Cycle 1
Health 2024-09-17 · Fire 2024-09-17
3 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Saint Louis, MO
Delmar Gardens South
4-star overall rating with 5-star inspections with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
5300 Butler Hill Road, Saint Louis, MO
(314) 842-0588
Overall
4 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
184
Certified beds
Average residents
171
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Delmar Gardens
Operator or chain grouping
Approved since
1987-04-20
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
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.47
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
1.07
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
4.00
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
5.54
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
1.54
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
5.19
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.48
CMS adjusted RN staffing hours
Adjusted total hours
5.69
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
28%
Annual RN turnover · state 51% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,305
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.06
Composite VBP score used to determine payment impact.
Payment multiplier
0.9833
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.75% · Performance 24.01% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0.56
Baseline 5.91% · Performance 7.67% · Measure score 0.56 · Achievement 0.56 · Improvement 0
Total nurse turnover
1.61
Baseline 50.72% · Performance 57.08% · Measure score 1.61 · Achievement 1.61 · Improvement 0
Adjusted total nurse staffing
7.45
Baseline 6.25 hours · Performance 5.20 hours · Measure score 7.45 · Achievement 7.45 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.97% |
10.72%
3.2 pts worse
|
Worse than the National Rate · Eligible stays 388 · Observed rate 14.95% · Lower 95% interval 11.06% |
| Discharge to community | 47.26% |
50.57%
3.3 pts worse
|
No Different than the National Rate · Eligible stays 385 · Observed rate 42.08% · Lower 95% interval 41.22% |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 96.05% |
95.27%
0.8 pts better
|
Numerator 170 · Denominator 177 |
| Falls with major injury | 0.56% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 177 |
| Discharge self-care score | 27.13% |
53.69%
26.6 pts worse
|
Numerator 35 · Denominator 129 |
| Discharge mobility score | 20.16% |
50.94%
30.8 pts worse
|
Numerator 26 · Denominator 129 |
| Pressure ulcers or injuries, new or worsened | 6.78% |
2.29%
4.5 pts worse
|
Numerator 12 · Denominator 177 · Adjusted rate 6.86% |
| Healthcare-associated infections requiring hospitalization | 7.67% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 203 · Observed rate 7.39% · Lower 95% interval 4.96% |
| Staff COVID-19 vaccination coverage | 10.11% |
8.2%
1.9 pts better
|
Numerator 38 · Denominator 376 |
| Staff flu vaccination coverage | 37.83% |
42%
4.2 pts worse
|
Numerator 143 · Denominator 378 |
| Discharge function score | 27.91% |
56.45%
28.5 pts worse
|
Numerator 36 · Denominator 129 |
| Transfer of health information to provider | 98.33% |
95.95%
2.4 pts better
|
Numerator 59 · Denominator 60 |
| Transfer of health information to patient | 98.63% |
96.28%
2.3 pts better
|
Numerator 72 · Denominator 73 |
| Resident COVID-19 vaccinations up to date | 35.29% |
25.2%
10.1 pts better
|
Numerator 30 · Denominator 85 |
Quality measures
Resident outcomes and process scores
| 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 1.3 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
2.3
1.6 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.7 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
84.8%
13.5 pts better
|
93.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.8% · Q2 96.4% · Q3 99.3% · Q4 100.0% · 4Q avg 98.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
90.9%
9.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
4.1%
1.5 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 1.4% · Q3 1.4% · Q4 3.9% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.8% |
14.7%
12.9 pts better
|
11.4%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 1.7% · Q3 0.9% · Q4 1.0% · 4Q avg 1.8% |
| Percentage of long-stay residents who lose too much weight | 5.0% |
5.5%
0.5 pts better
|
5.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 4.9% · Q3 4.3% · Q4 2.9% · 4Q avg 5.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 29.0% |
25.3%
3.7 pts worse
|
19.6%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.0% · Q2 30.1% · Q3 30.8% · Q4 27.9% · 4Q avg 29.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 29.8% |
25.0%
4.8 pts worse
|
16.7%
13.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.4% · Q2 29.1% · Q3 30.3% · Q4 26.7% · 4Q avg 29.8% · 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 | 17.7% |
20.3%
2.6 pts better
|
16.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.0% · Q2 12.3% · Q3 19.4% · Q4 17.2% · 4Q avg 17.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.3% |
19.8%
2.5 pts better
|
14.9%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 17.6% · Q3 19.3% · Q4 14.7% · 4Q avg 17.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
1.4%
0.7 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 1.1% · Q3 0.0% · Q4 1.1% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.5% |
2.6%
3.9 pts worse
|
1.7%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 7.2% · Q3 3.6% · Q4 8.5% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.6% |
18.1%
10.5 pts worse
|
19.8%
8.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.0% · Q2 27.2% · Q3 24.7% · Q4 27.4% · 4Q avg 28.6% |
| Percentage of long-stay residents with pressure ulcers | 3.8% |
5.0%
1.2 pts better
|
5.1%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 3.2% · Q3 4.5% · Q4 3.6% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 81.6% |
66.4%
15.2 pts better
|
81.7%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 85.9% · Q2 84.1% · Q3 77.7% · Q4 78.5% · 4Q avg 81.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.5% |
13.4%
2.1 pts worse
|
12.0%
3.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.5% · Observed 14.5% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
2.2%
0.4 pts better
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.4% · Q3 0.9% · Q4 2.8% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.2% |
63.5%
21.7 pts better
|
79.7%
5.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.9% |
25.3%
5.6 pts worse
|
23.9%
7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.9% · Observed 26.9% · Expected 20.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-08 · Fire 2023-07-08
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2019-10-24 · Fire 2019-10-24
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-01
E · Potential for more than minimal harm
2024-09-17
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-10-10
E · Potential for more than minimal harm
2024-09-17
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-10-08
E · Potential for more than minimal harm
2024-09-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-10
E · Potential for more than minimal harm
2024-09-17
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-10-08
F · Potential for more than minimal harm
2023-07-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-12
E · Potential for more than minimal harm
2023-07-08
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-08-12
E · Potential for more than minimal harm
2023-07-08
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-08-12
E · Potential for more than minimal harm
2023-07-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-08-12
E · Potential for more than minimal harm
2023-07-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-08-12
F · Potential for more than minimal harm
2019-10-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-12-06
E · Potential for more than minimal harm
2019-10-24
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-12-06
E · Potential for more than minimal harm
2019-10-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-12-06
E · Potential for more than minimal harm
2019-10-24
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2019-12-06
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-09-17
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 2024-10-08
D · Potential for more than minimal harm
2024-09-17
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 2024-10-08
C · Minimal harm
2024-09-17
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2024-10-05
G · Actual harm
2024-02-13
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 2024-03-01
D · Potential for more than minimal harm
2023-12-28
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-08-10
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 2023-08-30
D · Potential for more than minimal harm
2023-07-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-26
D · Potential for more than minimal harm
2023-03-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-09
F · Potential for more than minimal harm
2019-10-24
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 2019-12-06
E · Potential for more than minimal harm
2019-10-24
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-12-06
D · Potential for more than minimal harm
2019-10-24
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 2019-12-06
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
Bank Of America, N.a.
5% Or Greater Mortgage Interest · Organization
Delmar Gardens Management Services Inc
Operational/Managerial Control · Organization
Grossberg, Gabe
Corporate Director · Individual
Grossberg, Gabe
Corporate Officer · Individual
Marx, Kenneth
Corporate Officer · Individual
Marx, Kenneth
W-2 Managing Employee · Individual
Oppenheimer, Howard
Corporate Director · Individual
Oppenheimer, Howard
Corporate Officer · Individual
Rodgers, Lynn
W-2 Managing Employee · Individual
Woods, Jeanna
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Maple Grove Wellness & Rehabilitation
Fenton, MO
1-star overall rating with 2-star inspections with 22 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
South County Health Care Center
Arnold, MO
2-star overall rating with 3-star inspections with 20 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Woodland Manor Nursing Center
Arnold, MO
3-star overall rating with 3-star inspections with 15 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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