Inspection Reports for
Delmar Gardens of O’fallon
7068 SOUTH OUTER 364, O'FALLON, MO, 63368-7757
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
6.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
20% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
63% occupied
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 150
Deficiencies: 1
Date: Mar 19, 2025
Visit Reason
The inspection was conducted following a complaint regarding the unsafe transfer of a resident using a sit-to-stand lift, which resulted in a significant injury.
Complaint Details
The investigation was complaint-driven, triggered by an incident on 03/05/25 where the resident's legs gave way during transfer with a sit-to-stand lift, causing a large skin tear and requiring hospital treatment and surgery.
Findings
The facility failed to safely transfer a resident using a sit-to-stand lift, which was used contrary to the manufacturer's instructions as a transport device. The resident's legs buckled during transfer, causing a severe leg injury requiring surgical repair. Staff did not adequately respond to the resident's fatigue and transfer difficulties.
Deficiencies (1)
Failure to properly transfer a resident using a sit-to-stand lift, resulting in a significant leg injury.
Report Facts
Resident height: 64
Resident weight: 189
Skin tear length: 20
Hospital wound length: 35
Facility census: 150
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Assisted with resident transfer during incident and reported details of injury |
| CNA B | Certified Nursing Assistant | Assisted with resident transfer during incident and expressed concerns about transfer status |
| LPN C | Licensed Practical Nurse | Provided information about resident's transfer status changes and concerns |
| LPN D | Licensed Practical Nurse | Reported knowledge of resident's transfer difficulties and advised on communication protocols |
| PTA A | Physical Therapy Assistant | Evaluated resident's transfer status and provided therapy notes |
| PTA F | Physical Therapy Assistant | Provided therapy notes and recommendations regarding resident's transfer and fatigue |
| ADON | Assistant Director of Nursing | Investigated incident and provided details on resident's injury and transfer circumstances |
| DON | Director of Nursing | Commented on staff adherence to protocol and communication regarding resident's transfer status |
Inspection Report
Routine
Census: 172
Deficiencies: 1
Date: Aug 23, 2024
Visit Reason
The inspection was conducted to evaluate the facility's pest control program and ensure it effectively prevents and addresses rodent infestations in resident rooms.
Findings
The facility failed to provide an effective pest control program, as evidenced by numerous observations of rodent feces in multiple resident rooms and cabinets. Staff interviews confirmed sightings of mice and inconsistent cleaning of affected areas.
Deficiencies (1)
Failure to provide an effective pest control program to address rodents in resident rooms.
Report Facts
Facility census: 172
Date of inspection: Aug 23, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide A | Certified Nurse Aide | Reported seeing rodent feces in resident rooms |
| Housekeeper B | Housekeeper | Reported seeing mice and cleaning rooms but not cleaning resident cabinet drawers |
| Licensed Practical Nurse C | Licensed Practical Nurse | Described maintenance work orders and cleaning responsibilities |
| Housekeeping Supervisor | Housekeeping Supervisor | Reported knowledge of mice sightings and pest control measures |
| Licensed Practical Nurse D | Licensed Practical Nurse | Reported seeing mice in hallways and air conditioning units |
| Maintenance Director | Maintenance Director | Described pest control measures and glue board placement |
| Administrator | Administrator | Discussed staff reporting and cleaning responsibilities related to rodent feces |
Inspection Report
Annual Inspection
Census: 149
Deficiencies: 16
Date: May 14, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements including resident care, infection control, medication management, food service, and facility safety.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, call light accessibility, medication administration, nutritional care, infection control practices, medication storage and disposal, food service safety and preparation, equipment maintenance, and vaccination compliance.
Deficiencies (16)
Failure to treat residents with dignity and respect, including verbal abuse and inappropriate staff comments.
Call lights were not accessible to residents, resulting in delayed assistance and skin irritation.
Failure to provide written notice of bed hold policy to residents transferred to hospital.
Failure to follow physician orders for thickened liquids, resulting in residents receiving incorrect liquid consistency.
Failure to obtain weekly weights as ordered and failure to notify physician of weight loss or supplement refusals.
Failure to provide adequate assistance with activities of daily living including showers, nail care, shaving, oral care, and incontinence care.
Unsafe transfer technique used with gait belt, placing hands under resident's arms instead of on gait belt.
Resident served food on Styrofoam despite care plan prohibiting it; resident ingested Styrofoam.
Failure to provide appropriate catheter care including improper handling of drainage tubing and catheter bags touching floor.
Failure to provide food according to diet orders including serving incorrect diet textures, missing menu items, incorrect portion sizes, and food served at improper temperatures.
Failure to follow proper infection control practices including hand hygiene, glove use, gown use, and storage of respiratory equipment.
Failure to properly store, label, date, and discard food items; failure to maintain sanitary conditions in food preparation and storage areas; failure to clean and maintain ice machines and food service equipment; failure to follow hygienic practices during food preparation and serving.
Failure to prime insulin pens and hold dose knob for required time during insulin administration, risking incorrect dosing.
Failure to secure controlled medications and failure to properly dispose of controlled medications per policy.
Failure to offer and administer pneumococcal vaccines according to CDC guidelines for eligible residents.
Failure to maintain equipment in good repair including frayed power cord on food processor and non-functioning refrigerator compartment.
Report Facts
Residents affected: 3
Residents affected: 12
Residents affected: 35
Facility census: 149
Weight loss: 11.4
Weight loss percentage: 5.9
Weight loss: 23
Weight loss percentage: 14.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN W | Licensed Practical Nurse | Administered insulin without priming pen or holding dose knob; failed to wash hands and change gloves properly during wound care and catheter care |
| CNA UU | Certified Nurse Aide | Failed to follow enhanced barrier precautions, hand hygiene, and glove use during catheter care |
| LPN TT | Licensed Practical Nurse | Failed to wash hands and change gloves properly during incontinence care |
| Dietary Aide H | Dietary Aide | Prepared mechanical soft broccoli salad incorrectly and served incorrect pudding portion size |
| Dietary Manager | Dietary Manager | Unaware of some food safety issues and equipment malfunctions; expected staff to follow diet orders and maintain food safety |
| CNA GG | Certified Nurse Aide | Failed to wash hands and change gloves properly during incontinence care |
| CMT HH | Certified Medication Technician | Failed to wash hands and change gloves properly during incontinence care |
| LPN Z | Licensed Practical Nurse | Failed to wash hands and change gloves properly during wound care and incontinence care |
| CNA BBB | Certified Nurse Aide | Unaware of enhanced barrier precautions and failed to wear gown when required |
| Dietary Aide G | Dietary Aide | Handled food with soiled gloves and touched eating surfaces of plates |
| Dietary Aide J | Dietary Aide | Handled food with bare hands and touched face and hair without hand hygiene |
| Dietary Aide I | Dietary Aide | Handled toast with bare hands and did not wash hands after touching face and hair |
Inspection Report
Routine
Census: 167
Deficiencies: 1
Date: Mar 14, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with pressure ulcer care policies and procedures, specifically to assess whether the facility consistently completed skin assessments and implemented timely interventions for residents at risk of pressure ulcers.
Findings
The facility failed to consistently follow its policy to complete skin assessments and timely treatment for one sampled resident, resulting in delayed identification and treatment of a pressure ulcer. Documentation gaps and lack of wound care interventions were noted, despite the resident's risk factors and complaints.
Deficiencies (1)
Failure to consistently complete skin assessments to identify pressure ulcers and implement timely interventions for Resident #2.
Report Facts
Facility census: 167
Braden Scale score: 14
Size of open blister: 4.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Wound Nurse | Interviewed regarding skin assessment procedures and wound documentation |
| Director of Nursing | Interviewed about expectations for nursing staff to conduct thorough skin assessments and document wounds | |
| Physician A | Physician | Interviewed about expectations for skin inspection upon admission and weekly thereafter |
Inspection Report
Routine
Census: 123
Deficiencies: 1
Date: Apr 25, 2023
Visit Reason
The inspection was conducted to ensure the nursing home area was free from accident hazards and that adequate supervision was provided to prevent accidents, specifically reviewing the transfer methods used for residents.
Findings
The facility failed to employ appropriate transfer methods for one resident, as staff did not follow the resident's recommended two-person transfer method with a gait belt, resulting in unsafe transfer practices. Interviews and observations confirmed staff did not use gait belts and sometimes transferred residents alone despite care plans indicating two-person assistance was required.
Deficiencies (1)
Failure to follow resident's recommended transfer method and technique per plan of care, including not using a gait belt and not utilizing two staff as required.
Report Facts
Facility census: 123
Date of physician's order: Oct 23, 2021
Date of quarterly Minimum Data Set (MDS): Jan 22, 2023
Date of physical therapy evaluation: Jan 30, 2023
Date of care plan review: Feb 22, 2023
Date of observation and interviews: Apr 18, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA A | Nurse Assistant | Observed transferring resident without gait belt and alone, contrary to care plan |
| LPN C | Licensed Practical Nurse | Interviewed confirming resident required two staff and gait belt for transfers |
| Director of Nursing | Director of Nursing (DON) | Interviewed stating expectations for staff to follow transfer orders and use gait belts |
| Physical Therapy Director | Physical Therapy Director | Interviewed stating staff should follow resident's plan of care and use gait belts |
Inspection Report
Life Safety
Census: 136
Deficiencies: 1
Date: Oct 25, 2022
Visit Reason
The inspection was conducted as a life safety code tour of the facility to assess compliance with environmental safety standards, including cleanliness of ceiling vents and mold presence.
Findings
The facility failed to maintain ceiling vents free from a buildup of dust and failed to maintain ceilings in a clean condition, with multiple vents in resident rooms and utility areas covered with thick layers of dust. Additionally, black mold-like substances were found in some resident closets. The maintenance supervisor was unaware of these conditions, and the administrator expected vents to be clean and free of mold.
Deficiencies (1)
Facility failed to maintain ceiling vents free from buildup of dust and maintain ceilings in a clean condition.
Report Facts
Facility census: 136
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Responsible for cleaning vents; unaware of dust and mold issues | |
| Administrator | Expected vents to be clean and free of mold |
Inspection Report
Annual Inspection
Deficiencies: 12
Date: Oct 16, 2019
Visit Reason
The inspection was an annual survey to assess compliance with regulatory requirements including resident dignity, care, safety, medication management, staffing, nutrition, and infection control.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, inadequate assistance with activities of daily living, failure to honor resident preferences, insufficient nursing staff, improper medication management including lack of gradual dose reductions, failure to maintain proper food safety and nutrition standards, inadequate infection control program implementation, and failure to prevent pressure ulcers and falls.
Deficiencies (12)
Failure to ensure residents were treated with dignity and respect, including toileting delays and inappropriate staff behavior.
Failure to provide adequate assistance with activities of daily living including personal hygiene, shaving, nail care, and oral care.
Failure to honor residents' preferences for waking times and self-determination.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing, including failure to reposition residents timely.
Failure to employ appropriate methods for repositioning residents and failure to implement fall prevention interventions consistently.
Failure to maintain urinary drainage bags below bladder level and off the floor, and failure to cover catheter bags.
Failure to provide sufficient nursing staff to meet residents' needs.
Failure to implement gradual dose reductions and limit PRN psychotropic medication orders appropriately.
Failure to ensure menus met nutritional needs, including serving correct portion sizes and following dietary menus.
Failure to provide evening snacks to residents as per policy and resident requests.
Failure to maintain walk-in freezer at 0 degrees Fahrenheit or below, failure to label, date, cover, and discard expired food items, and failure to maintain appropriate air gap on ice machines.
Failure to maintain and implement a comprehensive infection control program to prevent waterborne pathogens.
Report Facts
Residents requiring assistance with dressing: 132
Residents totally dependent on staff: 14
Residents requiring assistance with bathing: 115
Residents totally dependent on staff: 38
Residents requiring assistance with eating: 58
Residents totally dependent on staff: 10
Residents requiring assistance with toileting: 118
Residents totally dependent on staff: 27
Residents requiring assistance with transfers: 95
Residents requiring two staff assistance for transfers: 24
Residents requiring stand-up lift: 11
Residents requiring full body lift: 32
Licensed nurses providing direct care: 4
Certified nurse aides providing direct care: 10
Walk-in freezer temperature: 10
Walk-in freezer temperature: 8
Walk-in freezer temperature: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA X | Certified Nurse Assistant | Named in feeding assistance deficiency |
| CNA DD | Certified Nurse Assistant | Named in oral care and catheter care deficiencies |
| CNA FF | Certified Nurse Assistant | Named in oral care and catheter care deficiencies |
| CNA F | Certified Nurse Assistant | Named in incontinence care and pressure ulcer deficiency |
| CNA E | Certified Nurse Assistant | Named in resident dignity and repositioning deficiencies |
| CNA B | Certified Nurse Assistant | Named in staffing and snack provision deficiencies |
| CNA I | Certified Nurse Assistant | Named in repositioning and incontinence care deficiencies |
| CNA J | Certified Nurse Assistant | Named in repositioning and incontinence care deficiencies |
| CNA G | Certified Nurse Assistant | Named in repositioning and resident preference deficiencies |
| CNA R | Certified Nurse Assistant | Named in repositioning and resident preference deficiencies |
| CNA M | Certified Nurse Assistant | Named in catheter care deficiency |
| CNA BB | Certified Nurse Assistant | Named in repositioning deficiency |
| RN A | Registered Nurse | Named in repositioning deficiency |
| CNA CC | Certified Nurse Assistant | Named in repositioning deficiency |
| CNA EE | Certified Nurse Assistant | Named in catheter care deficiency |
| CNA U | Certified Nurse Assistant | Named in catheter care deficiency |
| LPN Y | Licensed Practical Nurse | Named in dietary portion control deficiency |
| Dietary Manager | Named in dietary portion control and food safety deficiencies | |
| Maintenance Supervisor | Named in walk-in freezer and ice machine air gap deficiencies | |
| Maintenance Staff K | Named in Legionella water management program deficiency | |
| Director of Nursing | Director of Nursing | Named in multiple deficiencies including dignity, catheter care, staffing, medication management, and infection control |
| Administrator | Administrator | Named in Legionella water management program deficiency |
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