DELMAR GARDENS NORTH Inspection Report, Violations & Safety Grade (BLACK JACK, Missouri)

4401 PARKER ROAD, BLACK JACK, Missouri 63033

Phone: 3143551516

CMS Overall:3/5

Overview & Bed Count

Certified Beds

240

Avg Residents/Day

174.3

Ownership

For profit - Corporation

Provider Type

Medicare and Medicaid

County

St. Louis

Sprinkler Systems

Yes

Special Focus

None

Abuse Icon

CMS Star Ratings

Overall3/5

Health3/5

Staffing3/5

Quality2/5

Nurse Staffing Check

Metric	This Facility	Missouri Avg	Difference
RN Hours per Resident per Day	0.18	0.46	-0.28
Total Nurse Hours per Resident per Day	3.79	3.40	+0.39
CMS Staffing Rating	3/5	2.2/5	-
Nursing Staff Turnover	49.1%	56.9%	-

Health Citation History

34 health citations on record

Date	Category	Description	Severity
2025-11-17	Resident Rights Deficiencies	Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	E – Moderate Harm Potential
2025-11-17	Pharmacy Service Deficiencies	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.	E – Moderate Harm Potential
2025-11-17	Resident Rights Deficiencies	Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.	D – Moderate Harm Potential
2025-11-17	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	D – Moderate Harm Potential
2025-11-17	Quality of Life and Care Deficiencies	Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.	D – Moderate Harm Potential
2025-11-17	Quality of Life and Care Deficiencies	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.	D – Moderate Harm Potential
2025-02-10	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	J – Immediate Jeopardy
2024-12-26	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	D – Moderate Harm Potential
2024-07-26	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Respond appropriately to all alleged violations.	D – Moderate Harm Potential
2024-07-26	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	D – Moderate Harm Potential
2024-07-26	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	D – Moderate Harm Potential
2023-11-02	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Respond appropriately to all alleged violations.	G – Actual Harm
2023-11-02	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	G – Actual Harm
2023-10-06	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	F – Moderate Harm Potential
2023-10-06	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	E – Moderate Harm Potential
2023-10-06	Resident Rights Deficiencies	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.	D – Moderate Harm Potential
2023-10-06	Resident Assessment and Care Planning Deficiencies	Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted	D – Moderate Harm Potential
2023-10-06	Resident Assessment and Care Planning Deficiencies	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	D – Moderate Harm Potential
2023-10-06	Quality of Life and Care Deficiencies	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.	D – Moderate Harm Potential
2023-10-06	Quality of Life and Care Deficiencies	Provide safe and appropriate respiratory care for a resident when needed.	D – Moderate Harm Potential
2023-10-06	Administration Deficiencies	Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.	D – Moderate Harm Potential
2020-01-08	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	F – Moderate Harm Potential
2020-01-08	Resident Rights Deficiencies	Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	E – Moderate Harm Potential
2020-01-08	Resident Rights Deficiencies	Keep residents' personal and medical records private and confidential.	E – Moderate Harm Potential
2020-01-08	Resident Assessment and Care Planning Deficiencies	Ensure services provided by the nursing facility meet professional standards of quality.	E – Moderate Harm Potential
2020-01-08	Pharmacy Service Deficiencies	Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	E – Moderate Harm Potential
2020-01-08	Pharmacy Service Deficiencies	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.	E – Moderate Harm Potential
2020-01-08	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	E – Moderate Harm Potential
2020-01-08	Resident Assessment and Care Planning Deficiencies	Ensure each resident receives an accurate assessment.	D – Moderate Harm Potential
2020-01-08	Quality of Life and Care Deficiencies	Provide appropriate pressure ulcer care and prevent new ulcers from developing.	D – Moderate Harm Potential
2020-01-08	Quality of Life and Care Deficiencies	Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.	D – Moderate Harm Potential
2020-01-08	Quality of Life and Care Deficiencies	Provide enough food/fluids to maintain a resident's health.	D – Moderate Harm Potential
2020-01-08	Quality of Life and Care Deficiencies	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.	D – Moderate Harm Potential
2020-01-08	Quality of Life and Care Deficiencies	Provide safe, appropriate pain management for a resident who requires such services.	D – Moderate Harm Potential

Fire Safety Citation History

23 fire safety citations on record

Date	Category	Description	Severity
2025-11-17	Emergency Preparedness Deficiencies	Develop and maintain an Emergency Preparedness Program (EP).	F – Moderate Harm Potential
2025-11-17	Emergency Preparedness Deficiencies	Establish staff and initial training requirements.	F – Moderate Harm Potential
2025-11-17	Emergency Preparedness Deficiencies	Conduct testing and exercise requirements.	F – Moderate Harm Potential
2025-11-17	Services Deficiencies	Meet other general requirements that are deficient.	F – Moderate Harm Potential
2025-11-17	Egress Deficiencies	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.	E – Moderate Harm Potential
2025-11-17	Egress Deficiencies	Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.	E – Moderate Harm Potential
2025-11-17	Smoke Deficiencies	Inspect, test, and maintain automatic sprinkler systems.	E – Moderate Harm Potential
2025-11-17	Smoke Deficiencies	Properly select, install, inspect, or maintain portable fire extinguishes.	E – Moderate Harm Potential
2025-11-17	Smoke Deficiencies	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	E – Moderate Harm Potential
2025-11-17	Services Deficiencies	Have properly installed electrical wiring and gas equipment.	E – Moderate Harm Potential
2025-11-17	Miscellaneous Deficiencies	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	E – Moderate Harm Potential
2023-10-06	Smoke Deficiencies	Provide properly protected cooking facilities.	F – Moderate Harm Potential
2023-10-06	Gas, Vacuum, and Electrical Systems Deficiencies	Have generator or other power source capable of supplying service within 10 seconds.	F – Moderate Harm Potential
2023-10-06	Egress Deficiencies	Keep aisles, corridors, and exits free of obstruction in case of emergency.	E – Moderate Harm Potential
2023-10-06	Egress Deficiencies	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.	E – Moderate Harm Potential
2023-10-06	Egress Deficiencies	Install proper backup exit lighting.	E – Moderate Harm Potential
2023-10-06	Smoke Deficiencies	Install an approved automatic sprinkler system.	E – Moderate Harm Potential
2023-10-06	Smoke Deficiencies	Install corridor and hallway doors that block smoke.	E – Moderate Harm Potential
2023-10-06	Miscellaneous Deficiencies	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	E – Moderate Harm Potential
2020-01-08	Services Deficiencies	Have properly installed electrical wiring and gas equipment.	F – Moderate Harm Potential
2020-01-08	Miscellaneous Deficiencies	Have simulated fire drills held at unexpected times.	F – Moderate Harm Potential
2020-01-08	Egress Deficiencies	Have exits that are accessible at all times.	E – Moderate Harm Potential
2020-01-08	Smoke Deficiencies	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	E – Moderate Harm Potential

Total Penalties & Fines

$39,299

Total Fine Amount (CMS)

Number of Fines

Total Penalties

Date	Type	Fine Amount	Payment Denial
2025-02-10	Fine	$39,299	-

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3-Year Complete Report ($19)

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