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 West during CMS and state inspections, most recent first.
The facility failed to maintain an effective pest control program, leading to a significant infestation of roaches and gnats in the kitchen where residents' food was prepared and served. Observations revealed cockroaches on walls, floors, and food preparation areas. Staff and residents reported frequent sightings of pests, and the pest control measures in place were ineffective due to issues like standing water. The facility struggled to address the infestation despite regular pest control visits.
A resident with CHF did not have their daily weights sent to their cardiologist as ordered. Despite initial compliance, the facility failed to document the faxing of weights on subsequent Mondays. Staff interviews revealed that the responsibility for faxing was assigned to the nurse on duty, but lapses occurred. The cardiologist's office eventually received all weights, but the report does not specify the impact of the delay.
A resident with mobility issues fell during a transfer when a CNA attempted to use a Hoyer lift alone, contrary to the facility's policy requiring two staff members. The resident, who had conditions like stroke and hemiplegia, was sent to the hospital for evaluation. Staff interviews confirmed the policy, and the CNA was suspended.
A facility failed to provide adequate hot water for residents on the 100 unit for over three months, affecting their ability to maintain personal hygiene. Despite efforts to resolve the issue, including hiring plumbers and replacing shower heads, water temperatures remained below the standard range of 105 to 120 degrees Fahrenheit. This deficiency impacted residents' comfort and ability to shower, as confirmed by observations and facility logs.
A resident with major depression and homelessness was not provided access to behavioral health services despite expressing stress and anxiety over a 30-day discharge notice. The facility's policy on trauma-informed care was not followed, as the resident, who was on antidepressants, was not referred to a counselor or therapist. The resident faced multiple stressors, including financial issues and an impending discharge, without adequate support from the facility.
A resident with severe cognitive impairment and multiple diagnoses was found without a pulse, and despite having a full code status, CPR was not administered by the LPNs due to a misinterpretation of clinical signs of death. The staff failed to identify dependent lividity or rigor mortis, leading to a failure to provide timely basic life support.
Pest Control Deficiency in Facility Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a significant infestation of roaches and gnats in the kitchen where residents' food was prepared and served. Observations revealed bait traps filled with brown cockroaches, cockroaches crawling on walls and floors, and dead cockroaches in various areas, including on a prep table near food items. The presence of roaches was also noted on the silver platform where dishes were placed for washing, and in puddles of water on the floor. Additionally, there were large trash bags on the floor and a fan that was not running, which was intended to help keep the floor dry as part of pest control measures. Interviews with staff and residents highlighted ongoing issues with pest control. The Maintenance Director mentioned efforts to seal cracks and holes and the use of baking soda and vinegar in drains, but was unsure if the kitchen had been treated with chemicals. The Dietitian and Dietary Aides confirmed frequent sightings of roaches and gnats, with pest control visits occurring bi-weekly. However, there was uncertainty about the replacement of bait traps and the effectiveness of the pest control measures. Residents reported seeing roaches in their rooms and the dining area, with some residents having to move rooms due to infestations. The Administrator acknowledged the pest control company's visits and the use of chemical sprays, but noted that standing water on the kitchen floor rendered the chemicals ineffective. The pest control company suggested improvements in cleaning and removal of boxes, which were identified as sources of the infestation. Despite these efforts, the facility continued to struggle with pest control, as evidenced by the ongoing presence of roaches and gnats in the kitchen and other areas.
Failure to Send Resident's Daily Weights to Cardiologist
Penalty
Summary
The facility failed to adhere to professional standards of practice and the resident's plan of care by not obtaining and sending daily weights to the resident's cardiologist as per the physician's order. The resident, who had no cognitive impairment, was diagnosed with conditions including stroke, congestive heart failure (CHF), high blood pressure, and hemiplegia. The care plan required daily diuretic therapy and monitoring for signs of hypokalemia and dehydration, with an intervention to obtain and record weight as ordered. The physician's order specified that daily weights should be sent to the cardiologist weekly, starting from a specified date. Despite the order being entered into the electronic health record (EHR) and initial compliance with faxing weights, there was no documentation of weights being sent on subsequent Mondays as required. Interviews with staff, including LPNs and the Director of Nursing (DON), revealed that the responsibility for faxing weights was assigned to the nurse on duty each Monday. However, there was a lapse in following this procedure, as evidenced by missing documentation for certain dates. The DON confirmed that the cardiologist's office eventually received all the weights, but the report does not specify the impact of the delay.
Failure to Follow Transfer Policy Results in Resident Fall
Penalty
Summary
The facility failed to ensure a safe environment for residents by not adhering to its transfer policy, which mandates that two employees assist in transferring residents using a mechanical lift. This deficiency was highlighted when a Certified Nurse Aide (CNA) attempted to transfer a resident alone using a Hoyer lift, resulting in the resident sliding off the lift and hitting the floor. The incident led to the resident being sent to the hospital for evaluation. The resident involved in the incident had no cognitive impairment and was dependent on staff for transfers due to conditions such as stroke, congestive heart failure, high blood pressure, and hemiplegia. The resident's care plan clearly indicated the need for a two-person assist when using a Hoyer lift. Despite this, the CNA attempted the transfer alone, which was against the facility's policy and the resident's care plan. Interviews with various staff members, including a Licensed Practical Nurse (LPN), Certified Medication Technician (CMT), and other CNAs, confirmed that the facility's policy required two people to operate a mechanical lift. The Director of Nursing (DON) acknowledged the incident and emphasized that staff were expected to follow the physician's orders and the facility's transfer policy. The CNA involved was suspended following the incident.
Inadequate Hot Water Supply on 100 Unit
Penalty
Summary
The facility failed to provide a homelike environment by not ensuring sufficient hot water for residents on the 100 unit for at least three months. This deficiency was observed in three sampled residents, affecting potentially all 17 residents on the unit. Resident #1, who was cognitively intact and able to communicate, reported a lack of hot water since admission, limiting their ability to shower and maintain personal hygiene. Observations confirmed water temperatures in the resident's room were consistently below the standard range of 105 to 120 degrees Fahrenheit. Resident #4, with diagnoses including epilepsy and cognitive communication deficit, also experienced inadequate hot water, with temperatures recorded at 98 degrees Fahrenheit. Similarly, Resident #6, diagnosed with generalized anxiety disorder and cognitive communication deficit, had water temperatures in their room recorded at 90 degrees Fahrenheit. These observations were consistent with the facility's water temperature logs, which showed multiple instances of water temperatures below the required standard over several weeks. The Maintenance Director acknowledged the ongoing issue with low water temperatures on the 100 unit, despite efforts to resolve it, including hiring plumbers and replacing shower heads. The director noted that no residents had personally complained to them, but staff had reported the issue. The facility had spent significant resources attempting to identify and fix the problem, yet the deficiency persisted, affecting the residents' ability to maintain a safe and comfortable environment.
Failure to Provide Behavioral Health Services to Resident
Penalty
Summary
The facility failed to provide necessary behavioral health services to a resident who was issued a 30-day discharge notice and was known to be homeless with a diagnosis of major depression. Despite the resident's expressed stress and anxiety over losing their home and the impending discharge, the facility did not offer access to a therapist or counselor. The resident, who had been admitted for therapy services following neck surgery, was also dealing with financial stress due to a bill at the facility and had appealed the discharge notice. The facility's trauma-informed care and behavioral health management policy emphasizes early identification of trauma-related disorders and the implementation of non-pharmacological interventions. However, the resident, who was on routine antidepressants and had a history of anxiety and depression, was not referred to a counselor or therapist. The social worker acknowledged the resident's stressors but had not made any referrals for additional behavioral health support, despite the resident's interest in speaking to a counselor. Interviews with facility staff revealed that the resident had been evicted from their apartment during a hospital stay and had refused to apply for Medicaid. The resident was aware of other facilities willing to accept them but preferred to find a place in the community. The facility's failure to provide behavioral health services as per their policy contributed to the resident's ongoing stress and anxiety, as observed during interactions with staff and family.
Failure to Provide Timely CPR
Penalty
Summary
The facility failed to provide timely basic life support, including CPR, for a resident who had physician orders for CPR and was found by staff without a pulse. The resident, who had severe cognitive impairment and diagnoses of lung cancer, anxiety, and acute respiratory failure, was discovered by an LPN during rounds with no signs of life. Despite the resident's full code status, the LPN did not administer CPR, citing the presence of what they believed to be obvious signs of death, such as fixed pupils, dry mucus membranes, no chest movement, no bowel sounds, no pulse, cyanotic fingers and toes, and mottling of the hands and feet. However, the LPN did not identify dependent lividity or rigor mortis, which are clinical indicators required to forgo CPR according to the facility's policy and AHA guidelines. Another LPN was called to assist and confirmed the resident's lack of vital signs but also did not identify dependent lividity or rigor mortis. Both LPNs decided not to administer CPR based on their assessment of the resident's condition, which did not meet the clinical definitions required to withhold CPR. The facility's investigative summary and interviews with the involved staff revealed that the LPNs did not use the correct clinical terminology to describe the resident's condition, leading to a failure to initiate CPR as required by the resident's full code status. The facility's policy mandates that CPR should be performed unless there are clear signs of clinical death, which were not adequately identified in this case. The administrator acknowledged that the staff may not have been familiar with the correct terminology, contributing to the failure to provide the necessary life-saving measures.
Removal Plan
- The facility provided training and in-servicing for all staff regarding the facility's CPR policy.
- The facility provided training and in-servicing for all staff on using proper definitions/verbiage when reporting on CPR/Death Reporting Form.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 845 citations issued within 25 miles in the last 12 months — including the 14 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Town And Country
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mason Pointe Care Center | 0 mi | ★★★★★ | 0 | 0 |
| Brooking Park | 1 mi | ★★★★★ | 3 | 0 |
| Garden View Care Center Of Chesterfield | 1 mi | ★★★★★ | 1 | 0 |
| Westchester House, The | 1.4 mi | ★★★★★ | 0 | 0 |
| Friendship Village Chesterfield | 1.6 mi | ★★★★★ | 1 | 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.