Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Delmar Gardens Of Chesterfield during CMS and state inspections, most recent first.
Medication Administration Error Rate Exceeded Threshold: The facility had an 8% medication error rate, with two insulin administration errors identified during observation involving two residents with diabetes and CKD. An LPN failed to prime the insulin pen before giving insulin and, for one resident, dialed the pen to 6 units when 5 units were ordered. The DON acknowledged the LPN did not follow the insulin administration protocol.
Improper medication storage and labeling were observed on multiple CMT carts and in a medication storage room. Surveyors found loose and unlabeled pills in cart drawers, pre-pulled Tums and a vancomycin blister pack without resident identifiers, and personal items including drinks stored in a medication refrigerator and drawers. Staff acknowledged that loose meds should not be on carts and that personal items should not be kept in medication storage areas.
Misappropriation of Discontinued Controlled Medications: The facility failed to ensure discontinued controlled meds were destroyed per policy and free from misappropriation. An ADON removed and later possessed a discharged resident’s oxycodone and another resident’s discontinued Ativan, with the meds found during an investigation that began after concerns about her handling of another resident’s hydrocodone. The residents involved had significant medical issues, including pain after fracture repair, dementia, Parkinson’s disease, anxiety, and hospice care.
Unsafe transfer techniques were observed during both a Hoyer lift and a gait belt transfer. For one resident who required a two-person Hoyer lift, CNAs switched places during the transfer, left the resident unattended briefly, and allowed the resident’s leg to strike the lift. For another resident with severe cognitive impairment and Parkinson’s disease, CNAs placed a gait belt but lifted the resident under the arms instead of using the belt to support weight.
A resident with a g-tube, dysphagia, and aspiration history did not receive tube feedings at the ordered times and was observed with the HOB at about 10 degrees instead of 30 degrees. The MAR used broad shift-based entries rather than exact start and stop times, and staff observed the feeding pump off, later alarming with an empty bag, and the resident reported feedings were often hung late.
Physician documentation was incomplete for a resident’s monthly pharmacist DRR of quetiapine. The resident had dementia, Alzheimer’s disease, TBI, seizure disorder, anxiety, and was on hospice, with quetiapine ordered for behavioral disturbance. The pharmacist repeatedly noted that the chart lacked required documentation of a clinical contraindication to dose reduction, but the prescriber responses were limited to referrals to psych, hospice notes, or were left blank.
Hand hygiene and EBP procedures were not followed during care for a resident with a PICC line, surgical knee incisions, and IV ceftriaxone for a right knee infection with E. coli. CNAs entered the room without washing hands, did not consistently don gowns and gloves before transfer and brief care, handled the resident with bare hands, and carried used PPE out of the room to the soiled utility room. The DON stated staff should wash hands on entry, use full PPE for residents on EBP, and dispose of used PPE in the room.
A resident with multiple chronic conditions was discharged without a complete discharge summary as required by facility policy. Although some discharge planning and documentation occurred, the electronic medical record did not include a comprehensive summary from all departments, omitting key information such as a recapitulation of the stay and a final summary of the resident's status at discharge.
Two residents at high risk for pressure ulcers did not receive care in accordance with facility protocols, resulting in the development of a new Stage II ulcer for one and inadequate management of an existing Stage IV ulcer for another. Both residents experienced prolonged periods without repositioning or timely incontinence care, and wound care practices were not consistently followed, including improper dressing application and failure to keep the wound area clean.
Medication Administration Error Rate Exceeded Threshold
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5%, with 2 errors identified out of 25 opportunities for an 8% medication error rate involving Residents #45 and #145. The facility’s Medication Administration-General Guidelines policy required medications to be administered according to the physician’s order, including the right resident, medication, dosage, route, and time. The facility’s insulin administration policy also required the insulin pen to be primed immediately before injections by dialing up 2 units and pressing the button until a drop of insulin was seen at the needle tip. Resident #45 was cognitively intact and had diagnoses including diabetes, neuropathy, and chronic kidney disease. The resident had an order for insulin aspart sliding scale before meals and at night, with 2 units ordered for a blood sugar of 131 through 180. During observation, the resident’s blood sugar was 217, and LPN G administered 3 units but did not prime the insulin pen before giving the dose. Resident #145 was cognitively intact and had diagnoses including diabetes with chronic kidney disease. The resident had an order for lispro 3 units three times daily and an additional 2 units for blood sugars between 200 and 250. During observation and interview, the resident’s blood sugar was 200, requiring a total of 5 units, but LPN G dialed the pen to 6 units and did not prime the pen before administration. During interview, LPN G stated he/she adds an extra unit when administering insulin for priming. The DON stated staff were expected to follow insulin administration protocol and acknowledged that LPN G failed to prime the pen with 2 units before the ordered dose, and that the resident may not have received the ordered dose.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications in three of four certified medical technician (CMT) carts checked and one of four medication storage rooms checked. The facility’s Medication Storage Policy stated that drugs and medications are to be stored in their original containers, controlled drugs are to be separately locked, and compartments containing drugs are to be locked when not in use or unattended. On the 100-hall CMT cart, surveyors observed a small white pill with markings of 11/x in the far back of the second drawer and second column. On the 600-hall CMT cart, the second drawer contained 26 whole pills of varied sizes, colors, and shapes and 14 partial pills of varied sizes, shapes, and colors that were not in pharmacy-labeled medication containers. On the 700-hall CMT cart, surveyors observed a mini refrigerator containing personal items in a gallon Ziplock bag, including a 12-ounce can of Mountain Dew and a 20-ounce disposable water bottle. In the 700-hall medication storage room, surveyors observed five pre-pulled Tums in the top drawer without a resident identifier, a blister pack of vancomycin hydrochloride 125 mg capsule without a resident identifier, and a 20-ounce disposable water bottle in the third drawer on the far-right side. During interview, staff stated the water bottle belonged to them, that staff did not really have a place to put their things, that the cart should not have loose medications, and that there should be no personal items on medication carts or in medication storage rooms and refrigerators.
Misappropriation of Discontinued Controlled Medications
Penalty
Summary
The facility failed to ensure discontinued controlled medications were destroyed in accordance with policy and remained free from misappropriation. The deficiency involved one discharged resident’s oxycodone and another resident’s discontinued Ativan, both of which were later found in the possession of the Assistant Director of Nursing (ADON). The facility’s abuse, neglect, and misappropriation policy defined misappropriation as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident’s belongings or money without the resident’s consent, and the controlled substance policy required destruction of controlled substances by two licensed nurses or a licensed nurse and pharmacist. Resident #185 had diagnoses including a left femur fracture with surgical repair, heart failure, renal failure, hip fracture, and dementia. The resident received oxycodone for pain, with documentation showing pain monitoring and intermittent administration of the medication. After the resident was discharged to assisted living, the oxycodone was discontinued. Resident #131 had moderate cognitive impairment, Parkinson’s disease, anxiety, and hospice services. This resident had been prescribed Ativan, which was later changed from oral Ativan to liquid Ativan PRN, leaving the discontinued oral Ativan to be handled according to the facility’s medication destruction process. The facility’s investigation began after concerns were raised about the ADON’s handling of another resident’s discontinued hydrocodone. During the investigation, the ADON admitted to taking discontinued medications and produced Resident #185’s discontinued oxycodone and a bottle containing Resident #131’s discontinued Ativan. The report states the ADON had torn the label off the oxycodone card and had poured the resident’s Ativan into her own old Ativan bottle so it appeared to be hers. The DON reported that the ADON had asked for nurse cart keys and removed discontinued narcotics, and the investigation confirmed the ADON’s possession of the residents’ discontinued controlled medications.
Unsafe Hoyer Lift and Gait Belt Transfers
Penalty
Summary
The facility failed to ensure safe resident transfer techniques during a Hoyer lift for a resident who was dependent on staff for transfers and had diagnoses including Alzheimer’s disease, bipolar disorder, heart disease, vascular disease, and kidney failure. The resident’s care plan stated that a two-person Hoyer lift was required, and the physician order sheet included a Hoyer lift order. During observation, two CNAs performed the transfer, but one CNA held the back of the chair while the other operated the lift, the resident swung freely over the bed, and no support was given to the resident’s legs. As the staff switched places during the transfer, the resident was left unattended for about 10 seconds, and the resident’s right leg struck the main support post of the lift as the resident was lowered into the chair. The CNAs stated they did not perform the transfer correctly and said they wanted to conduct the transfer timely. They also stated that the staff who is not operating the lift should always have a hand on the resident and that staff switched places for resident positioning. The DON stated that when staff conduct a Hoyer lift, the staff not operating the lift should keep hands on the resident to ensure the resident’s legs or arms do not hit the lift, and staff should not switch places during the transfer. The facility also failed to ensure safe gait belt transfer technique for a resident with severe cognitive impairment who required partial to moderate staff assistance and had diagnoses including neurocognitive disorder with Lewy bodies, generalized muscle weakness, seizures, and Parkinson’s disease without dyskinesia. During observation, two CNAs placed a gait belt around the resident’s abdomen, then grabbed the resident under the arms and lifted the resident to standing before walking the resident to a dining room seat. The resident did not appear fully alert during the transfer. Staff interviews showed they knew residents should not be transferred under the arms and that the gait belt should be used to support the resident’s weight. The PTM stated staff should not pull on or underneath arms to lift a resident, and the DON stated gait belts should be applied snugly around the waist and residents who require a gait belt transfer should not be lifted under the arms.
Delayed tube feedings and improper head-of-bed elevation
Penalty
Summary
The facility failed to ensure a resident with a gastrostomy tube received tube feedings at the ordered times and failed to ensure the resident’s head of bed was elevated as ordered to 30 degrees. The resident was cognitively intact, had dysphagia, malnutrition, muscle weakness, coughing or choking during meals and medications, and received 51% of total calories through tube feeding. The care plan and physician orders directed Jevity 1.5 cal at 80 mL per hour for 18 hours, from 4:00 P.M. to 10:00 A.M., with head of bed elevation to 30 degrees. The MAR did not list a specific start or stop time for the tube feeding, instead showing broad shift-based documentation such as day shift off and evening and night shifts on. During observation, the resident stated the tube feeding was frequently hung late and that it was the only nutrition received. At 5:40 P.M., the resident was lying in bed with the head of bed at about 10 degrees, the feeding pump was turned off, and no tube feeding was attached. After the resident told an LPN the feeding should have started at 4:00 P.M., the LPN checked and returned about 20 minutes later to prepare the feeding. On another observation, the resident was again lying in bed with the head of bed at approximately 10 degrees while the feeding bag was connected and the pump alarmed because the bag was empty. The resident said the alarm had been sounding for about 10 minutes. A CNA said she would tell the nurse, and later the pump was turned off and remained attached to the resident while the head of bed stayed at about 10 degrees. Staff interviews confirmed the MAR did not reflect the exact start and stop times, that the orders were too broad, and that the resident’s head of bed should have been at 30 degrees because of the resident’s aspiration history.
Physician Did Not Document Response to Pharmacist Antipsychotic Review
Penalty
Summary
The facility failed to ensure that the attending physician documented actions taken to address irregularities noted by the consultant pharmacist during monthly drug regimen reviews for one sampled resident. The pharmacist reviewed the resident’s chart each month and identified that the resident was receiving quetiapine 50 mg three times daily for dementia with behavioral disturbance while on hospice, and that the required physician documentation of a clinical contraindication to a dose reduction was not present. Resident #7’s record showed diagnoses including non-traumatic brain dysfunction, Alzheimer’s disease, dementia, seizure disorder, traumatic brain injury, and anxiety disorder. The quarterly MDS indicated the resident rarely or never understood, had short- and long-term memory problems, and received an antipsychotic on a routine basis. The resident’s physician orders showed quetiapine had been ordered since 4/8/24 for dementia with behavioral disturbance. The pharmacist’s recommendations to the prescriber on 1/20/25, 2/28/25, 4/15/25, and 6/7/25 each noted that the resident did not appear to be a candidate for possible dose reduction, but the chart lacked the required physician documentation of a clinical contraindication. The prescriber responses varied between referring the matter to psychiatry, noting hospice status, or leaving the response blank, and one recommendation had no response documented. During interviews, the DON, Assistant Administrator, and Administrator stated that the physician should document a specific response addressing the pharmacist’s recommendation, including documentation of a clinical contraindication to dose reduction when applicable.
Hand Hygiene and EBP Not Followed During Resident Care
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when staff did not follow hand hygiene and enhanced barrier precautions (EBP) procedures for a resident who required full staff assistance. The resident had been re-admitted from the hospital with a PICC line to the left upper arm, multiple small surgical incisions to the right knee, and orders for IV ceftriaxone for a right knee infection after surgical irrigation and debridement; the hospital cultures grew E. coli. The resident’s room had an EBP magnet on the outer door frame and PPE supplies inside the room, including gowns, gloves, and masks. During observation, CNA O and CNA P entered the resident’s room, explained care, but did not perform hand hygiene before applying gloves and did not don gowns before placing the sling pad under the resident for transfer. The aides completed the transfer, removed their gloves, and performed hand hygiene afterward; both stated they were unaware the resident required EBP and did not observe the EBP magnet or PPE supplies. On another observation, CNA S and CNA T entered the room without hand hygiene, donned a gown and mask, and only one aide applied gloves. During brief care, CNA T unfastened a wet brief and tucked it under the resident’s hips and between the legs, while CNA S initially placed bare hands on the resident’s hip before applying gloves and assisting with turning. Both aides removed gowns and gloves in the room, held the used PPE in their bare hands, and carried it out of the room to dispose of it in the soiled utility room. The DON stated staff should wash hands when entering a resident’s room, apply gloves before starting care tasks, don full PPE for residents identified as needing EBP, and dispose of used PPE in the resident’s room.
Failure to Complete Required Discharge Summary for Resident
Penalty
Summary
The facility failed to ensure that a complete discharge summary was prepared for a resident at the time of a planned discharge. According to the facility's discharge and transfer policy, a discharge summary must be completed for all residents being discharged home or transferred to another facility. This summary should include a recapitulation of the resident's stay, a final summary of the resident's status at discharge, a list of medications, follow-up appointments, and other pertinent information to ensure continuity of care. However, record review revealed that for one resident, this process was not fully followed. The resident in question had multiple diagnoses, including vascular disease, heart failure, a left shoulder cuff tear, long-term use of diuretics and anticoagulants, and a history of stroke. The resident's care plan indicated a goal of returning home with family support, and various care conferences and social service notes documented ongoing discharge planning, including referrals to assisted living facilities and coordination with the family. Despite these efforts, the medical record lacked a comprehensive discharge summary from all departments, as required by policy. Progress notes and the physician's discharge summary provided some information about the resident's medications and discharge orders, but did not include a full recapitulation of the resident's stay or a detailed final summary of the resident's status at discharge. The Director of Nursing confirmed that the electronic medical record should contain a discharge summary from all departments, including details on medications, home health arrangements, and follow-up appointments, but this was not present for the resident in question.
Failure to Prevent and Properly Manage Pressure Ulcers
Penalty
Summary
The facility failed to follow its own wound care and pressure ulcer prevention protocols for two residents at high risk for pressure ulcers. One resident, who was incontinent, immobile, and receiving hospice care, developed a new Stage II pressure ulcer on the right buttock. Despite care plan interventions requiring frequent incontinence checks, prompt perineal care, and regular repositioning, observations showed the resident remained seated on their buttocks in a wheelchair for extended periods without repositioning or incontinence care. Staff interviews confirmed that the resident was not repositioned or checked for incontinence at least every two hours as required, and the lack of these interventions was acknowledged as a contributing factor to the development of the new pressure ulcer. Another resident, who was cognitively intact but dependent on staff for mobility and personal care, had an existing Stage IV pressure ulcer on the sacrum. The care plan required frequent repositioning, keeping the resident clean and dry, and proper wound care. However, observations revealed the resident was left lying flat on their back for prolonged periods, with no positioning devices used to offload pressure from the wound area. The resident was also found with a heavily soiled brief and dirty absorbent pads, and perineal care was not performed as frequently as required. Wound care was administered, but the dressing was not always properly secured, and fecal matter was found on and around the wound dressing, increasing the risk of infection and delayed healing. Staff interviews, including those with CNAs, LPNs, the wound nurse, and the DON, consistently indicated an expectation for residents at risk for pressure ulcers to be repositioned and checked for incontinence at least every two hours. Despite these expectations and facility policy, direct care observations and staff admissions demonstrated that these standards were not met for the two residents in question, resulting in the development of a new pressure ulcer for one resident and inadequate care for an existing Stage IV ulcer in another.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Chesterfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Garden View Care Center Of Chesterfield | 0.8 mi | ★★★★★ | 1 | 0 |
| Friendship Village Chesterfield | 1 mi | ★★★★★ | 1 | 0 |
| Westchester House, The | 1.4 mi | ★★★★★ | 0 | 0 |
| Mason Pointe Care Center | 1.7 mi | ★★★★★ | 0 | 0 |
| Delmar Gardens West | 1.7 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.