Delmar Gardens of Gwinnett

Inspectors wroteBased on record review and staff interview, and review of the Payroll-Based Journal (PBJ) Staffing Data [NAME] Report 1705D Fiscal Year (FY) Quarter 2 (January 1 - March 31), the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for three days in February 2025, and one day in March 2025.

Inspectors wroteBased on record review and staff interviews, the facility failed to follow the care plan for one of 33 sampled residents (R) (R4) related to oxygen (O2) therapy. In addition, the facility failed to develop a comprehensive, person-centered care plan for one of 33 sampled Rs (R55) related to Percutaneous Intravenous Centralized Catheter (PICC) line dressing.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility's policies titled, 'Name of Facility' Infusion Policy and Procedure Manual-Midline/Central Line Dressing Change and Physician Orders, Following, the facility failed to ensure physician orders were followed for two of 33 sampled residents (R) (R55 and R6). The deficient practice had the potential for R55 and R6 to experience medical complications.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Oxygen Administration, the facility failed to deliver oxygen (O2) per physician order for one of 4 residents (R) (R4) receiving O2 therapy. The deficient practice had the potential to cause respiratory distress.

Inspectors wroteBased on observations, interviews, record review, and review of the facility's policies titled, Food Storage Dry/Refrigerated/Frozen and Labeling/Dating Foods (Date Marking), the facility failed to ensure opened food items were properly dated and labeled in the cooler, freezer, and dry food pantry. In addition, the facility failed to ensure the oven and ice machines were clean, all dietary staff were wearing appropriate hair covering, and the recipe for pureed food was followed. This deficient practice had the potential to affect 58 of 58 residents who received an oral diet from the kitchen.

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to ensure one of two dumpsters had a plug in place and the surrounding area around the dumpster was free of trash and debris. This deficient practice had the potential to affect all residents. The census was 58 residents.

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to ensure the flat top oven was working. Specifically, the facility failed to ensure the oven door would close efficiently to prepare cooked meals. This deficient practice had the potential to affect 58 of 58 residents who received an oral diet from the kitchen.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled, Pre-admission Screening and Resident Review (PASARR) Program the facility failed to ensure a Level II PASARR was conducted for one of two sampled residents (R) (R21) reviewed for PASARR. Specifically, the facility failed to refer R21 to the appropriate state-designated authority for a Level II evaluation following a mental illness diagnosis.

Inspectors wroteBased on record review, staff interviews, and review of the facility's policy titled Care Plan Conference, Interdisciplinary, the facility failed to follow the individualized care plan for monitoring for side effects of anticoagulant drug use for two residents (R) (R27 and R31). The sample size was 25.

Inspectors wroteBased on staff and resident interviews, record review, review of the facility's policy titled Treatment/Devices to Maintain Hearing/Vision and review of the facility's document titled Job Description Director of Social Service, the facility failed to provide three out of five sampled residents (R) (R21, R30, and R7) reviewed for adequate assistance and support from social service with receiving vision care. In addition, R21 was hard of hearing and had not been provided assistance by an audiologist. The failure to adequately address the residents' concern has the potential to affect their quality of life.

Inspectors wroteBased on observation, record review, staff interviews, and review of facility's policy titled Coumadin Therapy/Dosing Protocol, the facility failed to document monitoring and side effects of anticoagulant use for two of five sampled residents (R) (R27, R31) reviewed for unnecessary medications.

Inspectors wroteBased on observations, interviews and review of the facility's policies titled Expiration Dating of Medications and Medications with Shortened Expiration Dates, and review of the Pharmacy Nurse Consultant report, the facility failed to ensure medications were dated appropriately when opened to determine the discard date. In addition, the facility failed to discard expired medical supplies prior to expiration dates in one of three medication carts. The sample size was 25.

Inspectors wroteBased on observations, interviews, and review of the facility policy titled, Trayline Refrigerated Leftover Storage, the facility failed to maintain a clean and sanitary kitchen. Specifically, the facility failed to ensure that food items had an open date and were properly labeled; failed to have the meat slicer and floor stand mixer cleaned and free from food debris to prevent cross contamination; and failed to properly use the three compartments sink to prevent food borne illness. The deficient practice had the potential to affect 56 out of 58 residents (R) receiving an oral diet.

Inspectors wroteBased on record review, staff interviews and review of facility policy titled Abuse, Neglect, and Exploitation, Freedom From, the facility failed to complete a background check screening process for four nursing staff of 10 total staff reviewed.

Inspectors wroteBased on record review, observation, staff interviews and review of the facility policy titled, Care Management, the facility failed to develop a person-centered comprehensive care plan for respiratory and oxygen therapy for one of 21 residents (R#58). The deficient practice had the potential to affect the overall implementation of the resident's care.

Inspectors wroteBased on record review, staff interview, and review of the facility policy titled, Behaviors Using Person-Centered Care, Accommodating the facility failed to ensure a stop date was implemented, not to exceed 14 days for psychotropic medications for one of five residents (R) (R#31) reviewed for unnecessary medications. Specifically, the facility failed to ensure a stop date was implemented for antianxiety medication ordered as need (PRN) for R#31.