C
61/100DELHAVEN MANOR Inspection Report, Violations & Safety Grade (SAINT LOUIS, Missouri)
5460 DELMAR BLVD, SAINT LOUIS, Missouri 63112
Phone: 3143612902
CMS Overall:3/5
Overview & Bed Count
Certified Beds
156
Avg Residents/Day
45.9
Ownership
For profit - Corporation
Provider Type
Medicare and Medicaid
County
St. Louis City
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall3/5
Health2/5
Staffing3/5
Quality5/5
Nurse Staffing Check
| Metric | This Facility | Missouri Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.30 | 0.46 | -0.16 |
| Total Nurse Hours per Resident per Day | 4.71 | 3.40 | +1.31 |
| CMS Staffing Rating | 3/5 | 2.2/5 | - |
| Nursing Staff Turnover | N/A | 56.9% | - |
Health Citation History
48 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-07-28 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | D – Moderate Harm Potential |
| 2026-03-16 | Quality of Life and Care Deficiencies | Provide safe, appropriate dialysis care/services for a resident who requires such services. | D – Moderate Harm Potential |
| 2024-11-13 | 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 |
| 2024-11-13 | Resident Rights Deficiencies | Assure the security of all personal funds of residents deposited with the facility. | E – Moderate Harm Potential |
| 2024-11-13 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2024-11-13 | Resident Rights Deficiencies | Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | D – Moderate Harm Potential |
| 2024-11-13 | Resident Assessment and Care Planning Deficiencies | Ensure each resident receives an accurate assessment. | D – Moderate Harm Potential |
| 2024-11-13 | Quality of Life and Care Deficiencies | Provide safe, appropriate dialysis care/services for a resident who requires such services. | D – Moderate Harm Potential |
| 2024-11-13 | Pharmacy Service Deficiencies | Ensure medication error rates are not 5 percent or greater. | D – Moderate Harm Potential |
| 2024-11-13 | Resident Rights Deficiencies | The resident has the right to receive notices in a format and a language he or she understands. | C – Minimal Harm Potential |
| 2024-08-14 | Administration Deficiencies | Employ staff that are licensed, certified, or registered in accordance with state laws. | E – Moderate Harm Potential |
| 2024-08-14 | Administration Deficiencies | Hire a qualified full-time social worker in a facility with more than 120 beds. | E – Moderate Harm Potential |
| 2024-07-10 | Quality of Life and Care Deficiencies | Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | J – Immediate Jeopardy |
| 2024-06-17 | Administration Deficiencies | Employ staff that are licensed, certified, or registered in accordance with state laws. | E – Moderate Harm Potential |
| 2024-06-17 | Administration Deficiencies | Hire a qualified full-time social worker in a facility with more than 120 beds. | E – Moderate Harm Potential |
| 2024-06-17 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D – Moderate Harm Potential |
| 2024-04-19 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D – Moderate Harm Potential |
| 2024-04-19 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | D – Moderate Harm Potential |
| 2024-04-19 | Pharmacy Service Deficiencies | Ensure that residents are free from significant medication errors. | D – Moderate Harm Potential |
| 2024-02-23 | Resident Rights Deficiencies | Reasonably accommodate the needs and preferences of each resident. | D – Moderate Harm Potential |
| 2024-02-23 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2024-02-23 | 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 |
| 2024-02-23 | Quality of Life and Care Deficiencies | Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | D – Moderate Harm Potential |
| 2023-06-30 | Nursing and Physician Services Deficiencies | Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | E – Moderate Harm Potential |
| 2023-06-30 | Resident Assessment and Care Planning Deficiencies | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | E – Moderate Harm Potential |
| 2023-06-30 | Resident Rights Deficiencies | Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | D – Moderate Harm Potential |
| 2023-06-30 | Resident Assessment and Care Planning Deficiencies | PASARR screening for Mental disorders or Intellectual Disabilities | D – Moderate Harm Potential |
| 2023-06-30 | 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 |
| 2023-06-30 | Quality of Life and Care Deficiencies | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | D – Moderate Harm Potential |
| 2023-06-30 | Quality of Life and Care Deficiencies | Provide safe, appropriate dialysis care/services for a resident who requires such services. | D – Moderate Harm Potential |
| 2023-06-30 | Pharmacy Service Deficiencies | 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. | D – Moderate Harm Potential |
| 2023-06-30 | Pharmacy Service Deficiencies | Ensure that residents are free from significant medication errors. | D – Moderate Harm Potential |
| 2019-10-11 | Resident Rights Deficiencies | Honor the resident's right to manage his or her financial affairs. | E – Moderate Harm Potential |
| 2019-10-11 | Resident Rights Deficiencies | Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | E – Moderate Harm Potential |
| 2019-10-11 | Resident Rights Deficiencies | Assure the security of all personal funds of residents deposited with the facility. | E – Moderate Harm Potential |
| 2019-10-11 | 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. | E – Moderate Harm Potential |
| 2019-10-11 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | E – Moderate Harm Potential |
| 2019-10-11 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | E – Moderate Harm Potential |
| 2019-10-11 | Quality of Life and Care Deficiencies | Provide safe, appropriate dialysis care/services for a resident who requires such services. | E – Moderate Harm Potential |
| 2019-10-11 | 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 |
| 2019-10-11 | Nutrition and Dietary Deficiencies | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | E – Moderate Harm Potential |
| 2019-10-11 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E – Moderate Harm Potential |
| 2019-10-11 | Administration Deficiencies | Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | E – Moderate Harm Potential |
| 2019-10-11 | Environmental Deficiencies | Make sure that a working call system is available in each resident's bathroom and bathing area. | E – Moderate Harm Potential |
| 2019-10-11 | Resident Assessment and Care Planning Deficiencies | Ensure each resident receives an accurate assessment. | D – Moderate Harm Potential |
| 2019-10-11 | Pharmacy Service Deficiencies | Ensure medication error rates are not 5 percent or greater. | D – Moderate Harm Potential |
| 2019-10-11 | Resident Rights Deficiencies | 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. | B – Minimal Harm Potential |
| 2019-10-11 | Resident Rights Deficiencies | 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. | B – Minimal Harm Potential |
Fire Safety Citation History
29 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2024-11-13 | Emergency Preparedness Deficiencies | Develop and maintain an Emergency Preparedness Program (EP). | F – Moderate Harm Potential |
| 2024-11-13 | Emergency Preparedness Deficiencies | List the names and contact information of those in the facility. | F – Moderate Harm Potential |
| 2024-11-13 | Emergency Preparedness Deficiencies | Conduct testing and exercise requirements. | F – Moderate Harm Potential |
| 2024-11-13 | Emergency Preparedness Deficiencies | Implement emergency and standby power systems. | F – Moderate Harm Potential |
| 2024-11-13 | Smoke Deficiencies | Install a fire alarm system that can be heard throughout the facility. | F – Moderate Harm Potential |
| 2024-11-13 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2024-11-13 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2024-11-13 | Services Deficiencies | Have elevators that firefighters can control in the event of a fire. | F – Moderate Harm Potential |
| 2024-11-13 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2024-11-13 | 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 |
| 2023-06-30 | Emergency Preparedness Deficiencies | Develop and maintain an Emergency Preparedness Program (EP). | F – Moderate Harm Potential |
| 2023-06-30 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2023-06-30 | Services Deficiencies | Have elevators that firefighters can control in the event of a fire. | F – Moderate Harm Potential |
| 2023-06-30 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2023-06-30 | Egress Deficiencies | Install emergency lighting that can last at least 1 1/2 hours. | E – Moderate Harm Potential |
| 2023-06-30 | 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 |
| 2023-06-30 | Smoke Deficiencies | Provide properly protected cooking facilities. | E – Moderate Harm Potential |
| 2023-06-30 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | E – Moderate Harm Potential |
| 2023-06-30 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | E – Moderate Harm Potential |
| 2023-06-30 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper medical gas storage and administration areas. | E – Moderate Harm Potential |
| 2019-10-11 | Egress Deficiencies | Install proper backup exit lighting. | F – Moderate Harm Potential |
| 2019-10-11 | Smoke Deficiencies | Provide properly protected cooking facilities. | F – Moderate Harm Potential |
| 2019-10-11 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2019-10-11 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | F – Moderate Harm Potential |
| 2019-10-11 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2019-10-11 | Egress Deficiencies | Have properly located and lighted "Exit" signs. | E – Moderate Harm Potential |
| 2019-10-11 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | E – Moderate Harm Potential |
| 2019-10-11 | 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 |
| 2019-10-11 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper medical gas storage and administration areas. | E – Moderate Harm Potential |
Total Penalties & Fines
$73,048
Total Fine Amount (CMS)
1
Number of Fines
2
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2024-06-17 | Fine | $73,048 | - |
| 2024-06-17 | Payment Denial | - | 5 days starting 2024-08-16 |
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3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the SAINT LOUIS area at no cost.
Find Safe, Vetted Facilities Near SAINT LOUIS
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.