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Delmar Gardens Of Smyrna

404 King Springs Village Pkwy, Smyrna, GA 30082 · For profit - Corporation · 120 certified beds · (770) 432-4444 Medicare & Medicaid certified

Call the home — (770) 432-4444 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citations on record (F0602, F0610) — most recent Aug 2025Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has abuse, neglect, or exploitation citations (F0602, F0610) — most recent Aug 2025
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Urgent care / clinic
3903 S Cobb Dr SE · (770) 333-7888 · Call to confirm hours
Pharmacy
3903 S Cobb Dr SE · (770) 436-0811 · Call to confirm hours
Grocery
Publix1.1 mi
4480 S Cobb Dr SE · (770) 434-6225 · Call to confirm hours
Park
4145 King Springs Rd SE · (770) 801-5343 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 4 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased9.7%15.3%15.4%better
Long-stay residents who lose too much weight4.9%5.6%5.4%typical
Long-stay residents with a catheter left in their bladder0.0%0.9%0.9%better
Long-stay residents with a urinary tract infection1.3%2.5%2.0%better
Long-stay residents with depressive symptoms0.4%11.3%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury0.3%3.2%3.3%better
Long-stay residents whose ability to walk worsened9.4%15.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication13.7%20.5%18.9%better
Long-stay residents given the seasonal flu vaccine92.4%95.0%95.3%typical
Long-stay residents with pressure ulcers6.2%5.6%4.7%worse
Long-stay residents with worsening bladder/bowel control13.3%15.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table23.3%19.9%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.2%2.6%1.4%better
Short-stay residents given the seasonal flu vaccine35.1%78.4%79.4%worse
Short-stay residents rehospitalized after admission19.8%25.0%22.6%better
Short-stay residents with an outpatient ER visit7.5%11.6%12.0%better
Long-stay hospitalizations per 1,000 resident days1.472.151.67better
Long-stay outpatient ER visits per 1,000 resident days0.431.901.80better

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

68.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 260 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

68.8%U.S. median 51.5%
Got home and stayed home
8.6%U.S. median 10.7%
Went back to hospital
43.2%U.S. median 56.6%
Met the expected recovery
0.34U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.15hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 43.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 95 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.34 therapist hours per resident per day in 2026Q1 — more than 57% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 26% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF68.8%CMS range 63.0–73.351.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF8.6%CMS range 6.4–11.310.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge43.2%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge46.3%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge24.2%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting86.7%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge89.5%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.8%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened7.8%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.8%CMS range 4.2–9.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.981.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.34
RN hours/ resident / day
0.75
LPN hours/ resident / day
2.58
Aide hours/ resident / day
3.67
Total nurse hours/ resident / day
0.29
RN hoursweekends
41.1%
Total nursing turnover
45.5%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 98.3 residents a day — about 82% occupied, or roughly 22 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.67 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.34 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.58 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.24 hrs/resident/day on weekends vs 3.84 on weekdays — 16% thinner on weekends. RN hours go from 0.36 to 0.29 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 41% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

2
deficiencies at the latest standard inspection (2026-02-12)
12
at the previous standard inspection (2024-12-19)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.

  • Actual harm · G2023-08-10 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY AMENDED 8/31/23 Based on record review, family and staff interviews, and review of the policy titled Abuse, Neglect and Exploitation, Freedom From, the facility failed to thoroughly investigate and follow-up on an allegation of verbal abuse for one of 32 sampled residents (R) (R#53). Actual harm was identified to have occurred on 8/2/23 when Administrations was made aware that R#53 made an alligation of abuse and failed to complete a though investigation. During an interview on 8/9/23 2:54 p.m. with R#53 revealed she is still scared for her life. Findings included: A review of the facility's policy titled, Abuse, Neglect and Exploitation, Freedom From last revised September 2022 indicated, I. Procedure for investigation 1. Administrator or designee on duty will assess the resident (including the size, location, etc. of any injury), and assure proper documentation of the date, time, and location of the reported or suspected incident. 2. The supervisor will do everything possible to protect the resident's welfare…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-02-12 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility policy titled, Medication Expiration Guidelines, the facility failed to discard expired supplements in two of two medication rooms and on two of four medication carts. This deficient practice created the potential for expired or improperly stored supplements to be used in resident care, placing residents at risk for compromised safety, potential adverse consequences. Findings Include:Review of the facility's policy Medication Expiration Guidelines revealed under section Oral Guidelines: If the liquid is dispensed in the manufactures bottle, the expiration date is the manufacturer's expiration date printed on the actual medication bottle.Observation on [DATE] at 11:34 AM of two of two medication storage rooms and two of four medication carts located in Front Annex A & B section and C Hall Annex revealed the following:Biologicals Supplements observed included Nephro, 2 Cal HN and Glucerna with outdated expiration dates.Observation…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-12 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview and record review, the facility failed to follow physician's orders to administer a nutritional enteral feeding and hydration according to the physician orders for one of three residents (R) (R99) receiving tube feeding in the facility. The deficient practice had the potential for the resident not to receive the correct amount of nutrition ordered by the physician which could result in a negative outcome for the resident. Findings include:Review of the facility's policy titled Tube Feeding Enteral revealed under Procedure: Review the physician's orders. The order should specify the amount of formula, and the flow rate.Observations on 02/10/2026 at 9:00 AM of the tube feeding in R99's room revealed tube feeding was not running but still connected to the resident. Syringe was in a container but not bagged or labeled.Observations on 02/10/2026 at 2:00 PM observed resident R99 up in bed. Tube feeding was not running per physician orders to start at 1:00 PM.Observations on…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-06 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and review of the facility policy titled, Abuse, Neglect, and Exploitation, Freedom From, the facility failed to protect the residents' right to be free from misappropriation of property for one of eight sampled residents (R ) (R1). Specifically, R1 had her bank card stolen from her handbag stored in her closet.Findings include:Review of the facility policy titled Abuse, Neglect, and Exploitation, Freedom From revised January 2019, Revised June 2021, July 2022, and September, 2022 revealed under Facility Safety Position Statement: it is the policy of [NAME] Gardens to maintain a work and living environment that is professional and residents are free from threat or occurrence of harassment , abuse (verbal, physical, mental or sexual), neglect, corporal punishment, involuntary seclusion and misappropriation of property. Under Definitions: Exploitation Exploitation means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-06 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and review of the facility policy tilted, Abuse, Neglect, and Exploitation, Free From, the facility failed to protect residents from sexual abuse by another resident by not immediately reporting nonconsensual sexual abuse between two resident (R) (R2) and (R3).The deficient practice diminished the facility's potential to protect R2 from possible future abuse and ensure a safe environment for other residents.Findings include:A review of the facility's policy titled Abuse, Neglect, and Exploitation, Free From revealed under Facility Safety Position Statement: It is the policy of [NAME] Gardens to maintain a work and living environment that is professional and residents are free from threat or occurrence of harassment, abuse, (verbal, physical, mental or sexual), neglect, corporal punishment, involuntary seclusion and misappropriation of property. Under Definitions: Sexual abuse is nonconsensual sexual contact of any type with a resident which includes, but not limited to,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-12-19 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility's policies titled, Handling of Soiled Linen and Resident Clothing, Isolation Precautions/Transmission Based Precautions, Hand Washing, and Cleaning Guidelines for Resident Care Equipment, the facility failed to ensure infection control procedures were followed. Specifically, the facility failed to ensure clean linen was covered during transport on one of five halls, failed to ensure Transmission Based Precautions (TBP) were followed for one resident (R) (R40) on TBP, failed to ensure a continuous positive airway pressure (CPAP) mask was properly stored when not in use for one R (R85), failed to ensure proper hand hygiene during medication pass, and failed to ensure shared medical equipment was cleaned between resident use. The deficient practices created the potential for cross-contamination and the spread of infections to the residents. The facility's census was 90 residents. Findings included: 1. Review of the facility's policy…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-19 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff and resident interviews, record review, and review of the facility-provided document titled, Residents' Rights, the facility failed to maintain dignity by ensuring a dignity bag was provided for one of five residents (R) (R48) who had an indwelling urinary catheter. This deficient practice had the potential to diminish the resident's quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life. Findings include: A review of the undated facility-provided document titled Residents' Rights included Your right to be treated with dignity and respect is the foundation on which all other resident rights and responsibilities are based. A review of R48's Face Sheet revealed diagnoses included benign prostatic hyperplasia with lower urinary tract symptoms. A review of R48's Quarterly Minimum Data Set (MDS) Assessment, dated 11/20/2024, revealed section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 14 (indicating little to no cognitive impairment) and Section H (Bowel and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-19 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility policy titled, Medications, Self-Administration of, the facility failed to ensure unauthorized medications were not stored at the bedside for one of 28 sampled residents (R) (R85). This deficient practice had the potential to allow unauthorized access to unsecured medications to R85, other residents, and visitors. Findings include: Review of the facility's policy titled, Medications, Self-Administration of, reviewed 6/2021, revealed the Procedure section included 1. Before a resident is considered for self-administration of medications, an assessment will be performed by the charge nurse and reviewed by the interdisciplinary care plan team for approval. 2. Following approval of the assessment, the charge nurse will obtain a physician's order for the resident to self-administer medications, noting which medications may be self-administered. Review of R85's electronic medical record (EMR) revealed diagnoses included, but were not…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-19 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, records review, and review of the facility policy titled, Care Management, the facility failed to ensure reasonable accommodation of needs was provided for one of 28 sampled residents (R) (R62) related to providing a wheelchair to accommodate a physician's order to elevate both feet at all times. The deficient practice had the potential to place R62 at risk for medical complications, unmet needs, and a diminished quality of life. Findings Include 1. Review of the facility policy titled, Care Management, revised 5/2021, revealed the Policy section included A. All Resident care is designed to meet a resident's individual needs and is directed toward conservation and restoration of an optimal physical and emotional state. Review of R62's electronic medical record (EMR) revealed diagnoses including impaired mobility and reperfusion edema. Review of R62's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Section GG (Functional Abilities and Goals) documented…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-19 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and family interviews, record review, and a review of the facility policy titled, Condition Change of the Resident, the facility failed to promptly notify the responsible party of a change in condition for one of 19 residents (R) (R62) reviewed for change in condition related to a deep tissue injury. Findings include: A review of the policy titled, Condition Change of the Resident, revised 7/2012, revealed the Procedure section included . 5. Notify resident's responsible party . Review of R62's Face Sheet revealed diagnoses included pressure-induced deep tissue damage of left 1st toe, non-pressure chronic ulcer of other part of left foot with fat layer exposed - left distal foot and left 2nd toe, vascular dementia, and hemiplegia ad hemiparesis right dominant side. Review of R62's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Section GG (Functional Abilities and Goals) documented R62 required substantial/maximal assistance with bed mobility. Section M (Skin…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-19 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, and record review, the facility failed to provide accurate Minimum Data Set (MDS) assessment data for two of 28 sampled residents (R) (R26 and R40). This deficient practice had the potential to affect the assessment of R26 and R40's care needs. Findings include: A facility policy for resident assessments was requested but not provided. 1. Review of R26's Face Sheet revealed diagnoses including, but not limited to, unspecified bilateral hearing loss. Review of R26's admission MDS assessment dated [DATE] revealed Section B (Hearing, Speech, and Vision) documented R26's ability to hear was highly impaired, and speech clarity was coded as no speech-absence of spoken words. Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 14 (indicating little to no cognitive impairment). Review of R26's care plan dated 10/18/2024 revealed a Problem area of bilateral hearing loss. Goals included the resident will compensate for hearing loss…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · D2024-12-19 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility policy titled, Care Plan Conference Interdisciplinary, the facility failed to develop a baseline care plan for enteral tube feeding for one of three residents (R) (R502) who received enteral tube feeding, within 48 hours of admission. This deficient practice had the potential to place R502 at risk for not receiving treatment and/or care according to their needs. Findings include: 1. Review of the facility policy titled, Care Plan Conference Interdisciplinary, revised May 2021, revealed the Standard section included An Interdisciplinary Care Plan Conference identifies resident needs and establishes obtainable goals. An appropriate plan of action is designed to ensure optimal levels of activity and independence for all residents . Documentation is done in the care conference action of the EHR [electronic health record]. The Purpose section included . 6. Initial care plan should be completed in (electronic health record) within 48…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-19 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Care Plan Conference Interdisciplinary, the facility failed to ensure a comprehensive person-centered care plan was developed for one of seven residents (R) (R26) reviewed for the use of unnecessary medications. This deficient practice had the potential to place R26 at risk for not receiving treatment and/or care according to their needs. Findings include: Review of the facility's policy titled, Care Management, revised 5/2021, revealed the Policy section included A. All resident care is designed to meet a resident's individual needs and is directed toward conservation and restoration of an optimal physical and emotional state. B. Coordination of the plan of care is the responsibility of nursing. However, planning, implementation, and evaluation requires joint participation by each discipline rendering service. C. 5. The plan of care is reviewed and revised to reflect the current needs of the resident.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-19 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, record review, and review of the facility's policy titled, Shaving, the facility failed to provide Activities of Daily Living (ADL) care for one of 28 sampled residents (R) (R21). Specifically, the facility failed to remove excessive facial hair for R21. This deficient practice placed R21 at risk for unmet needs and a diminished quality of life. Findings include: Review of the facility's policy titled, Shaving, reviewed 5/2021, revealed the Purpose section included To remove excessive hair from the face. To promote cleanliness. To improve resident morale and appearance. Review of R21's Face Sheet revealed diagnoses including, but not limited to, cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, vascular dementia, and muscle weakness. Review of R21's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Section GG (Functional Abilities and Goals) documented R21 had impairment on one side for…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-19 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and review of the facility's policy titled, Hemodialysis, the facility failed to ensure communication between the facility and dialysis center was documented after each dialysis session for one of one resident (R) (R85) reviewed for dialysis care. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs, and a diminished quality of life. The sample size was 25. Findings include: Review of the facility's policy titled, Hemodialysis, revised 1/2021, revealed the Policy section stated, To ensure effective communication and collaboration between the community and the resident's dialysis center. The Procedure section included 1. Nurse staff must complete the Dialysis Communication Form (DGE108) on days the resident attends dialysis. 2. Nursing staff must fax and/or send the Dialysis Communication Form to the dialysis. 5. Scan/drop completed Dialysis Communication Form received from dialysis center into the resident HER…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-19 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Bed Mobility Assist Devices, the facility failed to ensure one of six residents (R) (R63) reviewed had the necessary consent, physician's order and completed assessment for the use of bilateral half-side rails on their bed. This deficient practice had the potential to place R63 at risk of physical injury and entrapment. Findings include: Review of the facility policy titled, Bed Mobility Assist Devices, dated 2/2021, revealed the Procedure section included, . 3. Once appropriate alternatives have been trialed and failed, a physician's order for an assist device should be obtained if the need for an assist device for bed mobility and transfer still exists. 4. A Bed Mobility Device Evaluation should be completed by the nurse upon the assessed need, quarterly, annually, and with significant change thereafter. 5. Bed Mobility Assist Device Informed Consent and Release form should be reviewed and signed by…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-19 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and review of the facility's policy titled, Behaviors Using Person-Centered Care, Accommodating, the facility failed to ensure psychotropic medications were not ordered as needed (PRN) for more than 14 days unless clinically indicated for one of seven residents (R) (R31) reviewed for the use of unnecessary medications. This deficient practice had the potential to affect R31's highest practicable mental, physical, and psychosocial well-being. Findings include: Review of the facility's policy titled, Behaviors Using Person-Centered Care, Accommodating, revised 2/2021, revealed the Overview section included, VI. A PRN order for psychotropic medications should only be limited to 14 days. Review of R31's electronic medical record (EMR) revealed diagnoses including anxiety. Review of R31's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Section N (Medications) documented R31 received an antianxiety medication. Review of R31's Physician's Orders included an order dated…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-08-10 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, and review of the facility policy titled, All foods stored will be properly labeled according to the following guidelines the facility failed to ensure opened food items in the refrigerator and the dry storage room were properly labeled and dated; and failed to dry cleaned dishes appropriately. This deficient practice affects 98 of 100 residents. Findings included: During an initial kitchen tour with the Dietary [NAME] AA on 8/8/23 at 9:40 a.m., the following was identified: observation of the refrigerator revealed one medium size clear container of various chopped and shredded vegetable was not dated; one half empty 5-pound container of pimento cheese to was not labeled with an opened date; one opened 2-pound butter was not labeled with an opened date; and one opened 5-pound Blue Cheese was not labeled with an opened date. These observations were verified by the Dietary [NAME] AA. Further observation revealed three stacks of steam table serving pans stacked on the storage rack with visible moisture between the pans; four sheet pans stacked…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-08-10 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff interviews, the facility failed: (1) to ensure that comfortable water temperatures were maintained for 11 of 66 resident rooms (Rooms 9222, 9224, 9225, 9226, 9227, 9228, 9229, 9230, 9231, 9232, and 9233); (2) to ensure that the facility was maintained in a safe, clean, and comfortable home-like environment for three of 66 resident rooms (rooms [ROOM NUMBER]) related to unlabeled and unbagged contoured bedpan, fracture bedpan, graduated urinal containers, specimen collector pans, wash basins, and a dirty bedside toilet commode. Findings included: 1. A review of the policy titled, Monitoring Water Temperatures revised November 2022 indicated, This facility will safeguard residents who cannot fully guard themselves from environmental hazards to which they are likely to be exposed, including, but not limited to being exposed to water that is too hot. Purpose: Hot water can cause scalding, i.e., second and third degree burns in which the skin blisters and swells. This…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-08-10 · tag F0609 — failed to report abuse allegations — pattern
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, family and staff interviews, and review of the policy titled Abuse, Neglect and Exploitation, Freedom From, the facility failed to ensure that an allegation of verbal abuse was reported to the State Agency (SA) for one of 32 sampled residents (R) (R#53) in a timely manner of within the required two hours of discovery. Findings included: A review of the facility's policy titled, Abuse, Neglect and Exploitation, Freedom From last revised September 2022 indicated, H. Reporting suspected violations 3. The administrator or designee will be responsible to ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property are reported immediately, not later than 2 hours after the allegation is made, to other officials in accordance with state law including to the state survey and certification agency. I. Procedure for investigation 6. Any employee suspected of violation of these resident safety policies,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-10 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident and staff interviews and review of the facility policy titled Fall Risk/Prevention Program, the facility failed to follow the care plan related to fall prevention interventions for one of 32 residents (R) (R#77). Findings included: A review of the policy titled Fall Risk/Prevention Program with a review date of April 2021, revealed the purpose is to identify residents at risk for falls and implement fall prevention interventions. To also ensure appropriate and prompt follow up of residents falls. The policy states that if a resident scores 51 or higher on the Morse Fall Scale Assessment, the resident will be identified as a High Fall Risk by activating the High Fall Risk physician order in the admission order set, implement resident specific fall interventions based on the reason why the resident is at high risk on the care plan, add this identification to the CNA profile, and add the Fall Risk banner flag to the residents face sheet. A review of the electronic…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-10 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure that Activities of Daily Living (ADL) care was provided for dependent residents for two of 32 sampled residents (R) (R#31 and R#68) related to nail care for R#31 and shower assistance for R#68. Findings included: 1. A review of the policy titled Nails, Care of (Finger and Toe) with a review date of May 2021, revealed that the purpose of nail care was to provide cleanliness, to prevent spread of infection, for comfort and to prevent skin problems. Further review revealed a note that stated that fingernails of diabetic residents are to be cut by the nurse. A review of the electronic medical record revealed that R#31 was admitted to the facility on [DATE] with diagnoses that included but were not limited to hypertension, chronic diastolic congestive heart failure, and type 2 diabetes. A review of the Annual [NAME] Data Set (MDS) assessment dated [DATE] revealed that R#31 has a Basic Interview for Mental Status (BIMS) score of nine,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-10 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to follow physician orders and store oxygen equipment properly for one of 32 sampled residents (R) (R#77). Findings included: A review of the Oxygen Administration policy dated July 2016 and revised on May 2021, revealed that the purpose of the policy is to provide higher concentration of oxygen than is available in room air. It also revealed that you must have a physician's order to apply oxygen. If administrating over three liters, attach humidifier. A review of the electronic medical record revealed that R#77 was admitted to the facility on [DATE] with diagnoses that included but were not limited to chronic obstructive pulmonary disease (COPD), Acute respiratory failure with hypoxia, dementia, anxiety, and depression. A review of the physician orders for R#77 revealed that he was to have oxygen administered at two liters per nasal cannula as needed and that staff was to change oxygen tubing weekly and as needed. A review of the care plan…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to DELMAR GARDENS — 12 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 52.8+0.2 vs chain
Health inspection 2 of 53.0-1.0 vs chain
Staffing 2 of 52.8-0.8 vs chain
Quality measures 5 of 52.5+2.5 vs chain
The other 11 homes this chain runs (chain average 2.8★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
DELMAR GARDENS ENTERPRISES INCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 03/14/2003
GABE GROSSBERG AND GEORGE GROSSBERG, TRUSTEES OF THE HENRY AND BARBARAOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST8%since 03/14/2003
GEORGE GROSSBERG AND GABE GROSSBERG, TRUSTEES OF THE HENRY AND BARBARAOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST8%since 03/14/2003
GOLDBERG-NOM LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST25%since 03/14/2003
NON-GST FAMILY TRUST EST U/W OF ISRAEL GOLDBERG FBO JANICE BITANSKIOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST6%since 04/10/2013
NON-GST FAMILY TRUST ESTABLISHED U/W OF ISRAEL GOLDBERG FBO HARRY ZVIOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST6%since 04/10/2013
NON-GSTFAMILY TRUST EST U/W ISRAEL GOLDBERG FBO DIANE FREDMANOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST6%since 04/10/2013
GROSSBERG, GABEIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER16%since 02/18/2005
GROSSBERG, GEORGEIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST11%since 03/14/2003
THILO, JENNIFERIndividualCONTRACTED MANAGING EMPLOYEEsince 03/01/2016
LEE, LOKYEEIndividualW-2 MANAGING EMPLOYEEsince 02/15/2021
RODGERS, LYNNIndividualW-2 MANAGING EMPLOYEEsince 01/05/2020
MARX, KENNETHIndividualCORPORATE OFFICERsince 06/11/2019
OPPENHEIMER, HOWARDIndividualCORPORATE OFFICERsince 02/18/2005
DELMAR GARDENS MANAGEMENT SERVICES INCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2005

CMS files one row per role, so the 16 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted.

8 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$16.8M
Net patient revenuemost recent cost report
-1.0%
Operating marginrevenue minus expenses
$2.0M
Related-party expense12% of expenses
Who pays — share of resident-days
Medicaid 30%Medicare 8%Other / private 62%

This home reported $2.0M paid to related parties — landlords or management companies under common ownership — equal to about 12% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$218per resident / day
operating cost
$6,634per month
≈ monthly operating cost
$216per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in GA

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Georgia Medicaid page.

Typical monthly cost in Georgia
$8,821/mo
Nursing home (semi-private)
$9,429/mo
Nursing home (private)
$5,300/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 115330. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-12, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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