6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
11 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Black Jack, MO
3-star overall rating with 3-star inspections with $39,299 in total fines with 6 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
4401 Parker Road, Black Jack, MO
(314) 355-1516
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
Beds
240
Certified beds
Average residents
175
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Delmar Gardens
Operator or chain grouping
Approved since
1988-05-17
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
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.18
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
0.87
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.71
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.75
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
1.04
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
3.39
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.13
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.20
CMS adjusted RN staffing hours
Adjusted total hours
4.31
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 51% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Program rank
3,026
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.37
Composite VBP score used to determine payment impact.
Payment multiplier
0.9997
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
5.78
Baseline 21.65% · Performance 18.75% · Measure score 5.78 · Achievement 5.78 · Improvement 5.77
Healthcare-associated infections
5.15
Baseline 6.21% · Performance 6.30% · Measure score 5.15 · Achievement 5.15 · Improvement 0
Total nurse turnover
4.03
Baseline 55.94% · Performance 47.22% · Measure score 4.03 · Achievement 4.03 · Improvement 2.31
Adjusted total nurse staffing
3.59
Baseline 4.45 hours · Performance 4.10 hours · Measure score 3.59 · Achievement 3.59 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.59% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 141 · Observed rate 13.48% · Lower 95% interval 7.74% |
| Discharge to community | 50.64% |
50.57%
0.1 pts better
|
No Different than the National Rate · Eligible stays 120 · Observed rate 38.33% · Lower 95% interval 38.61% |
| Medicare spending per beneficiary | 0.67 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 98.67% |
95.27%
3.4 pts better
|
Numerator 74 · Denominator 75 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 75 |
| Discharge self-care score | 27.27% |
53.69%
26.4 pts worse
|
Numerator 15 · Denominator 55 |
| Discharge mobility score | 21.82% |
50.94%
29.1 pts worse
|
Numerator 12 · Denominator 55 |
| Pressure ulcers or injuries, new or worsened | 10.67% |
2.29%
8.4 pts worse
|
Numerator 8 · Denominator 75 · Adjusted rate 10.49% |
| Healthcare-associated infections requiring hospitalization | 6.3% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 52 · Observed rate 3.85% · Lower 95% interval 3.14% |
| Staff COVID-19 vaccination coverage | 2.73% |
8.2%
5.5 pts worse
|
Numerator 6 · Denominator 220 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 21.82% |
56.45%
34.6 pts worse
|
Numerator 12 · Denominator 55 |
| Transfer of health information to provider | 96.3% |
95.95%
0.3 pts better
|
Numerator 26 · Denominator 27 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 20.93% |
25.2%
4.3 pts worse
|
Numerator 9 · Denominator 43 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 82.6% |
84.8%
2.2 pts worse
|
93.4%
10.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 85.6% · Q2 82.9% · Q3 73.7% · Q4 88.1% · 4Q avg 82.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.9% |
90.9%
1 pts better
|
95.5%
3.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.1% |
4.1%
About the same
|
3.3%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 5.3% · Q3 4.6% · Q4 3.8% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
14.7%
14.3 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.8% · Q4 0.8% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 7.3% |
5.5%
1.8 pts worse
|
5.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 8.9% · Q3 7.5% · Q4 5.1% · 4Q avg 7.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.8% |
25.3%
7.5 pts better
|
19.6%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 19.7% · Q3 18.8% · Q4 17.5% · 4Q avg 17.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.1% |
25.0%
11.9 pts better
|
16.7%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 13.8% · Q3 12.1% · Q4 10.4% · 4Q avg 13.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
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 | 14.6% |
20.3%
5.7 pts better
|
16.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 15.7% · Q3 17.0% · Q4 9.8% · 4Q avg 14.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.9% |
19.8%
6.9 pts better
|
14.9%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 11.8% · Q3 12.9% · Q4 10.9% · 4Q avg 12.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.4% |
1.4%
1 pts worse
|
1.0%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.6% · Q3 2.5% · Q4 2.3% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.1% |
2.6%
0.5 pts better
|
1.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 1.3% · Q3 3.3% · Q4 3.1% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.2% |
18.1%
9.9 pts better
|
19.8%
11.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 7.7% · Q3 5.2% · Q4 10.7% · 4Q avg 8.2% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
5.0%
0.4 pts worse
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 6.3% · Q3 6.4% · Q4 5.2% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 55.2% |
66.4%
11.2 pts worse
|
81.7%
26.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 57.7% · Q2 50.0% · Q3 49.5% · Q4 64.1% · 4Q avg 55.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.8% |
13.4%
8.4 pts worse
|
12.0%
9.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 21.8% · Observed 24.5% · Expected 12.6% · 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 2.1% · Q2 1.8% · Q3 0.9% · Q4 1.1% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 63.5% |
63.5%
About the same
|
79.7%
16.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 63.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.5% |
25.3%
5.8 pts better
|
23.9%
4.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.5% · Observed 22.4% · Expected 27.5% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (3 deficiencies)
11 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
8 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Top issue: Quality of Life and Care (6 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire Safety
Establish staff and initial training requirements.
Corrected 2026-01-01
Fire Safety
Conduct testing and exercise requirements.
Corrected 2026-01-01
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2026-01-01
Fire Safety
Meet other general requirements that are deficient.
Corrected 2026-01-01
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2026-01-01
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2026-01-13
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-01-01
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2026-01-01
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2026-01-01
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2026-01-01
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2026-01-01
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-11-15
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-15
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-12-16
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-11-15
Fire Safety
Install proper backup exit lighting.
Corrected 2023-12-16
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-11-15
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-15
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-11-15
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2020-02-21
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2020-02-21
Fire Safety
Have exits that are accessible at all times.
Corrected 2020-02-21
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2020-02-21
Inspection history
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2026-01-01
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 2026-01-07
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2026-01-01
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-01-01
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2026-01-01
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2026-01-01
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-14
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-12-11
Health
Respond appropriately to all alleged violations.
Corrected 2024-08-23
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-08-23
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-23
Health
Respond appropriately to all alleged violations.
Corrected 2023-12-05
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-05
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-12-16
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-15
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-11-15
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-11-15
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-11-15
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-11-15
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-11-15
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-11-15
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2020-02-21
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2020-02-21
Health
Keep residents' personal and medical records private and confidential.
Corrected 2020-02-21
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2020-02-21
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2020-02-21
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 2020-02-21
Health
Provide and implement an infection prevention and control program.
Corrected 2020-02-21
Health
Ensure each resident receives an accurate assessment.
Corrected 2020-02-21
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2020-02-21
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2020-02-21
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2020-02-21
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2020-02-21
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2020-02-21
Penalties and ownership
Fine · fine $39,299
Fine
Payment Denial · denial start 2023-12-07 · 9 days
9 day denial
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
Corporate Officer · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Corporate Officer · Individual
W-2 Managing Employee · Individual
W-2 Managing Employee · Individual
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