Cycle 1
Health 2025-08-14 · Fire 2025-08-14
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Lawrenceville, GA
Delmar Gardens Of Gwinnett
3-star overall rating with 3-star inspections with 4 recent health deficiencies
3100 Club Drive, Lawrenceville, GA
(770) 923-3100
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
67
Certified beds
Average residents
59
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Delmar Gardens
Operator or chain grouping
Approved since
1989-02-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
13 facilities
Chain averages 3 overall / 3 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.40
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.90
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
3.25
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
4.55
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.30
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
4.28
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.17
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.41
CMS adjusted RN staffing hours
Adjusted total hours
4.62
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
71%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,637
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.18
Composite VBP score used to determine payment impact.
Payment multiplier
0.9853
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.97
Baseline 21.93% · Performance 19.25% · Measure score 4.97 · Achievement 4.71 · Improvement 4.97
Healthcare-associated infections
4.46
Baseline 7.46% · Performance 6.50% · Measure score 4.46 · Achievement 4.46 · Improvement 3.40
Total nurse turnover
0.81
Baseline 44.44% · Performance 60.38% · Measure score 0.81 · Achievement 0.81 · Improvement 0
Adjusted total nurse staffing
1.43
Baseline 2.74 hours · Performance 3.33 hours · Measure score 1.43 · Achievement 0.87 · Improvement 1.43
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.41% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 138 · Observed rate 10.87% · Lower 95% interval 7.94% |
| Discharge to community | 58.85% |
50.57%
8.3 pts better
|
Better than the National Rate · Eligible stays 137 · Observed rate 54.74% · Lower 95% interval 51.24% |
| Medicare spending per beneficiary | 0.79 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 91.04% |
95.27%
4.2 pts worse
|
Numerator 61 · Denominator 67 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 67 |
| Discharge self-care score | 51.02% |
53.69%
2.7 pts worse
|
Numerator 25 · Denominator 49 |
| Discharge mobility score | 40.82% |
50.94%
10.1 pts worse
|
Numerator 20 · Denominator 49 |
| Pressure ulcers or injuries, new or worsened | 1.49% |
2.29%
0.8 pts better
|
Numerator 1 · Denominator 67 · Adjusted rate 1.31% |
| Healthcare-associated infections requiring hospitalization | 6.5% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 79 · Observed rate 5.06% · Lower 95% interval 3.36% |
| Staff COVID-19 vaccination coverage | 1.16% |
8.2%
7 pts worse
|
Numerator 1 · Denominator 86 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 44.9% |
56.45%
11.6 pts worse
|
Numerator 22 · Denominator 49 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 35 · Denominator 35 |
| Resident COVID-19 vaccinations up to date | 34.38% |
25.2%
9.2 pts better
|
Numerator 11 · Denominator 32 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
2.2
0.2 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 1.8 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
2.0
0.1 pts worse
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.7 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.0% |
91.2%
1.8 pts better
|
93.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 72.9% · Q2 97.9% · Q3 100.0% · Q4 100.0% · 4Q avg 93.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.0% |
3.2%
1.2 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 2.0% · Q4 3.6% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
9.6%
9.6 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 7.5% |
5.9%
1.6 pts worse
|
5.4%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 7.9% · Q3 12.8% · Q4 4.7% · 4Q avg 7.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.5% |
20.7%
14.2 pts better
|
19.6%
13.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 5.1% · Q3 9.3% · Q4 4.3% · 4Q avg 6.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 28.7% |
21.4%
7.3 pts worse
|
16.7%
12 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 25.7% · Q3 26.5% · Q4 33.3% · 4Q avg 28.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 27.4% |
17.9%
9.5 pts worse
|
16.3%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 27.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.3% |
16.2%
10.1 pts worse
|
14.9%
11.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.0% · Q2 16.7% · Q3 23.1% · Q4 34.1% · 4Q avg 26.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
1.1%
0.6 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 7.9% |
2.5%
5.4 pts worse
|
1.7%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 4.3% · Q3 2.2% · Q4 11.8% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.6% |
16.1%
2.5 pts worse
|
19.8%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 29.7% · Q3 17.3% · Q4 9.9% · 4Q avg 18.6% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
6.2%
1.6 pts better
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 1.6% · Q3 5.0% · Q4 6.4% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.7% |
80.4%
8.3 pts better
|
81.7%
7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 80.8% · Q2 86.4% · Q3 96.9% · Q4 93.8% · 4Q avg 88.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.8% |
12.2%
5.6 pts worse
|
12.0%
5.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.8% · Observed 15.9% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
2.2%
0.9 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.8% · Q4 3.6% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.8% |
78.2%
15.6 pts better
|
79.7%
14.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.1% |
24.2%
4.1 pts better
|
23.9%
3.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.1% · Observed 19.0% · Expected 22.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-16 · Fire 2024-04-16
8 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2022-12-04 · Fire 2022-12-04
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-04-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-13
E · Potential for more than minimal harm
2024-04-16
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-04-13
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-08-14
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2025-09-26
D · Potential for more than minimal harm
2025-08-14
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-09-26
D · Potential for more than minimal harm
2025-08-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-26
D · Potential for more than minimal harm
2025-08-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-09-26
F · Potential for more than minimal harm
2024-04-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-05-31
F · Potential for more than minimal harm
2024-04-16
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-05-31
F · Potential for more than minimal harm
2024-04-16
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-04-16
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-04-16
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-04-16
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-04-16
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-04-16
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-05-31
F · Potential for more than minimal harm
2022-12-04
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-01-15
E · Potential for more than minimal harm
2022-12-04
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-01-15
D · Potential for more than minimal harm
2022-12-04
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-01-15
D · Potential for more than minimal harm
2022-12-04
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-01-15
Penalties and ownership
What sits behind the stars
Ownership
Delmar Gardens Enterprises Inc
5% Or Greater Direct Ownership Interest · Organization
Goldberg-Nom LLC
5% Or Greater Indirect Ownership Interest · Organization
Grossberg, Gabe
5% Or Greater Indirect Ownership Interest · Individual
Grossberg, George
5% Or Greater Indirect Ownership Interest · Individual
Gabe Grossberg And George Grossberg, Trustees Of The Henry And Barbara
5% Or Greater Indirect Ownership Interest · Organization
George Grossberg And Gabe Grossberg, Trustees Of The Henry And Barbara
5% Or Greater Indirect Ownership Interest · Organization
Non-Gst Family Trust Est U/W Of Israel Goldberg Fbo Janice Bitanski
5% Or Greater Indirect Ownership Interest · Organization
Non-Gst Family Trust Established U/W Of Israel Goldberg Fbo Harry Zvi
5% Or Greater Indirect Ownership Interest · Organization
Non-Gstfamily Trust Est U/W Israel Goldberg Fbo Diane Fredman
5% Or Greater Indirect Ownership Interest · Organization
Delmar Gardens Management Services Inc
Operational/Managerial Control · Organization
Grossberg, Gabe
Corporate Officer · Individual
Marx, Kenneth
Corporate Officer · Individual
Oppenheimer, Howard
Corporate Officer · Individual
Valleray, Kaline
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Life Care Center Of Gwinnett
Lawrenceville, GA
5-star overall rating with 4-star inspections with 3 recent health deficiencies
#2
Pruitthealth - Lilburn
Lilburn, GA
1-star overall rating with 1-star inspections with $59,423 in total fines with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Life Care Ctr Of Lawrenceville
Lawrenceville, GA
2-star overall rating with 1-star inspections with $167,336 in total fines with 6 recent health deficiencies
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