Cycle 1
Health 2024-05-14 · Fire 2024-05-14
18 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
O Fallon, MO
Delmar Gardens Of O'fallon
3-star overall rating with 2-star inspections with 18 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
7068 South Outer 364, O Fallon, MO
(636) 240-6100
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
198
Certified beds
Average residents
155
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Delmar Gardens
Operator or chain grouping
Approved since
2004-12-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.42
Registered nurse staffing
LPN hours / resident day
0.82
Licensed practical nurse staffing
Aide hours / resident day
3.10
Nurse aide staffing
Weekend hours
4.07
Weekend nurse staffing
RN turnover
19%
Annual RN turnover
Total nurse turnover
43%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
2.1
0.7 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
2.3
0.5 pts better
|
1.8
About the same
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
84.8%
15.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.7% |
90.9%
6.8 pts better
|
95.5%
2.2 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.9% |
4.1%
0.2 pts better
|
3.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 6.7% |
14.7%
8 pts better
|
11.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 16.2% |
5.5%
10.7 pts worse
|
5.4%
10.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.1% |
25.3%
0.2 pts better
|
19.6%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 20.5% |
25.0%
4.5 pts better
|
16.7%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 9.5% |
20.3%
10.8 pts better
|
16.3%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.2% |
19.8%
9.6 pts better
|
14.9%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
1.4%
0.4 pts better
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 6.7% |
2.6%
4.1 pts worse
|
1.7%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 6.2% |
18.1%
11.9 pts better
|
19.8%
13.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 3.4% |
5.0%
1.6 pts better
|
5.1%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.4% |
66.4%
30 pts better
|
81.7%
14.7 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.1% |
13.4%
4.3 pts better
|
12.0%
2.9 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
2.2%
1.7 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.9% |
63.5%
25.4 pts better
|
79.7%
9.2 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.4% |
25.3%
8.9 pts better
|
23.9%
7.5 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-10-27 · Fire 2022-10-27
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2019-10-16 · Fire 2019-10-16
13 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-05-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-24
E · Potential for more than minimal harm
2024-05-14
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-06-24
E · Potential for more than minimal harm
2024-05-14
K222 · Egress Deficiencies
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 2024-06-24
E · Potential for more than minimal harm
2024-05-14
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-06-24
E · Potential for more than minimal harm
2024-05-14
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-06-24
E · Potential for more than minimal harm
2024-05-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-06-24
E · Potential for more than minimal harm
2024-05-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-06-24
E · Potential for more than minimal harm
2024-05-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-06-24
E · Potential for more than minimal harm
2024-05-14
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-06-24
E · Potential for more than minimal harm
2024-05-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-06-24
E · Potential for more than minimal harm
2024-05-14
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-06-24
D · Potential for more than minimal harm
2024-05-14
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-06-24
D · Potential for more than minimal harm
2024-05-14
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-06-24
F · Potential for more than minimal harm
2022-10-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-23
F · Potential for more than minimal harm
2022-10-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-23
F · Potential for more than minimal harm
2022-10-27
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2022-11-23
E · Potential for more than minimal harm
2022-10-27
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2022-11-23
E · Potential for more than minimal harm
2022-10-27
K222 · Egress Deficiencies
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 2022-11-23
E · Potential for more than minimal harm
2022-10-27
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2022-11-23
E · Potential for more than minimal harm
2022-10-27
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2022-11-23
E · Potential for more than minimal harm
2022-10-27
K321 · Smoke Deficiencies
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 2022-11-23
E · Potential for more than minimal harm
2022-10-27
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-04-27
E · Potential for more than minimal harm
2022-10-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-11-23
E · Potential for more than minimal harm
2022-10-27
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-11-23
E · Potential for more than minimal harm
2022-10-27
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-11-23
E · Potential for more than minimal harm
2022-10-27
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-11-23
E · Potential for more than minimal harm
2022-10-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-11-23
F · Potential for more than minimal harm
2019-10-16
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2019-11-27
E · Potential for more than minimal harm
2019-10-16
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-11-27
E · Potential for more than minimal harm
2019-10-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-11-27
Inspection history
Recent health citations
G · Actual harm
2025-03-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-11
E · Potential for more than minimal harm
2024-08-23
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-10-09
F · Potential for more than minimal harm
2024-05-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-06-24
E · Potential for more than minimal harm
2024-05-14
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-06-24
E · Potential for more than minimal harm
2024-05-14
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-06-24
E · Potential for more than minimal harm
2024-05-14
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-06-24
E · Potential for more than minimal harm
2024-05-14
F690 · Quality of Life and Care Deficiencies
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 2024-06-24
E · Potential for more than minimal harm
2024-05-14
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-06-24
E · Potential for more than minimal harm
2024-05-14
F761 · Pharmacy Service Deficiencies
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 2024-06-24
E · Potential for more than minimal harm
2024-05-14
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-06-24
E · Potential for more than minimal harm
2024-05-14
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-06-24
E · Potential for more than minimal harm
2024-05-14
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-06-24
E · Potential for more than minimal harm
2024-05-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-24
E · Potential for more than minimal harm
2024-05-14
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-06-24
D · Potential for more than minimal harm
2024-05-14
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-06-24
D · Potential for more than minimal harm
2024-05-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-06-24
D · Potential for more than minimal harm
2024-05-14
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-06-24
D · Potential for more than minimal harm
2024-05-14
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-06-24
B · Minimal harm
2024-05-14
F625 · Resident Rights Deficiencies
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 2024-06-24
D · Potential for more than minimal harm
2024-03-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-19
D · Potential for more than minimal harm
2023-04-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-23
F · Potential for more than minimal harm
2022-10-27
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-11-23
E · Potential for more than minimal harm
2022-10-27
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2022-11-23
E · Potential for more than minimal harm
2022-10-27
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2022-11-23
D · Potential for more than minimal harm
2022-10-27
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-11-23
D · Potential for more than minimal harm
2022-10-27
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2022-11-23
D · Potential for more than minimal harm
2022-10-27
F761 · Pharmacy Service Deficiencies
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 2022-11-23
F · Potential for more than minimal harm
2019-10-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-11-27
E · Potential for more than minimal harm
2019-10-16
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2019-11-27
E · Potential for more than minimal harm
2019-10-16
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2019-11-27
E · Potential for more than minimal harm
2019-10-16
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2019-11-27
E · Potential for more than minimal harm
2019-10-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-11-27
E · Potential for more than minimal harm
2019-10-16
F690 · Quality of Life and Care Deficiencies
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 2019-11-27
E · Potential for more than minimal harm
2019-10-16
F725 · Nursing and Physician Services Deficiencies
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 2019-11-27
E · Potential for more than minimal harm
2019-10-16
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2019-11-27
E · Potential for more than minimal harm
2019-10-16
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2019-11-27
D · Potential for more than minimal harm
2019-10-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-11-27
D · Potential for more than minimal harm
2019-10-16
F758 · Pharmacy Service Deficiencies
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 2019-11-27
D · Potential for more than minimal harm
2019-10-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-11-27
Penalties and ownership
What sits behind the stars
Ownership
Delmar Gardens Enterprises Inc
5% Or Greater Direct Ownership Interest · Organization
Goldberg-Nom LLC
5% Or Greater Indirect Ownership Interest · Organization
Grossberg, Gabe
5% Or Greater Indirect Ownership Interest · Individual
Grossberg, George
5% Or Greater Indirect Ownership Interest · Individual
Gabe Grossberg And George Grossberg, Trustees Of The Henry And Barbara
5% Or Greater Indirect Ownership Interest · Organization
George Grossberg And Gabe Grossberg, Trustees Of The Henry And Barbara
5% Or Greater Indirect Ownership Interest · Organization
Non-Gst Family Trust Est U/W Of Israel Goldberg Fbo Janice Bitanski
5% Or Greater Indirect Ownership Interest · Organization
Non-Gst Family Trust Established U/W Of Israel Goldberg Fbo Harry Zvi
5% Or Greater Indirect Ownership Interest · Organization
Non-Gstfamily Trust Est U/W Israel Goldberg Fbo Diane Fredman
5% Or Greater Indirect Ownership Interest · Organization
Delmar Gardens Management Services Inc
Operational/Managerial Control · Organization
Grossberg, Gabe
Corporate Officer · Individual
Marx, Kenneth
Corporate Officer · Individual
Oppenheimer, Howard
Corporate Officer · Individual
Reiter, Teresa
W-2 Managing Employee · Individual
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