Cycle 1
Health 2024-12-19 · Fire 2024-12-19
14 health deficiencies
Top issue: Resident Rights (4 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Smyrna, GA
Delmar Gardens Of Smyrna
2-star overall rating with 2-star inspections with $23,537 in total fines with 14 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
404 King Springs Village Pkwy, Smyrna, GA
(770) 432-4444
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
93
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Delmar Gardens
Operator or chain grouping
Approved since
1985-01-09
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
0.44
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.82
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.58
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.83
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.26
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.41
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.43
CMS adjusted RN staffing hours
Adjusted total hours
3.81
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,385
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
57.06
Composite VBP score used to determine payment impact.
Payment multiplier
1.0122
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.46
Baseline 19.55% · Performance 17.97% · Measure score 7.46 · Achievement 7.46 · Improvement 5.75
Healthcare-associated infections
3.35
Baseline 7.14% · Performance 6.83% · Measure score 3.35 · Achievement 3.35 · Improvement 0.95
Total nurse turnover
8.82
Performance 27.63% · Measure score 8.82 · Achievement 8.82 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.20
Baseline 3.05 hours · Performance 3.99 hours · Measure score 3.20 · Achievement 3.20 · Improvement 2.93
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.6% |
10.72%
2.1 pts better
|
No Different than the National Rate · Eligible stays 270 · Observed rate 5.93% · Lower 95% interval 6.38% |
| Discharge to community | 68.84% |
50.57%
18.3 pts better
|
Better than the National Rate · Eligible stays 260 · Observed rate 65.38% · Lower 95% interval 63% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 133 · Denominator 133 |
| Falls with major injury | 0.75% |
0.77%
About the same
|
Numerator 1 · Denominator 133 |
| Discharge self-care score | 52.58% |
53.69%
1.1 pts worse
|
Numerator 51 · Denominator 97 |
| Discharge mobility score | 21.65% |
50.94%
29.3 pts worse
|
Numerator 21 · Denominator 97 |
| Pressure ulcers or injuries, new or worsened | 5.26% |
2.29%
3 pts worse
|
Numerator 7 · Denominator 133 · Adjusted rate 6.48% |
| Healthcare-associated infections requiring hospitalization | 6.83% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 165 · Observed rate 6.67% · Lower 95% interval 4.19% |
| Staff COVID-19 vaccination coverage | 5.71% |
8.2%
2.5 pts worse
|
Numerator 10 · Denominator 175 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 44.33% |
56.45%
12.1 pts worse
|
Numerator 43 · Denominator 97 |
| Transfer of health information to provider | 96.43% |
95.95%
0.5 pts better
|
Numerator 27 · Denominator 28 |
| Transfer of health information to patient | 93.67% |
96.28%
2.6 pts worse
|
Numerator 74 · Denominator 79 |
| Resident COVID-19 vaccinations up to date | 4.55% |
25.2%
20.6 pts worse
|
Numerator 3 · Denominator 66 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
2.2
0.1 pts better
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.7 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
2.0
1.2 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 1.0 · Expected 2.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.4% |
91.2%
2.2 pts better
|
93.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 98.5% · Q2 93.0% · Q3 90.8% · Q4 92.0% · 4Q avg 93.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.4% |
95.0%
2.6 pts worse
|
95.5%
3.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.4% |
3.2%
0.8 pts better
|
3.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 2.8% · Q3 1.3% · Q4 0.0% · 4Q avg 2.4% · 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 | 5.8% |
5.9%
0.1 pts better
|
5.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 5.0% · Q3 6.5% · Q4 4.8% · 4Q avg 5.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.0% |
20.7%
12.7 pts better
|
19.6%
11.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 4.8% · Q3 6.2% · Q4 12.3% · 4Q avg 8.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.7% |
21.4%
0.7 pts better
|
16.7%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 20.0% · Q3 21.2% · Q4 23.6% · 4Q avg 20.7% · 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 | 18.3% |
17.9%
0.4 pts worse
|
16.3%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.5% |
16.2%
1.7 pts better
|
14.9%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 18.6% · Q3 15.5% · Q4 12.5% · 4Q avg 14.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.1%
1.1 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.8% |
2.5%
0.7 pts better
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 2.9% · Q3 0.0% · Q4 2.7% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.9% |
16.1%
0.8 pts worse
|
19.8%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 22.6% · Q3 17.0% · Q4 11.8% · 4Q avg 16.9% |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
6.2%
0.9 pts better
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 6.3% · Q3 6.8% · Q4 4.2% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 39.6% |
80.4%
40.8 pts worse
|
81.7%
42.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 45.5% · Q2 37.2% · Q3 28.2% · Q4 47.7% · 4Q avg 39.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.1% |
12.2%
5.1 pts better
|
12.0%
4.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.1% · Observed 6.4% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
2.2%
0.8 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 1.3% · Q3 1.4% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 35.1% |
78.2%
43.1 pts worse
|
79.7%
44.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 35.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.2% |
24.2%
4 pts better
|
23.9%
3.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.2% · Observed 18.6% · Expected 22.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-10 · Fire 2023-08-10
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-02-03 · Fire 2022-02-03
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-12-19
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-02-02
D · Potential for more than minimal harm
2023-08-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-08-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-08-10
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-09-15
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-06
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-09-20
D · Potential for more than minimal harm
2025-08-06
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-09-20
F · Potential for more than minimal harm
2024-12-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-02
D · Potential for more than minimal harm
2024-12-19
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-02-02
D · Potential for more than minimal harm
2024-12-19
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-02-02
D · Potential for more than minimal harm
2024-12-19
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-02-02
D · Potential for more than minimal harm
2024-12-19
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-02-02
D · Potential for more than minimal harm
2024-12-19
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-02-02
D · Potential for more than minimal harm
2024-12-19
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-02-02
D · Potential for more than minimal harm
2024-12-19
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 2025-02-02
D · Potential for more than minimal harm
2024-12-19
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-02-02
D · Potential for more than minimal harm
2024-12-19
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-02-02
D · Potential for more than minimal harm
2024-12-19
F700 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2025-02-02
D · Potential for more than minimal harm
2024-12-19
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 2025-02-02
G · Actual harm
2023-08-10
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-09-28
F · Potential for more than minimal harm
2023-08-10
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 2023-09-28
E · Potential for more than minimal harm
2023-08-10
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-09-28
E · Potential for more than minimal harm
2023-08-10
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-09-28
D · Potential for more than minimal harm
2023-08-10
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 2023-09-28
D · Potential for more than minimal harm
2023-08-10
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-09-28
D · Potential for more than minimal harm
2023-08-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-09-28
D · Potential for more than minimal harm
2022-02-03
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-03-18
Penalties and ownership
What sits behind the stars
$23,537
2023-08-10
Fine
Fine · fine $23,537
Fine
$0
2023-08-10
Payment Denial
Payment Denial · denial start 2023-09-12 · 16 days
16 day denial
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
Lee, Lokyee
W-2 Managing Employee · Individual
Marx, Kenneth
Corporate Officer · Individual
Oppenheimer, Howard
Corporate Officer · Individual
Rodgers, Lynn
W-2 Managing Employee · Individual
Thilo, Jennifer
Contracted Managing Employee · Individual
Nearby options
Other facilities in reach
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Pruitthealth - Marietta
Marietta, GA
2-star overall rating with 2-star inspections with $13,520 in total fines with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Autumn Breeze Health And Rehab
Marietta, GA
1-star overall rating with 1-star inspections with 1 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Pruitthealth - Austell
Austell, GA
1-star overall rating with 1-star inspections with 16 recent health deficiencies
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