Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Smyrna during CMS and state inspections, most recent first.
Expired supplements were found in two medication rooms and on two medication carts, including Nephro, 2 Cal HN, and Glucerna with outdated expiration dates. Surveyors observed bottles in the main storage room, including 2 Cal HN and Nephro products being used by multiple residents, and staff confirmed that nurses were responsible for checking dates when retrieving and administering the supplements, while medical records stocked and controlled the supply.
A resident with aphasia, dysphagia, and a gastrostomy tube was ordered Jevity 1.5 at 70 mL/hr for 20 hours with specific on/off times and water flushes, but surveyors observed the tube feeding not running when it should have been on and later still infusing when it should have been off. The resident’s tube feeding supplies were also observed with a syringe not bagged or labeled, and an LPN confirmed the feeding had not been turned off per the physician order.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
The facility failed to follow infection control procedures, including transporting clean linen uncovered, not adhering to TBP for a resident with MRSA, improper storage of a CPAP mask, and inadequate hand hygiene and equipment cleaning by an LPN. These deficiencies were confirmed by staff and highlighted breaches in infection control practices.
A resident with an indwelling urinary catheter was observed with an uncovered drainage bag visible from the hallway, contrary to the facility's expectations for maintaining resident dignity. An LPN confirmed the oversight, and the DON stated that staff should ensure such bags are covered after care incidents.
A resident with moderate cognitive impairment and multiple health issues had an inhaler stored at their bedside without a proper assessment or physician's order for self-administration. Facility policy requires an assessment and approval for self-administration, which was not conducted for this resident. An LPN and the DON confirmed the deficiency, noting that medications should not be at the bedside without proper authorization.
A resident with impaired mobility and reperfusion edema did not have her feet elevated as required by a physician's order due to the facility's lack of appropriate wheelchair equipment. Observations showed her feet on the floor, and staff interviews confirmed the inconsistency in compliance with the order, attributing it to equipment unavailability.
A facility failed to notify a resident's representative of a change in condition related to a deep tissue injury. The resident had a history of pressure-induced deep tissue damage and other conditions. Despite the facility's policy requiring notification, there was no documentation of informing the representative about the worsening condition or new treatment orders. Interviews confirmed the lack of communication, and the DON acknowledged the expectation for notification.
The facility failed to provide accurate MDS assessment data for two residents, potentially affecting their care needs. One resident's MDS inaccurately documented hearing and speech abilities, while another's failed to include a dementia diagnosis. The MDS Coordinator confirmed these inaccuracies, highlighting the importance of accurate assessments for appropriate care.
A facility failed to develop a baseline care plan for a resident receiving enteral tube feeding within 48 hours of admission, as required by their policy. The resident, admitted with cerebral infarction and pneumonitis, did not have a documented care plan for enteral feeding. Observations confirmed the resident was receiving enteral feeding, and interviews with the DON and MDS Director acknowledged the oversight.
A facility failed to create a comprehensive care plan for a resident receiving multiple medications, including antipsychotics, antidepressants, and antianxiety drugs. Despite the facility's policy requiring individualized care plans, the resident's care plan lacked areas addressing these medications. The MDS Coordinator confirmed the oversight, acknowledging the importance of care plan areas to inform staff of the resident's needs.
A facility failed to provide adequate grooming assistance to a resident with cerebral infarction and hemiplegia, resulting in excessive facial hair. Despite the facility's policy and the resident's need for substantial assistance with personal hygiene, observations revealed the resident had excessive facial hair after a scheduled shower. Staff interviews confirmed the deficiency, highlighting a lapse in meeting the resident's grooming needs.
A facility failed to document communication between the facility and dialysis center for a resident requiring dialysis. Despite policy requirements, the first documented communication form was completed several days after the resident began dialysis. Staff interviews confirmed the importance of these forms for continuity of care, but they were not consistently completed, potentially risking the resident's health.
A facility failed to obtain the necessary consent, physician's order, and assessment for a resident's use of bilateral half-side rails, as required by their policy. The resident, with moderate cognitive impairment and a history of falls, was observed with the side rails up without proper documentation. Staff interviews confirmed the absence of required documentation, and the resident was unaware of the reason for the side rails.
A facility failed to limit a PRN order for Ativan (lorazepam) for a resident with anxiety to 14 days, as required by its policy. The order was open-ended, lacking a definitive stop date, which was confirmed by the DON. This oversight had the potential to affect the resident's well-being.
Expired supplements found in medication storage areas and carts
Penalty
Summary
The facility failed to discard expired supplements in two of two medication rooms and on two of four medication carts. During observation, surveyors found biological supplements including Nephro, 2 Cal HN, and Glucerna with outdated expiration dates in the Front Annex A & B section, C Hall Annex, and the main storage room. In the main storage room, three bottles of 2 Cal HN were observed, including one dated September 2024, and there were two residents in the facility receiving this supplement. Outdated Nephro supplements were also observed, with three residents in the facility receiving this supplement, along with an outdated Glucerna supplement. Review of the facility policy titled Medication Expiration Guidelines stated that when liquid is dispensed in the manufacturer's bottle, the expiration date is the manufacturer's expiration date printed on the bottle. During interviews, an LPN confirmed the outdated supplements in the main supply room on the annex hall and stated nurses were responsible for obtaining and checking supplements when retrieved from the supply room, while they were stocked and controlled by medical records. An LPN and a CMA stated they checked expiration dates when giving supplements, and the Administrator stated medical records was in charge of central supply and putting supplements in the storage room for nursing, while nursing should check dates prior to administration.
Tube Feeding Not Administered Per Physician Orders
Penalty
Summary
The facility failed to follow physician orders for R99’s enteral nutrition and hydration. R99 was admitted with diagnoses including aphasia following cerebral infarction, dysphagia following cerebral infarction, and attention to gastrostomy. The MDS showed a BIMS score of 15, indicating intact cognitive status, and the resident was dependent on staff for ADLs and received tube feeding as a source of nutrition. The physician order directed Jevity 1.5 at 70 mL/hr for 20 hours, with the feeding to be on at 1:00 PM and off at 9:00 AM, along with ordered water flushes. Survey observations showed the tube feeding was not running at 9:00 AM while still connected to the resident, and the syringe was in a container but not bagged or labeled. Later observations showed the tube feeding was still not running at 2:00 PM and again at 3:00 PM, despite the physician order to start at 1:00 PM. On the following day, the tube feeding was observed infusing at 70 mL/hr at 11:19 AM even though the physician order required it to be stopped at 9:00 AM. An LPN confirmed that the feeding was still infusing and stated she had not turned it off per the physician order.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Infection Control Deficiencies in Linen Transport, TBP, and Equipment Handling
Penalty
Summary
The facility failed to adhere to its infection control procedures, as evidenced by several observations and staff interviews. Housekeeping staff were observed transporting clean linen uncovered on multiple occasions, contrary to the facility's policy that requires clean linen to be covered during transport. This was confirmed by the housekeeping staff and the Infection Preventionist, who both acknowledged the expectation for linen to be covered to prevent the spread of infection. Additionally, the facility did not follow Transmission Based Precautions (TBP) for a resident diagnosed with MRSA. The resident's care plan required the use of personal protective equipment during high-contact activities, but a Certified Nursing Assistant was observed providing care with only gloves and no gown. The absence of a TBP sign on the resident's door was also noted, which was confirmed by the Infection Preventionist and the Director of Nursing as a failure to adhere to the required precautions for residents with MRSA. The facility also failed to properly store a CPAP mask for a resident with chronic respiratory conditions. The mask was observed lying on the floor and not placed in a bag when not in use, as required. Furthermore, during a medication pass, an LPN did not perform hand hygiene before entering a resident's room and failed to clean shared medical equipment between uses. These actions were acknowledged by the LPN and the Director of Nursing, highlighting a breach in infection control practices.
Failure to Provide Dignity Bag for Urinary Catheter
Penalty
Summary
The facility failed to maintain the dignity of a resident with an indwelling urinary catheter by not providing a dignity bag to cover the urinary catheter drainage bag. The resident, who had a diagnosis of benign prostatic hyperplasia with lower urinary tract symptoms, was observed on two separate occasions with the urinary catheter drainage bag uncovered and visible from the hallway. This was confirmed by an LPN who acknowledged that the drainage bags should always be covered when visible to others. The facility's document on Residents' Rights emphasizes the importance of treating residents with dignity and respect. Despite this, the Director of Nursing stated that staff are expected to ensure urinary catheter drainage bags are covered after each care incident, indicating a lapse in adherence to this expectation. The resident involved had a BIMS score indicating little to no cognitive impairment, suggesting awareness of the situation, which could further impact their sense of dignity.
Unauthorized Medication Storage at Bedside
Penalty
Summary
The facility failed to ensure that unauthorized medications were not stored at the bedside for one resident, identified as R85. The facility's policy requires an assessment by the charge nurse and approval by the interdisciplinary care plan team before a resident can self-administer medications. Additionally, a physician's order is necessary to specify which medications may be self-administered. However, R85's electronic medical record showed no assessment for self-administration of medications, and there was no physician's order for self-administration. Despite this, a fluticasone furoate and vilanterol inhaler was observed on R85's bedside dresser. R85's medical history included chronic obstructive pulmonary disease (COPD), respiratory failure, heart failure, dysphagia, and major depression. The Quarterly Minimum Data Set (MDS) assessment indicated moderate cognitive impairment and dependency on a helper for various activities. During an interview, an LPN confirmed that the inhaler should not have been at the bedside, as R85 was not assessed for self-administration. The Director of Nursing reiterated that medications should not be kept at the bedside without a physician's order for self-administration, and that nurses should administer medications to residents who have not been assessed for self-administration.
Failure to Provide Appropriate Wheelchair for Resident's Needs
Penalty
Summary
The facility failed to reasonably accommodate the needs of a resident, identified as R62, by not providing a wheelchair that allowed for the elevation of both feet as per a physician's order. R62 had diagnoses including impaired mobility and reperfusion edema, and the physician's order dated 12/2/2024 required that her legs be elevated above heart level at all times to manage her condition. Observations on 12/17/2024 revealed that R62 was in a wheelchair with her feet on the floor, contrary to the physician's order and her care plan dated 12/6/2024, which included keeping her legs elevated at all times. Interviews with facility staff, including a Registered Nurse, a Unit Manager LPN, and the Director of Nursing, confirmed that R62's feet were not consistently elevated due to the lack of appropriate wheelchair equipment. The staff acknowledged that compliance with the physician's order was inconsistent, and the Director of Nursing stated that the delay in obtaining the necessary equipment contributed to the issue. This deficiency had the potential to place R62 at risk for medical complications, unmet needs, and a diminished quality of life.
Failure to Notify Resident's Representative of Change in Condition
Penalty
Summary
The facility failed to promptly notify the responsible party of a change in condition for a resident who was reviewed for a change in condition related to a deep tissue injury. The facility's policy titled 'Condition Change of the Resident' requires notifying the resident's responsible party of any changes. However, there was no documentation indicating that the resident's representative was informed of the worsening condition of the resident's toe or the new treatment orders on two separate occasions. The resident in question had a medical history that included pressure-induced deep tissue damage, vascular dementia, and hemiplegia. The resident's care plan noted a risk for skin breakdown, and a deep tissue injury was identified on the left great toe. Despite this, the resident's representative was not informed of the condition's progression or the treatment plan, as confirmed by interviews with the resident's representative and the Unit Manager. The Director of Nursing also confirmed the expectation that the resident's representative should have been notified of any changes in the resident's condition or treatment plan.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to provide accurate Minimum Data Set (MDS) assessment data for two residents, which could potentially affect their care needs. For one resident, the MDS assessment inaccurately documented the resident's hearing and speech abilities. The resident was noted to have unspecified bilateral hearing loss and was documented as having highly impaired hearing and no speech. However, during an interview, the resident was able to respond verbally, indicating that the MDS assessment was incorrect. The resident's care plan and physician's orders also contradicted the MDS assessment, as they indicated the resident was deaf and required communication via a whiteboard. For another resident, the MDS assessment failed to document a diagnosis of dementia, despite the resident having a diagnosis of unspecified dementia and being prescribed memantine, a medication used to treat dementia. The resident's care plan acknowledged cognitive loss/dementia, but the MDS assessment did not reflect this diagnosis. The MDS Coordinator confirmed the inaccuracies in both residents' assessments and acknowledged the importance of accurate MDS assessments to ensure appropriate care is provided.
Failure to Develop Baseline Care Plan for Enteral Feeding
Penalty
Summary
The facility failed to develop a baseline care plan for a resident who was receiving enteral tube feeding within 48 hours of admission, as required by their policy. The facility's policy, titled 'Care Plan Conference Interdisciplinary,' mandates that an initial care plan should be completed in the electronic health record within 48 hours of admission. However, upon review, it was found that the resident, who was admitted with diagnoses including cerebral infarction and pneumonitis due to inhalation of food and vomit, did not have a care plan for enteral tube feeding documented in their care plan dated 12/12/2024. Observations conducted on 12/17/2024 and 12/18/2024 confirmed that the resident was receiving enteral feeding via a feeding tube. Interviews with the Director of Nursing and the MDS Director revealed an acknowledgment of the oversight, with the MDS Director confirming that a baseline care plan for enteral tube feeding should have been created but was not. This deficiency had the potential to place the resident at risk for not receiving treatment and/or care according to their needs.
Failure to Develop Comprehensive Care Plan for Resident on Multiple Medications
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, identified as R26, who was receiving unnecessary medications. The facility's policy on Care Management, revised in May 2021, mandates that all resident care should be tailored to meet individual needs and requires joint participation from each discipline involved in the resident's care. However, a review of R26's electronic medical record revealed that despite being prescribed multiple medications, including antipsychotics, antidepressants, and antianxiety medications, there were no corresponding care plan areas addressing these medications. The deficiency was confirmed during an interview with the MDS Coordinator, who acknowledged her involvement in care plan development and verified that R26 was receiving the aforementioned medications. She admitted that there were no care plan areas for these medications and stated that such areas are crucial to inform staff of the resident's care needs. This oversight had the potential to place R26 at risk for not receiving treatment and/or care according to their needs.
Failure to Provide Adequate Grooming Assistance
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for one resident, identified as R21, by not removing excessive facial hair. The facility's policy on shaving, reviewed in May 2021, emphasizes the importance of removing excessive facial hair to promote cleanliness and improve resident morale and appearance. R21's medical history includes cerebral infarction, hemiplegia, hemiparesis, vascular dementia, and muscle weakness, which necessitates substantial assistance for personal hygiene. Observations on two consecutive days revealed that R21 had excessive mustache and chin hair, even after a scheduled shower. Interviews with staff, including a Certified Nursing Assistant (CNA) and the Director of Nursing (DON), confirmed the deficiency. The CNA acknowledged that R21 never refused grooming and confirmed the need for shaving. The DON stated that her expectations for ADL care included face washing and grooming, and that staff should assist with shaving if the resident allows. Despite these expectations, the facility did not ensure that R21 received the necessary grooming assistance, resulting in unmet needs and a diminished quality of life for the resident.
Failure to Document Dialysis Communication
Penalty
Summary
The facility failed to ensure proper communication between the facility and the dialysis center for a resident requiring dialysis services. The facility's policy, revised in January 2021, mandates that nursing staff complete a Dialysis Communication Form on the days a resident attends dialysis, send it to the dialysis center, and then scan the completed form into the resident's electronic health record. However, for one resident, identified as R85, who was diagnosed with end-stage renal disease and dependent on renal dialysis, this procedure was not consistently followed. The resident's care plan required the documentation of pre and post-dialysis vital signs, and physician's orders specified the completion and sending of the communication form on designated days. Interviews with staff revealed that the communication forms for R85 were kept in a binder at the nurse's station, but the first documented form was not completed until several days after the resident began dialysis. The LPN confirmed that the forms should have been completed from the first day of dialysis sessions. The Director of Nursing also confirmed that a communication form should be sent and received for each dialysis visit to ensure continuity of care. The lack of documented communication forms had the potential to place the resident at risk for medical complications and unmet needs.
Failure to Obtain Consent and Assessment for Bed Rail Use
Penalty
Summary
The facility failed to ensure that a resident had the necessary consent, physician's order, and completed assessment for the use of bilateral half-side rails on their bed. The facility's policy on Bed Mobility Assist Devices requires that once alternatives have been trialed and failed, a physician's order should be obtained, and a Bed Mobility Device Evaluation should be completed. Additionally, informed consent should be obtained and documented in the electronic health record. However, for the resident in question, there was no physician's order, no bed rail assessment conducted, and no informed consent obtained, despite the resident being observed with bilateral half-side rails in the up position on multiple occasions. The resident involved had diagnoses including dementia, muscle weakness, and a history of falls, with a documented moderate cognitive impairment and a medium fall risk. Interviews with staff, including an LPN and the DON, confirmed that the required steps for using side rails, such as obtaining consent, completing an assessment, and securing a physician's order, were not documented for this resident. The resident themselves was unaware of the reason for the side rails being up, indicating a lack of communication and documentation regarding the use of the bed rails.
Failure to Limit PRN Psychotropic Medication Order
Penalty
Summary
The facility failed to adhere to its policy regarding the use of PRN psychotropic medications, specifically for a resident diagnosed with anxiety. The policy, revised in February 2021, mandates that PRN orders for psychotropic medications should be limited to 14 days unless clinically indicated otherwise. However, a review of the resident's electronic medical record revealed an open-ended PRN order for Ativan (lorazepam) 0.5 mg every four hours for anxiety, dated December 18, 2023, without a definitive stop date. During an interview, the Director of Nursing confirmed the absence of a stop date for the lorazepam order, acknowledging that it should have had a definitive end date. This oversight had the potential to affect the resident's highest practicable mental, physical, and psychosocial well-being.
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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 Smyrna
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth - Marietta | 4.7 mi | ★★★★★ | 6 | 0 |
| Autumn Breeze Health And Rehab | 4.8 mi | ★★★★★ | 6 | 0 |
| Pruitthealth - Austell | 5.1 mi | ★★★★★ | 10 | 0 |
| A.g. Rhodes Home, Inc - Cobb | 5.2 mi | ★★★★★ | 4 | 0 |
| William Breman Jewish Home, The | 5.3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.