Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 On The Green during CMS and state inspections, most recent first.
A resident with metabolic encephalopathy, dysphagia, MASD, and an unstageable wound had initial wound measurements documented on admission, but weekly skin assessments and wound measurements were not completed or entered into the EHR as ordered. The DON stated wounds were expected to be measured and charted by facility nurses, and leadership acknowledged that the wound assessments and admission audit were incomplete.
A resident with multiple medical conditions and a history of falls was found with several unexplained injuries, including bruises and abrasions. The facility did not conduct a thorough investigation as required by policy, failed to obtain staff statements, and did not ensure agency staff were in-serviced or interviewed regarding the incident. Documentation was incomplete, and the source of the injuries was not clearly established.
A resident with multiple diagnoses, including muscular dystrophy, did not receive a new treatment order for a wound due to staff failing to transcribe it onto the eTAR. This resulted in the wound showing signs of infection. The facility's policy required immediate entry of physician orders into the EHR, but the order for gentamicin was not documented. Interviews revealed a lack of communication and documentation, leading to the resident's condition deteriorating and requiring hospital treatment.
The facility failed to maintain resident dignity and privacy by leaving residents exposed, inadequately dressed, and with visible catheter bags. Staff entered rooms without knocking, disregarding residents' preferences and privacy. The administration acknowledged these lapses in maintaining dignity.
The facility failed to issue required transfer notices to residents during hospital transfers, affecting seven residents with various medical conditions, including cognitive impairments and chronic illnesses. Despite multiple transfers and returns, the facility did not adhere to its policy of providing due notice, as confirmed by the Administrator.
The facility failed to provide written notice of the bed hold policy to residents or their representatives during hospital transfers. Seven residents with various medical conditions, including cognitive impairments and heart failure, were affected. Interviews revealed that the policy was not issued upon discharge, indicating a systemic issue.
The facility failed to accurately reconcile controlled drugs, specifically tramadol, due to discrepancies in the electronic narcotic count. The electronic system showed 120 tablets, while the cart had 114 tablets. Despite being reported to the DON, the issue persisted for days, highlighting a failure in the facility's medication administration policy.
A long-term care facility was found to have a medication error rate of 16.67%, exceeding the acceptable limit of 5%. Errors included improper insulin administration without priming the pen and failure to follow physician orders for mouth rinsing after using Advair Diskus. These deficiencies were observed in multiple residents, with staff failing to adhere to established protocols.
The facility failed to properly label and store medications, with expired and undated medications found in a medication room and cart. Personal items were improperly stored in the medication area. Staff interviews revealed a lack of awareness and adherence to policies regarding medication management.
The facility failed to ensure cleanliness and proper food storage in the kitchen, affecting all residents. Observations showed dirty floors, cluttered preparation areas, and appliances with rust and grease. Outdated food items were found in storage, and interviews revealed a lack of adherence to cleaning protocols due to short staffing.
The facility failed to follow infection control standards, with staff neglecting hand hygiene between glove changes and not using PPE for residents requiring Enhanced Barrier Precautions. Instances included improper hand hygiene by an RN and LPN during insulin administration and blood sugar tests, a catheter bag left on the floor, and inadequate PPE use for a resident with an MDRO and indwelling catheter.
The facility did not complete TPL forms within 30 days for deceased residents, resulting in delayed final accounting for three residents with remaining funds. The BOM recognized the lapse in timely submission upon reviewing records, noting that funds were not managed within the required timeframe.
A resident with severe cognitive impairment and mobility limitations fell and was injured during a transfer on a shower bed. The CNA used an incorrect sling and was alone, contrary to policy requiring two staff members. The resident attempted to hold onto the wall and fell, resulting in a laceration and other injuries.
Failure to Document Pressure Ulcer Measurements
Penalty
Summary
The facility failed to obtain and document initial and weekly measurements of pressure ulcers for one resident. The resident had a hospital record showing consults for wound/skin management with moisture-associated skin damage to the scrotum and sacral area, and a left trochanter wound present on admission measuring 4.0 x 4.0 x 0.2 cm. On admission to the facility, staff documented open areas to the left hip, right sacrum, and coccyx, but no other measurements were documented until the resident was discharged to the hospital. The resident’s record showed diagnoses of metabolic encephalopathy and dysphagia. The annual MDS indicated the resident was at risk for pressure ulcers/injuries, had one or more unhealed pressure ulcers/injuries, and had one unstageable pressure ulcer. The care plan addressed an unstageable wound to the left hip and MASD to the sacrum/buttocks and included weekly skin inspection, attention to bony prominences, turning and repositioning, and supplements per physician order. The record also showed orders for weekly skin audits and complete Braden Scale observations on admission and weekly for four weeks, but no skin assessments were documented as completed on two scheduled weekly dates. During interviews, the DON stated wounds were expected to be documented and measured by facility nurses and that it was her responsibility to ensure wounds were charted properly and the medical record updated. The facility leadership acknowledged that the wound assessments were not completed weekly and that the admission audit was incomplete, and the Wound Nurse and other staff did not document the wound measurements in the EHR.
Failure to Investigate Unexplained Resident Injuries
Penalty
Summary
The facility failed to conduct a thorough investigation after a nurse discovered a resident with multiple unexplained injuries, including a bruise on the chest, an abrasion above the right eye, a skin tear on the nose, and an abrasion on the right elbow. The resident, who was cognitively intact but had some confusion at the time, could not recall how the injuries occurred. The facility's policies required a complete investigation, including staff statements, body assessment, and timely notifications, when injuries of unknown source were identified. However, documentation and interviews revealed that the source of the injuries was not clearly established, and the required investigative steps were not fully completed. The resident had significant medical history, including congestive heart failure, peripheral vascular disease, end stage renal disease, diabetes, and an above-knee amputation. The resident required substantial assistance with mobility and transfers and had a history of falls. Progress notes indicated that the resident reported rolling out of bed, but staff were unsure who assisted the resident back to bed, and there was a lack of documentation regarding the incident. The Director of Nursing (DON) and Administrator acknowledged that the investigation was incomplete, and staff statements were not obtained as required by policy. On the night of the incident, the facility was staffed primarily by agency nurses and facility CNAs. Interviews with agency staff indicated inconsistent familiarity with facility policies and procedures, and the DON confirmed that agency staff were not in-serviced regarding the incident. The facility did not complete a full investigation into the injuries, did not ensure all staff were interviewed, and did not provide in-service training to agency staff involved, as required by their own policies for injuries of unknown origin.
Failure to Transcribe Treatment Order Leads to Wound Infection
Penalty
Summary
The facility failed to ensure professional standards of practice were met when staff did not transcribe a new treatment order for a resident onto the electronic treatment administration record (eTAR). This oversight resulted in the resident not receiving the prescribed treatment from July 24 to August 2, as ordered by the physician. The resident, who was cognitively intact and had diagnoses including anemia, high blood pressure, diabetes, and muscular dystrophy, had an alteration in skin integrity requiring wound monitoring. The care plan aimed to prevent the wound from increasing in size or showing signs of infection, but the failure to administer the treatment led to the wound showing signs of infection. The facility's policy required that all physician orders be immediately entered into the electronic health record (EHR) by the nurse obtaining the order. However, the order for gentamicin was not entered into the eTAR, and there was no documentation of the treatment being completed or any refusal by the resident. The wound management team noted the presence of multiple wounds, including a pressure ulcer on the scrotum, which was initially unstageable and later showed deterioration with 100% necrotic tissue. Despite the wound management team's recommendations and the nurse practitioner's likely verbal order for gentamicin, the treatment was not consistently documented or administered. Interviews with facility staff, including the wound nurse, nurse manager, and nurse practitioner, revealed a lack of communication and documentation regarding the new treatment orders. The nurse manager expected orders to be documented on the physician order sheet and the eTAR, but this was not done for the gentamicin order. The administrator also expected staff to follow physician orders and complete weekly skin audits, which were not consistently performed. The resident's condition deteriorated, leading to a recommendation for hospital treatment due to the wound's deterioration and signs of infection.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain the dignity of several residents by leaving them exposed or inadequately dressed, and by not ensuring privacy during care. One resident was left undressed with only a towel covering their genitals, visible from the hallway, despite their preference for a closed door. Another resident was observed in the dining room wearing a hospital gown that exposed their back, contrary to their preference for wearing a shirt during meals. Staff acknowledged that residents should be dressed appropriately and not removed from meals to change clothing, as this could disrupt their eating. Additionally, the facility did not ensure that catheter bags were covered, compromising the dignity of residents with indwelling catheters. Two residents had their catheter bags visible from the hallway, which was against the facility's policy to store collection bags inside a protective dignity pouch. Staff interviews confirmed that catheter bags should be covered to maintain residents' dignity. Furthermore, staff entered residents' rooms without knocking, failing to respect their privacy. One resident reported that a CNA entered their room without knocking, turned off the call light without speaking, and left without addressing their needs. Another resident corroborated this behavior, noting that the CNA often entered without announcing themselves and sometimes slammed the door. The facility's administration acknowledged that staff should knock before entering a resident's room to uphold their dignity and privacy.
Failure to Provide Transfer Notices to Residents
Penalty
Summary
The facility failed to provide required transfer notices to residents when they were transferred to the hospital. This deficiency was identified for seven residents who were investigated for hospital transfers. The facility's Residents' Rights Policy mandates that residents receive due notice of the reasons for transfer or discharge, but this was not adhered to in the cases reviewed. The residents involved had various medical conditions, including cognitive impairments, heart failure, high blood pressure, and other chronic illnesses, which necessitated multiple hospital transfers. For each of the seven residents, there was no documentation of transfer notices being issued when they were sent to the hospital. The residents experienced multiple transfers and returns between the facility and the hospital, yet the facility did not provide the necessary notifications as required by their policy. This oversight was confirmed during an interview with the Administrator, who acknowledged that no notices of transfer had been issued to residents upon their discharges to the hospital.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide written notice of the bed hold policy to residents or their legal representatives at the time of transfer to the hospital. This deficiency was identified for seven residents who were transferred to the hospital. The facility's bed hold policy requires that residents or their representatives be notified in writing at the time of admission, upon discharge, or when transferred to a hospital or during therapeutic leave. However, there was no documentation that this policy was followed for any of the seven residents investigated. The residents involved had various medical conditions, including cognitive impairments, heart failure, high blood pressure, and other serious health issues. For instance, one resident with both long-term and short-term memory loss was transferred to the hospital multiple times without receiving the required written notice. Another resident with severe cognitive impairment and multiple hospital transfers also did not receive the necessary documentation. These omissions were consistent across all seven residents reviewed, indicating a systemic issue in the facility's adherence to its bed hold policy. Interviews with facility staff, including a registered nurse and the administrator, revealed that the bed hold policy was not being issued to residents upon discharge to the hospital. The administrator acknowledged the oversight and mentioned that the issue had been identified in Quality Assurance. Despite this acknowledgment, the deficiency persisted, affecting the residents' rights to be informed about their bed hold status during hospital transfers.
Failure in Controlled Drug Reconciliation
Penalty
Summary
The facility failed to establish a system of records for the receipt and disposition of controlled drugs, leading to inaccurate reconciliation. Specifically, the facility did not ensure accuracy and monitoring for controlled substances, as evidenced by a discrepancy in the electronic narcotic count for tramadol. The electronic system showed 120 tablets, while the physical count in the cart was 114 tablets. This discrepancy was noted by a Certified Medication Technician, who reported it to the Director of Nursing, but the issue persisted for several days. Interviews with staff, including a Licensed Practical Nurse and the interim Director of Nursing, confirmed that narcotics should be counted at the beginning and end of each shift, and any discrepancies should be reported and corrected immediately. However, the count remained incorrect for several days, indicating a failure in the facility's medication administration policy and procedures.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 16.67% error rate during the survey. This deficiency was identified through observations, interviews, and record reviews involving four residents. The errors primarily involved the improper administration of insulin using pen devices and the failure to follow physician orders for medication administration. Specifically, insulin pens were not primed before administration, which is a necessary step to ensure the correct dosage is delivered. Resident #50, diagnosed with diabetes and other conditions, had a blood sugar level of 179, but the insulin pen was not primed before administering 17 units of insulin. Similarly, Resident #19, with a blood sugar level of 307, received 18 units of insulin without the pen being primed. In both cases, the registered nurse involved believed that priming was unnecessary, which contradicted the facility's policy and the manufacturer's instructions. Additionally, Resident #74, who was prescribed Advair Diskus for COPD, was not provided with water to rinse their mouth after inhalation, as required to prevent fungal infections. This oversight was observed during medication administration, and the staff involved did not adhere to the physician's orders. Resident #26 also received insulin without the pen being primed, further contributing to the facility's high medication error rate. Interviews with staff, including the interim Director of Nursing, confirmed the necessity of priming insulin pens to ensure accurate dosing.
Deficiencies in Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to acceptable standards of practice. During an observation of the 300 Division medication room, expired medications were found, including two bottles of True Metrix Control Solution and an opened bottle of Levetiracetam without a date. Additionally, a bottle of Robitussin had its expiration date blacked out and was not dated when opened. Personal items such as food and drinks were improperly stored in the medication cabinet. Interviews with staff revealed that it was the nurses' responsibility to remove expired medications, and personal items should not be stored in medication rooms. In another instance, a medication cart in the Division 100 was found with an opened bottle of Geri Tussin that had dry residue under the cap and was not dated when opened. The Certified Medication Technician (CMT) was unaware of the requirement to date items when opened, despite the pharmacy's weekly checks. Interviews with the LPN and interim DON confirmed that medications should be dated when opened, expired medications should be removed, and personal items should not be stored in medication areas. The facility's policies on drug storage and pharmacy responsibilities were not adhered to, leading to these deficiencies.
Facility Fails to Maintain Kitchen Cleanliness and Proper Food Storage
Penalty
Summary
The facility failed to maintain cleanliness and proper food storage in the main kitchen, affecting all residents who consumed meals prepared there. Observations revealed that the kitchen floors were consistently dirty, with white specs, dust, grease, and water stains present. The preparation area was cluttered with dirty dish rags, and containers of spices and sauces were found with debris and spillage. Appliances such as the stove, oven, fryer, and tilt skillet were covered in rust, dirt, and grease. The dry storage area was littered with balled-up napkins and outdated food items, including five boxes of cake mix past their use-by date. Additionally, the walk-in freezer contained a bag of chicken and a smoked cigar on the floor, further indicating a lack of proper sanitation practices. Interviews with dietary staff and management highlighted a disconnect between expected and actual cleaning practices. A dietary aide admitted that the kitchen was not clean, with significant build-up on appliances that were supposedly deep cleaned a month prior. The dietary manager acknowledged that while cleaning was expected after each meal service, the kitchen was short-staffed, prioritizing timely meal delivery over cleanliness. The administrator also expressed an expectation for a clean kitchen and the disposal of expired foods, yet these standards were not met, leading to the observed deficiencies.
Infection Control Deficiencies in Hand Hygiene and PPE Use
Penalty
Summary
The facility failed to adhere to proper infection control standards, as evidenced by multiple instances of staff neglecting to perform hand hygiene between glove changes and between resident interactions. Specifically, Registered Nurse (RN) A and Licensed Practical Nurse (LPN) E were observed not washing their hands between glove changes while administering insulin and performing blood sugar tests for several residents. This failure to follow hand hygiene protocols was noted during interactions with residents who had various medical conditions, including diabetes, heart failure, and kidney disease. Additionally, the facility did not maintain proper catheter care for a resident, as the catheter bag was observed lying on the floor without a protective barrier. This was contrary to the facility's catheter care policy, which requires catheter bags to be off the floor to prevent infection. Interviews with staff confirmed that catheter bags should not be placed on the floor, highlighting a lapse in adherence to infection control procedures. Furthermore, the facility did not implement Enhanced Barrier Precautions (EBP) for a resident with a multidrug-resistant organism (MDRO) and an indwelling catheter. Staff were observed not wearing the appropriate personal protective equipment (PPE), such as gowns, during high-contact activities with the resident. Despite the presence of PPE and signage indicating the need for EBP, staff failed to comply with these requirements, as confirmed by interviews with the nursing staff and the Nurse Manager.
Delayed TPL Form Submission for Deceased Residents
Penalty
Summary
The facility failed to complete third party liability (TPL) forms within 30 days for the final accounting of residents who had expired, affecting three sampled residents. These residents had money remaining in their accounts for longer than the stipulated 30 days. Specifically, Resident #301 had an ending balance of $150.13, Resident #302 had $50.00, and Resident #300 had $0.13. The Business Office Manager (BOM) acknowledged that the facility was required to send the TPL forms within 30 days and noted that upon starting her role in April, she observed that some records were not concurrent, with funds lapsing beyond the acceptable timeframe.
Resident Fall Due to Improper Transfer Procedure
Penalty
Summary
The facility failed to ensure the safe positioning of a resident during a transfer on a shower bed, resulting in a fall and injury. The incident involved a resident with severe cognitive impairment, functional limitations in the lower extremities, and a history of falls. The resident was dependent on staff for transfers and activities of daily living due to an acquired absence of the right leg above the knee and other health conditions. During the incident, the resident was being assisted by a CNA who used a regular lift sling instead of the appropriate shower sling, and the resident fell while being turned on the shower bed. The CNA attempted to turn the resident onto their left side after providing a shower, during which the resident tried to hold onto the wall but fell off the shower bed. The fall resulted in a laceration on the resident's left eyebrow, requiring 14 stitches, and additional bruising and skin tears. The CNA was alone in the shower room at the time of the incident, contrary to the facility's policy that required two staff members to be present during such transfers. The resident was found face down on the floor with significant bleeding and was subsequently sent to the hospital for evaluation and treatment. Interviews with staff revealed that the CNA did not follow the correct procedure by using the wrong sling and not having a second staff member present. The Nurse Manager confirmed that two staff members should be present when a resident is on a shower bed, and it was inappropriate for the resident to be asked to hold onto the wall. The Administrator acknowledged that the procedure was not followed, leading to the resident's fall and injury.
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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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Illustrative
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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) |
|---|---|---|---|---|
| Manchester Rehab And Healthcare Center | 2.1 mi | ★★★★★ | 0 | 0 |
| Garden View Care Center Of Chesterfield | 2.6 mi | ★★★★★ | 1 | 0 |
| Lutheran Senior Services At Meramec Bluffs | 2.8 mi | ★★★★★ | 2 | 0 |
| Athene Nursing And Rehabilitation | 2.9 mi | ★★★★★ | 46 | 0 |
| Ellisville Rehabilitation And Nursing | 2.9 mi | ★★★★★ | 22 | 3 |
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