9 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Chesterfield, MO
3-star overall rating with 3-star inspections with $17,160 in total fines with 9 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
14855 North Outer 40 Road, Chesterfield, MO
(636) 532-0150
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
227
Certified beds
Average residents
162
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Delmar Gardens
Operator or chain grouping
Approved since
1982-05-26
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
0.25
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
0.84
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.79
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.88
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
1.09
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
3.57
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.18
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.27
CMS adjusted RN staffing hours
Adjusted total hours
4.30
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 51% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Program rank
11,746
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.46
Composite VBP score used to determine payment impact.
Payment multiplier
0.9815
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 21.12% · Performance 21.76% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 8.69% · Performance 9.79% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.44
Performance 57.78% · Measure score 1.44 · Achievement 1.44 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
4.74
Baseline 3.87 hours · Performance 4.43 hours · Measure score 4.74 · Achievement 4.74 · Improvement 2.41
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.45% |
10.72%
2.7 pts worse
|
No Different than the National Rate · Eligible stays 248 · Observed rate 16.53% · Lower 95% interval 10.49% |
| Discharge to community | 47.21% |
50.57%
3.4 pts worse
|
No Different than the National Rate · Eligible stays 196 · Observed rate 38.78% · Lower 95% interval 40.37% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 97.35% |
95.27%
2.1 pts better
|
Numerator 110 · Denominator 113 |
| Falls with major injury | 1.77% |
0.77%
1 pts worse
|
Numerator 2 · Denominator 113 |
| Discharge self-care score | 40.26% |
53.69%
13.4 pts worse
|
Numerator 31 · Denominator 77 |
| Discharge mobility score | 16.88% |
50.94%
34.1 pts worse
|
Numerator 13 · Denominator 77 |
| Pressure ulcers or injuries, new or worsened | 4.42% |
2.29%
2.1 pts worse
|
Numerator 5 · Denominator 113 · Adjusted rate 5.54% |
| Healthcare-associated infections requiring hospitalization | 9.79% |
7.12%
2.7 pts worse
|
No Different than the National Rate · Eligible stays 113 · Observed rate 13.27% · Lower 95% interval 6.77% |
| Staff COVID-19 vaccination coverage | 7.88% |
8.2%
0.3 pts worse
|
Numerator 16 · Denominator 203 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 23.38% |
56.45%
33.1 pts worse
|
Numerator 18 · Denominator 77 |
| Transfer of health information to provider | 89.66% |
95.95%
6.3 pts worse
|
Numerator 26 · Denominator 29 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 46 · Denominator 46 |
| Resident COVID-19 vaccinations up to date | 31.03% |
25.2%
5.8 pts better
|
Numerator 18 · Denominator 58 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
2.1
0.8 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.1 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
2.3
1.1 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 66.7% |
84.8%
18.1 pts worse
|
93.4%
26.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 69.4% · Q2 68.0% · Q3 67.1% · Q4 62.1% · 4Q avg 66.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 88.5% |
90.9%
2.4 pts worse
|
95.5%
7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 88.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.3% |
4.1%
2.2 pts worse
|
3.3%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 6.8% · Q3 5.7% · Q4 7.1% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.6% |
14.7%
13.1 pts better
|
11.4%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.8% · Q3 2.6% · Q4 1.7% · 4Q avg 1.6% |
| Percentage of long-stay residents who lose too much weight | 5.6% |
5.5%
0.1 pts worse
|
5.4%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 4.8% · Q3 5.0% · Q4 5.3% · 4Q avg 5.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.8% |
25.3%
11.5 pts better
|
19.6%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 15.9% · Q3 12.5% · Q4 11.9% · 4Q avg 13.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.3% |
25.0%
5.7 pts better
|
16.7%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 20.4% · Q3 19.8% · Q4 18.0% · 4Q avg 19.3% · 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 | 18.2% |
20.3%
2.1 pts better
|
16.3%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.4% · Q2 15.7% · Q3 15.1% · Q4 16.5% · 4Q avg 18.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.1% |
19.8%
5.7 pts better
|
14.9%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 11.4% · Q3 12.0% · Q4 14.8% · 4Q avg 14.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
1.4%
0.1 pts better
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 2.3% · Q3 1.8% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
2.6%
1 pts better
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 1.4% · Q4 3.7% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 9.6% |
18.1%
8.5 pts better
|
19.8%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 8.6% · Q3 12.8% · Q4 11.6% · 4Q avg 9.6% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
5.0%
0.4 pts better
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 6.3% · Q3 3.2% · Q4 3.0% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 55.3% |
66.4%
11.1 pts worse
|
81.7%
26.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 60.1% · Q2 62.0% · Q3 53.6% · Q4 45.8% · 4Q avg 55.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.3% |
13.4%
3.1 pts better
|
12.0%
1.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.3% · Observed 9.7% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
2.2%
1.1 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 0.9% · Q3 0.0% · Q4 0.9% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 59.2% |
63.5%
4.3 pts worse
|
79.7%
20.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 59.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.7% |
25.3%
7.4 pts worse
|
23.9%
8.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.7% · Observed 30.1% · Expected 22.0% · Used in QM five-star |
Survey summary
Top issue: Pharmacy Service (3 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Top issue: Resident Assessment and Care Planning (3 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Resident Rights (6 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-09-18
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-18
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-09-18
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-09-18
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-09-18
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-09-18
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-09-18
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-26
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-23
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-03-26
Fire Safety
Install proper backup exit lighting.
Corrected 2024-03-26
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-03-26
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-06-01
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-03-26
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-03-26
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-01-05
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-01-05
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-01-05
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-02-22
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-01-05
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-01-05
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-01-05
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-01-05
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-01-05
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-01-05
Inspection history
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-09-18
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 2025-09-18
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-06-29
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-09-18
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 2025-09-18
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-09-18
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-18
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2025-05-16
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-05-16
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2024-03-26
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-26
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2024-03-26
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-03-26
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-03-26
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 2024-03-26
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-03-26
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2024-03-26
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-03-26
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-03-26
Health
Provide activities to meet all resident's needs.
Corrected 2024-03-26
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-03-26
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 2024-03-26
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-03-26
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-03-26
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-07-25
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-07-25
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-25
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-01-05
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-01-05
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2022-01-05
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2022-01-05
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2022-01-05
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-01-05
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-01-05
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-01-05
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2022-01-05
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 2022-01-05
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-01-05
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2022-01-05
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-01-05
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-01-05
Health
Provide and implement an infection prevention and control program.
Corrected 2022-01-05
Penalties and ownership
Fine · fine $17,160
Fine
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
5% Or Greater Indirect Ownership Interest · Organization
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
W-2 Managing Employee · Individual
Corporate Officer · Individual
Nearby options
Chesterfield, MO
4-star overall rating with 4-star inspections with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
Chesterfield, MO
5-star overall rating with 4-star inspections with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
Chesterfield, MO
2-star overall rating with 2-star inspections with $83,824 in total fines with 16 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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