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DELMAR GARDENS WEST Inspection Report, Violations & Safety Grade (TOWN AND COUNTRY, Missouri)

13550 SOUTH OUTER 40 ROAD, TOWN AND COUNTRY, Missouri 63017

Phone: 3148781330

CMS Overall:3/5

Overview & Bed Count

Certified Beds
321
Avg Residents/Day
191.1
Ownership
For profit - Corporation
Provider Type
Medicare and Medicaid
County
St. Louis
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No

CMS Star Ratings

Overall3/5
Health3/5
Staffing4/5
Quality2/5

Nurse Staffing Check

MetricThis FacilityMissouri AvgDifference
RN Hours per Resident per Day0.470.46+0.01
Total Nurse Hours per Resident per Day3.703.40+0.30
CMS Staffing Rating4/52.2/5-
Nursing Staff Turnover40.3%56.9%-

Health Citation History

30 health citations on record

DateCategoryDescriptionSeverity
2026-08-20Freedom from Abuse, Neglect, and Exploitation DeficienciesTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.D – Moderate Harm Potential
2025-04-11Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.F – Moderate Harm Potential
2025-04-11Pharmacy Service DeficienciesEnsure medication error rates are not 5 percent or greater.E – Moderate Harm Potential
2025-04-11Pharmacy Service DeficienciesEnsure 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
2025-04-11Infection Control DeficienciesProvide and implement an infection prevention and control program.E – Moderate Harm Potential
2025-04-11Resident Rights DeficienciesHonor 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.D – Moderate Harm Potential
2025-04-11Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.D – Moderate Harm Potential
2025-04-11Quality of Life and Care DeficienciesProvide for the safe, appropriate administration of IV fluids for a resident when needed.D – Moderate Harm Potential
2025-04-11Pharmacy Service DeficienciesEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.D – Moderate Harm Potential
2024-10-09Resident Assessment and Care Planning DeficienciesEnsure services provided by the nursing facility meet professional standards of quality.D – Moderate Harm Potential
2024-10-09Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.D – Moderate Harm Potential
2024-08-21Environmental DeficienciesMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.F – Moderate Harm Potential
2024-08-21Resident Assessment and Care Planning DeficienciesEnsure services provided by the nursing facility meet professional standards of quality.D – Moderate Harm Potential
2024-08-21Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.D – Moderate Harm Potential
2024-04-29Resident Rights DeficienciesHonor 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.D – Moderate Harm Potential
2024-04-29Quality of Life and Care DeficienciesEnsure each resident must receive and the facility must provide necessary behavioral health care and services.D – Moderate Harm Potential
2024-04-02Quality of Life and Care DeficienciesProvide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.J – Immediate Jeopardy
2023-11-17Resident Rights DeficienciesHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.E – Moderate Harm Potential
2023-11-17Resident Assessment and Care Planning DeficienciesEnsure services provided by the nursing facility meet professional standards of quality.E – Moderate Harm Potential
2023-11-17Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.E – Moderate Harm Potential
2023-11-17Quality of Life and Care DeficienciesProvide care and assistance to perform activities of daily living for any resident who is unable.D – Moderate Harm Potential
2023-11-17Quality of Life and Care DeficienciesProvide safe and appropriate respiratory care for a resident when needed.D – Moderate Harm Potential
2023-11-17Pharmacy Service DeficienciesEnsure that residents are free from significant medication errors.D – Moderate Harm Potential
2023-11-17Pharmacy Service DeficienciesEnsure 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.D – Moderate Harm Potential
2020-01-15Resident Rights DeficienciesAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.E – Moderate Harm Potential
2020-01-15Resident Assessment and Care Planning DeficienciesEnsure services provided by the nursing facility meet professional standards of quality.E – Moderate Harm Potential
2020-01-15Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.E – Moderate Harm Potential
2020-01-15Pharmacy Service DeficienciesEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.E – Moderate Harm Potential
2020-01-15Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.E – Moderate Harm Potential
2020-01-15Infection Control DeficienciesProvide and implement an infection prevention and control program.E – Moderate Harm Potential

Fire Safety Citation History

22 fire safety citations on record

DateCategoryDescriptionSeverity
2025-04-11Miscellaneous DeficienciesProvide a written emergency evacuation plan.F – Moderate Harm Potential
2025-04-11Egress DeficienciesKeep aisles, corridors, and exits free of obstruction in case of emergency.E – Moderate Harm Potential
2025-04-11Smoke DeficienciesInspect, test, and maintain automatic sprinkler systems.E – Moderate Harm Potential
2025-04-11Smoke DeficienciesInstall corridor and hallway doors that block smoke.E – Moderate Harm Potential
2025-04-11Services DeficienciesHave properly installed electrical wiring and gas equipment.E – Moderate Harm Potential
2025-04-11Miscellaneous DeficienciesHave posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.E – Moderate Harm Potential
2023-11-17Emergency Preparedness DeficienciesDevelop and maintain an Emergency Preparedness Program (EP).F – Moderate Harm Potential
2023-11-17Emergency Preparedness DeficienciesList the names and contact information of those in the facility.F – Moderate Harm Potential
2023-11-17Gas, Vacuum, and Electrical Systems DeficienciesEnsure proper usage of power strips and extension cords.F – Moderate Harm Potential
2023-11-17Egress DeficienciesKeep aisles, corridors, and exits free of obstruction in case of emergency.E – Moderate Harm Potential
2023-11-17Egress DeficienciesAdd 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
2023-11-17Smoke DeficienciesEnsure 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
2023-11-17Smoke DeficienciesInstall an approved automatic sprinkler system.E – Moderate Harm Potential
2023-11-17Smoke DeficienciesInspect, test, and maintain automatic sprinkler systems.E – Moderate Harm Potential
2023-11-17Smoke DeficienciesInstall corridor and hallway doors that block smoke.E – Moderate Harm Potential
2023-11-17Services DeficienciesHave properly installed electrical wiring and gas equipment.E – Moderate Harm Potential
2023-11-17Miscellaneous DeficienciesHave posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.E – Moderate Harm Potential
2020-01-15Gas, Vacuum, and Electrical Systems DeficienciesEnsure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.F – Moderate Harm Potential
2020-01-15Gas, Vacuum, and Electrical Systems DeficienciesHave generator or other power source capable of supplying service within 10 seconds.F – Moderate Harm Potential
2020-01-15Smoke DeficienciesInstall smoke barrier doors that can resist smoke for at least 20 minutes.E – Moderate Harm Potential
2020-01-15Miscellaneous DeficienciesHave posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.E – Moderate Harm Potential
2020-01-15Gas, Vacuum, and Electrical Systems DeficienciesHave proper medical gas storage and administration areas.E – Moderate Harm Potential

Total Penalties & Fines

$14,433
Total Fine Amount (CMS)
1
Number of Fines
1
Total Penalties
DateTypeFine AmountPayment Denial
2024-04-02Fine$14,433-

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