
Failure to follow the care plan was identified for a resident with COPD, asthma, and chronic respiratory failure who was ordered oxygen via nasal cannula at 4 LPM continuously. During observations on 8/12/2025 and 8/13/2025, the resident's oxygen concentration was set at 5 LPM instead of the ordered 4 LPM. The resident's care plan stated the resident was oxygen dependent and included interventions to administer oxygen as ordered by the MD. The DON stated that staff were expected to follow the resident care plan and any updates to it. A comprehensive, person-centered care plan was not developed for a resident receiving IV therapy through a PICC line. The resident's care plan, last edited 8/7/2025, addressed MDRO precautions, MRSA in a left lower extremity foot wound, and IV therapy, including PICC dressing changes every week or as ordered, heparin lock site changes every three days, IV tubing changes every 24 hours, flushing per protocol, labs as ordered, and monitoring the site for redness, swelling, tenderness, or drainage. Physician orders included PICC dressing changes every 7 days and as needed if soiled or loose, contact precautions for MRSA in the left lower extremity wound, and flushing orders for the non-valved PICC line. During observation on 8/12/2025, the date written on the resident's one-lumen PICC dressing was 7/23/2025. The DON stated that nurses were expected to change PICC line dressings every seven days.
Failure to Follow Physician Orders for PICC Care and Ordered Mattress
Penalty
Summary
The facility failed to follow physician orders for two residents. One resident had a PICC line for IV antibiotic therapy and orders for the PICC dressing to be changed every 7 days on Wednesdays, with a 5 ml heparin flush after a 10 ml normal saline flush. Observation showed the PICC dressing date did not match the ordered schedule, and staff interviews confirmed that only RNs changed PICC dressings. The DON acknowledged the dressing schedule in the order and stated the dressing had been changed by an RN the prior night, while also confirming the order called for heparin even though staff were not using it. The same resident’s IV tubing was observed hanging over the IV pole with no cap on the end, and an LPN stated she always used new tubing for every infusion and was not aware of the policy on how long tubing should be used. During a later observation, the LPN flushed the PICC line with normal saline only and did not use the ordered heparin flush. The LPN confirmed she only used normal saline, and the DON confirmed the order included heparin but stated the facility no longer used heparin to flush PICC lines. A second resident had a physician order for a deep perimeter defining mattress. The resident was observed using a mattress with raised outer edges and a lowered center, covered by a fitted sheet, and stated she had asked Social Services multiple times about returning to a regular mattress. Social Services stated the mattress had been changed after the resident and her son were told about the safety issues and chose the regular mattress, while also stating she was unsure whether an order was needed. The DON later confirmed the facility should have called the physician and spoken with the doctor about switching out the mattress.
Incorrect Oxygen Flow Rate
Penalty
Summary
The facility failed to deliver oxygen per physician order for one of four residents receiving oxygen therapy. R4 was admitted with diagnoses including COPD, asthma, chronic respiratory failure, and unspecified hypoxia or hypercapnia. Her most recent quarterly MDS showed a BIMS score of 11, indicating moderate cognitive impairment, and her care plan identified her as O2 dependent with interventions to administer oxygen as ordered by the MD. The physician’s order documented oxygen by nasal cannula at 4 liters per minute continuous. During observations on 8/12/2025 and 8/13/2025, R4’s oxygen concentrator was set at 5 liters per minute instead of the ordered 4 liters per minute. During an observation and interview on 8/13/2025, a CMA confirmed the flow rate was set incorrectly and stated it should have been set at 4 liters per minute. The CMA also stated nurses on night shift were supposed to check the oxygen concentrator every shift to ensure it was set at the correct level. During an interview on 8/14/2025, the DON stated she believed R4’s roommate was manipulating her oxygen levels and that R4 would be moved to a different room.
Failure to Properly Date and Label Food Items and Maintain Cleanliness in Kitchen
Penalty
Summary
The facility failed to ensure that opened food items were properly dated and labeled in the cooler, freezer, and dry food pantry. During a tour of the kitchen, several food items, including slider buns, lentils, spinach, okra, and corn flakes, were found without open dates. Additionally, the oven flat top was dirty with old grease and food, and the ice machine filters and the area around the opening were also dirty. Furthermore, a utility worker was observed not wearing a hairnet, and the recipe for pureed food was not followed as the thickening agent was not measured. Interviews with staff revealed inconsistencies in labeling and dating food items, with some staff unsure about the process and others discarding undated food items. The Chef admitted to not knowing how to read certain codes on food containers, leading to expired items being stored in the pantry. The facility's policies on food storage and labeling were not adhered to, as evidenced by the observations and staff interviews. The Chef and Dietary Manager were unable to read the codes on several food containers, resulting in expired items being kept in the pantry. The Administrator acknowledged that there should be systems in place and that staff should be educated on labeling procedures. Despite the presence of a representative providing information on how to read the codes, the Dietary Manager and Chef still could not determine the expiration dates of several items. This deficiency had the potential to affect all 58 residents who received an oral diet from the kitchen.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure one of two dumpsters had a plug in place and that the surrounding area around the dumpster was free of trash and debris. During an observation, it was revealed that the dumpster on the left side was unplugged and did not have a cap on it. Additionally, trash, including soiled diapers, was observed on the ground behind the dumpster. The Dietary Manager began to pick up the trash and put it in the dumpster. The Maintenance Director confirmed that the dumpster on the left side was unplugged and did not have a cap, stating that the opening was sealed and the drain was inside the dumpster. The Administrator indicated that staff should have a system in place to address such problems and that this issue should be taken to the Quality Assurance meeting.
Failure to Maintain Essential Kitchen Equipment
Penalty
Summary
The facility failed to ensure the flat top oven in the kitchen was working properly, specifically that the oven door would close efficiently to prepare cooked meals. This issue had the potential to affect all 58 residents who received an oral diet from the kitchen. The Nursing Home Maintenance work orders from 2/14/2024 through 4/13/2024 revealed no order to repair the oven. During a kitchen tour and interview with the Chef on 4/13/2024, it was observed that the oven was not clean and had a towel pushed between the door and stove to keep it closed. The Chef admitted the door was broken and had verbally informed the Maintenance Director (MD) about it. However, no written work order was submitted for the repair. The MD confirmed that he fixed the oven door and stated that staff should complete a maintenance work order for broken equipment, but he did not receive any written request for this issue. The Administrator expected staff to have a system in place to address such problems and mentioned that this process should be discussed in the Quality Assurance (QA) meeting. Interviews with kitchen staff revealed that the flat top stove had been broken for a couple of weeks. Cook GG and Cook HH both confirmed the stove's condition and mentioned that it was used for storage during this period. The Chef admitted to not filling out a work order for the broken oven door but had verbally informed the MD. This lack of proper documentation and follow-through led to the deficiency in ensuring the essential kitchen equipment was functioning correctly, potentially impacting the quality of meals prepared for the residents.
Failure to Conduct Level II PASARR for Resident with Mental Illness Diagnosis
Penalty
Summary
The facility failed to ensure a Level II PASARR was conducted for a resident (R21) following a mental illness diagnosis. The resident was readmitted to the facility with diagnoses including generalized anxiety disorder and depression. The facility's policy mandates that all residents receive a Pre-Admission Screening and Resident Review (PASARR) in accordance with state and federal regulations. However, the review of R21's records revealed that the Level I PASARR assessment did not indicate any mental illness, and thus, a Level II evaluation was not triggered. The resident's care plan noted the use of antipsychotic and antidepressant medications, which should have prompted further review for a Level II PASARR evaluation. Interviews with the Social Service Director (SSD) and the facility's Administrator revealed that the Level I PASARR was completed by the hospital prior to admission, and the previous admission director did not select the diagnoses of anxiety and depression on the application. The SSD confirmed that there was no process in place to review the Level I PASARR for accuracy. Consequently, the facility was unable to ensure that a Level II PASARR was not required, leading to a failure in compliance with the PASARR program requirements.
Failure to Follow Care Plans for Anticoagulant Monitoring
Penalty
Summary
The facility failed to follow the individualized care plan for monitoring side effects of anticoagulant drug use for two residents. Resident 27, who has diagnoses including deep vein thromboses and atrial fibrillation, was prescribed Coumadin. The care plan for Resident 27 included monitoring for adverse effects such as abnormal bruising or bleeding and observing stools for blood. However, the facility did not adhere to this care plan. Similarly, Resident 31, diagnosed with atrial fibrillation and anxiety, was prescribed Eliquis. The care plan for Resident 31 also included monitoring for signs of abnormal bruising or bleeding and observing stools for blood, but this was not followed either. Interviews with the Minimum Data Set (MDS) Nurse and the Director of Nursing (DON) revealed that the care plans are generated from MDS assessments and are expected to be followed by all staff. The MDS Nurse confirmed that she is responsible for ensuring the accuracy of assessments and the development of care plans reflecting the residents' current status. The DON stated that it is her expectation that residents on anticoagulant medications should have a care plan for monitoring side effects and that all staff should follow these care plans. Despite these expectations, the facility did not follow the care plans for monitoring the side effects of anticoagulant medications for the two residents in question.
Failure to Provide Adequate Vision and Hearing Care
Penalty
Summary
The facility failed to provide adequate assistance and support from social services for three residents (R21, R30, and R7) in receiving vision care. R21, who had macular degeneration and was almost blind, had not had an eye exam in two years and also reported difficulty hearing. Despite these issues, there was no documented vision or hearing care plan for R21. Similarly, R30, a diabetic resident, had not seen an optometrist in two years and expressed concerns about his vision. He mentioned that it was difficult to go out for appointments and had never been offered in-house optometry services. R7, another diabetic resident, also reported not having her vision checked in a while despite wearing glasses and recognizing the need for regular vision checks due to her condition. Interviews with the Social Service Director (SSD) and the Administrator revealed that the facility did not have an optometrist visiting the facility and relied on outside services for vision care. The SSD was unaware that vision services could be provided in-house, and the Administrator admitted to a lack of knowledge regarding the provision of in-house vision services. The MDS Coordinator, responsible for assessing residents' vision, stated that any complaints about vision would be reported to the Director of Nursing and the physician, but this process did not seem to be effectively addressing the residents' needs. The facility's policy on maintaining hearing and vision abilities indicated that residents should receive proper treatment and assistive devices, but this was not being implemented effectively. The failure to provide necessary vision and hearing care for these residents has the potential to affect their quality of life, as evidenced by the residents' expressed concerns and the lack of documented care plans addressing these issues.
Failure to Monitor Anticoagulant Use
Penalty
Summary
The facility failed to document monitoring and side effects of anticoagulant use for two residents, R27 and R31, who were receiving Coumadin and Eliquis, respectively. R27, with diagnoses including deep vein thrombosis, congestive heart failure, and atrial fibrillation, had no documented monitoring for anticoagulant use from April 1 through April 16, 2024. Similarly, R31, with diagnoses including atrial fibrillation and congestive heart failure, also had no documented monitoring for anticoagulant use during the same period. The facility's policy required licensed nurses to chart all pertinent information related to Coumadin administration, including signs and symptoms of hemorrhagic adverse effects, but this was not followed for these residents. Interviews with staff revealed a lack of awareness and understanding of the need to monitor residents on anticoagulants for side effects. LPN MM stated that medication techs should be monitoring residents' behaviors and side effects of anticoagulants, but this was not being done. CNA/CMA LL and LPN NN both indicated they were unaware of the need to monitor for signs of bleeding or bruising, as it was not on the medication record. The MDS Nurse and the DON confirmed that the monitoring orders were not entered into the system, and thus, the monitoring was not documented on the MAR for R27 and R31.
Failure to Date and Discard Medications Appropriately
Penalty
Summary
The facility failed to ensure medications were dated appropriately when opened to determine the discard date, and also failed to discard expired medical supplies in one of three medication carts. During an observation of medication administration, it was found that a Symbicort inhaler and a bottle of artificial tears were not labeled with an open or discard date. The Certified Medication Aide (CMA) responsible for the cart stated she did not know who had opened the medications and did not pay attention to the dates on the bottles. Additionally, a medication cart check revealed a vial of Levemir insulin and a bottle of fluticasone propionate without open or discard dates, and a bottle of Magnesium Citrate with a broken seal. Another cart check found olopatadine eye drops with an open date that exceeded the manufacturer's discard instructions and a Kardex of hydrocodone tablets for a discharged resident still in the cart's narcotic box. The Director of Nursing (DON) acknowledged the issues and stated that the Central Supply clerk was on leave, which contributed to the oversight of expired oral supplements in the storage room. The DON also mentioned that the pharmacy consultant nurse conducts quarterly audits and provides in-service training to address these issues, but the problems persisted. The facility's policies on expiration dating of medications and medications with shortened expiration dates were not followed, as evidenced by multiple medications not being labeled with open dates. The Pharmacy Nurse Consultant's report confirmed that the medication carts had several medications, including inhalers, nasal sprays, and insulin vials/pens, which were not labeled with an open date. The consultant nurse also noted that the facility had a history of similar issues and had provided in-service training to staff, but the deficiencies continued to occur. Interviews with staff members revealed that they were aware of the requirement to date medications when opened but failed to consistently follow this procedure. The Director of Nursing (DON) and the Infection Preventionist found expired oral supplements in the medication storage room, which were discarded immediately. The DON admitted to missing the expiration dates due to the absence of the Central Supply clerk and stated that she would check all the bottles of the supplement on the medication carts to ensure they were not expired. The Pharmacy Nurse Consultant confirmed that she visits the facility approximately every eight to ten weeks to conduct cart audits and provide written reports for in-service training. Despite these efforts, the facility continued to have issues with expired medications and medications not being labeled with open dates, leading to the identified deficiencies.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lawrenceville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Gwinnett | 3.1 mi | ★★★★★ | 0 | 0 |
| Pruitthealth - Lilburn | 4.2 mi | ★★★★★ | 0 | 0 |
| Life Care Ctr Of Lawrenceville | 5.8 mi | ★★★★★ | 6 | 0 |
| Cambridge Post Acute Care Center | 6.6 mi | ★★★★★ | 10 | 0 |
| Salude - The Art Of Recovery | 6.8 mi | ★★★★★ | 0 | 0 |
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