Inspection Reports for
Delmar Gardens of O’fallon
7068 SOUTH OUTER 364, O'FALLON, MO, 63368-7757
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
12.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
129% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
32
24
16
8
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: 2
Date: Mar 19, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to safely transfer a resident using a sit-to-stand mechanical lift, which resulted in a significant injury.
Complaint Details
The complaint investigation substantiated that the facility failed to safely transfer Resident #1 using a sit-to-stand lift, resulting in a significant injury. The resident's care plans and physician orders required a two-person transfer, but staff did not comply, causing the resident's legs to buckle and a large skin tear requiring hospital treatment.
Findings
The facility failed to properly transfer a resident with a sit-to-stand lift, leading to the resident sustaining a significant leg injury requiring surgical repair. Staff did not follow the manufacturer's instructions for the lift, and the resident's care plans and physician orders indicated a two-person transfer was required.
Deficiencies (2)
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to safely transfer a resident using a sit-to-stand lift, resulting in a significant injury due to improper use and failure to follow the manufacturer's instructions.
A4075 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation is not met as evidenced by the failure to safely transfer the resident per F689.
Report Facts
Facility census: 150
Date of injury event: Mar 5, 2025
Skin tear length: 20
Skin flap opening length: 35
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
Annual Inspection
Census: 172
Deficiencies: 2
Date: Aug 23, 2024
Visit Reason
Annual inspection survey conducted to evaluate the facility's compliance with pest control and rodent management regulations.
Findings
The facility failed to maintain an effective pest control program, evidenced by numerous observations of rodent feces in multiple resident rooms and common areas. Interviews with staff confirmed ongoing rodent presence and inconsistent cleaning of resident cabinets and drawers.
Deficiencies (2)
F925 Maintain an effective pest control program so that the facility is free of pests and rodents. The facility was found with numerous rodent feces in resident rooms and common areas, indicating failure to control pests effectively.
A6039 Effective measures to minimize rodents and insects were not met, as evidenced by the rodent infestation referenced in F925. The violation was classified as Class II due to the extent of the issue.
Report Facts
Facility census: 172
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
Plan of Correction
Census: 167
Deficiencies: 2
Date: Mar 14, 2024
Visit Reason
The inspection was conducted to assess compliance with regulations related to pressure ulcer prevention and treatment at Delmar Gardens of O'Fallon.
Findings
The facility failed to consistently follow its policy to complete skin assessments and timely interventions for pressure ulcers for one sampled resident. Documentation and treatment of pressure ulcers were incomplete or delayed, and staff did not perform required skin assessments as scheduled.
Deficiencies (2)
F686: The facility failed to ensure a resident received care to prevent and treat pressure ulcers consistent with professional standards. Skin assessments and treatments were not consistently completed or documented for Resident #2.
A4083: The facility did not keep residents free from avoidable pressure sores and failed to provide adequate treatment. This deficiency references F686.
Report Facts
Facility census: 167
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Luisa L. Ruter | Administrator | Signed the statement of deficiencies and plan of correction |
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
Plan of Correction
Census: 123
Deficiencies: 2
Date: Apr 25, 2023
Visit Reason
The inspection was conducted to assess compliance with regulations regarding resident transfer methods and accident hazards, following observations, interviews, and record reviews.
Findings
The facility failed to employ appropriate methods for transferring one resident, not following the resident's recommended transfer method and technique. Staff did not consistently use gait belts or follow proper transfer protocols, leading to unsafe transfer practices.
Deficiencies (2)
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to employ appropriate methods for transferring a resident, not following the resident's recommended transfer method and technique.
A4075 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with their condition; this regulation was not met as evidenced by the deficiency at F689.
Report Facts
Facility census: 123
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA A | Nurse Assistant | Named in transfer method deficiency for improper transfer technique |
| Licensed Practical Nurse C | Licensed Practical Nurse | Interviewed regarding resident transfer practices |
| Director of Nursing | Director of Nursing | Provided statements on staff expectations and transfer protocols |
| Director of Education/designee | Director of Education/designee | Responsible for staff training on transfer policy |
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
Renewal
Census: 139
Deficiencies: 6
Date: Oct 27, 2022
Visit Reason
A recertification survey was conducted by Healthcare Management Solutions, LLC, on behalf of the State of Missouri, Department of Health, and Senior Services to assess compliance with federal regulations.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies were identified related to safe environment, quarterly assessments, activities, behavioral health services, medication management, and food safety.
Deficiencies (6)
F584 Safe Environment: The facility failed to maintain ceiling vents free from a buildup of dust and maintain ceilings in a clean condition.
F638 Quarterly Assessment: The facility failed to timely complete and submit quarterly Minimum Data Set (MDS) assessments for six residents, resulting in missed opportunities for care.
F679 Activities: The facility failed to provide an activity calendar and invite one resident to attend activities, limiting resident engagement.
F740 Behavioral Health Services: The facility failed to ensure behavioral health services were provided for one resident, including psychiatric evaluation and staff education.
F761 Label/Store Drugs and Biologicals: Medication carts and treatments were unsecured when unattended, risking medication diversion or misuse.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: The facility failed to maintain kitchen sanitation, including broken soap dispenser, unclean equipment, expired food items, and improper food storage.
Report Facts
Survey Census: 139
Sample Size: 41
Supplemental Residents: 5
Inspection Report
Plan of Correction
Census: 136
Deficiencies: 2
Date: Oct 27, 2022
Visit Reason
The inspection was conducted as a life safety code tour of the facility to assess compliance with cleanliness and maintenance regulations for walls, ceilings, doors, windows, and vents.
Findings
The facility failed to maintain ceilings and vents in a clean condition, with multiple resident rooms and utility areas showing black mold-like substance and thick layers of dust on vents. Interviews revealed that staff were unaware of these conditions.
Deficiencies (2)
19 CSR 30-87.020(15) Walls/Ceilings/Doors/Windows Clean: The facility failed to maintain ceilings in a clean condition, with black mold-like substance observed in multiple resident room closets.
19 CSR 30-87.020(19) List Fixtures, Vent Covers, Décor Cleanable: The facility failed to maintain ceiling vents free from a buildup of dust, with thick layers of dust observed in multiple resident rooms and utility areas.
Report Facts
Facility census: 136
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
Complaint Investigation
Census: 140
Deficiencies: 2
Date: Jun 24, 2022
Visit Reason
The inspection was conducted due to a complaint investigation regarding the treatment of a resident by staff.
Complaint Details
The complaint involved allegations of rude and obnoxious behavior by a Registered Nurse towards Resident #1, which was substantiated by interviews with residents and staff.
Findings
The facility failed to ensure one resident was treated with dignity and respect, as evidenced by staff behavior and resident interviews. The report documents inappropriate comments made by a Registered Nurse and the Director of Nursing's response.
Deficiencies (2)
F550 Resident Rights: The facility failed to ensure one resident was treated with dignity and respect, including incidents of staff making inappropriate and unprofessional comments.
A8030 Dignity/Privacy: The facility did not meet the requirement to treat residents with full recognition of dignity and privacy, referencing the F550 deficiency.
Report Facts
Facility census: 140
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in findings related to inappropriate comments to Resident #1 |
| Director of Nursing | Director of Nursing | Interviewed regarding staff professionalism and dignity issues |
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 2
Date: Mar 10, 2022
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of inadequate supervision and assistance to prevent accidents among residents with dementia and a history of falls.
Complaint Details
The complaint investigation was substantiated based on interviews, record reviews, and observations showing inadequate supervision and unsafe resident behaviors.
Findings
The facility failed to provide adequate supervision for two residents with dementia, resulting in unsafe behaviors including inappropriate touching and changing of clothing by residents. The facility lacked proper interventions and care plan documentation to address these behaviors and prevent accidents.
Deficiencies (2)
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure the resident environment was free of accident hazards and did not provide adequate supervision and assistance devices to prevent accidents for residents with dementia and a history of falls.
A4074 Protective Oversight, Voluntary Leave: The facility did not have adequate procedures to inquire about residents' whereabouts and length of absence during voluntary leave.
Report Facts
Certified Nursing Aide (CNA) statements: 2
Resident falls: 1
Facility certified census: 95
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Denise L. Reuter | Administrator | Signed the inspection report and plan of correction. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 29, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and Infection Control Survey were conducted to assess compliance with CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with 42 CFR483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 24, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 1, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 11, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Jun 25, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Complaint Investigation
Census: 199
Deficiencies: 2
Date: Feb 11, 2020
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to follow professional standards of care and physician orders for wound care treatments.
Complaint Details
The complaint investigation found substantiated failure to follow physician orders and professional standards for wound care treatments for two residents.
Findings
The facility failed to follow physician orders and professional standards of care for wound treatments for two residents, as evidenced by incomplete or missed treatments documented in records and observed during the visit.
Deficiencies (2)
F658 Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i). The facility failed to follow professional standards of practice and physician orders for wound care treatments for two residents, resulting in incomplete or missed treatments.
A4074 19 CSR 30-85.042(67) Nursing Care per Resident Condition. Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by the deficiency in F658.
Report Facts
Facility census: 199
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Luisa L. Ruter | Administrator | Signed the inspection report and plan of correction |
| RN F | Registered Nurse | Documented incomplete treatments during inspection |
| LPN D | Licensed Practical Nurse | Documented incomplete treatments during inspection |
| LPN E | Licensed Practical Nurse | Documented incomplete treatments during inspection |
| LPN G | Licensed Practical Nurse | Documented incomplete treatments during inspection |
| RN B | Registered Nurse | Documented incomplete treatments during inspection |
| RN C | Registered Nurse | Documented wound dressing placement |
| LPN H | Licensed Practical Nurse | Documented incomplete treatments during inspection |
| Assistant Director of Nursing | ADON | Interviewed regarding staff expectations for following physician orders |
Inspection Report
Complaint Investigation
Census: 198
Deficiencies: 3
Date: Jan 23, 2020
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, and mistreatment involving a resident at Delmar Gardens of O'Fallon.
Complaint Details
Complaint #MO165136 involved allegations of sexual abuse of Resident #1 by a Certified Nurse Assistant (CNA) on 1/1/20. The complaint was substantiated as the facility failed to report the allegation timely and failed to protect the resident. The resident had a history of false allegations but no evidence of abuse was found for those prior claims.
Findings
The facility failed to report an allegation of sexual abuse involving a resident within the required timeframe and failed to conduct a timely and thorough investigation. The facility also allowed a staff member accused of sexual abuse to continue working, potentially affecting other residents.
Deficiencies (3)
F609: The facility failed to report an allegation of sexual abuse involving a resident immediately as required by regulation. The facility also failed to conduct a timely and thorough investigation and follow policy when a resident alleged sexual abuse by a staff member.
A8023: The facility failed to develop and implement written policies prohibiting mistreatment, neglect, and abuse of residents and misappropriation of resident property and funds.
A8025: The facility failed to immediately report to the Department of Health and Senior Services and Department of Mental Health any suspected abuse or neglect of a resident by an employee or administrator.
Report Facts
Facility census: 198
Certified census: 143
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in failure to report allegation and investigation findings |
| CNA C | Certified Nurse Assistant | Alleged perpetrator of sexual abuse |
| Administrator | Administrator | Named in failure to report and oversee investigation |
| Director of Nursing | Director of Nursing | Involved in investigation and reporting |
| Assistant Director of Nursing | Assistant Director of Nursing | Involved in investigation and reporting |
Inspection Report
Annual Inspection
Deficiencies: 11
Date: Oct 16, 2019
Visit Reason
Annual survey conducted to assess compliance with federal and state regulations for Delmar Gardens of O'Fallon nursing facility.
Findings
The facility was found to have multiple deficiencies related to resident dignity, self-determination, nursing staff sufficiency, treatment of pressure ulcers, infection control, medication management, and care planning. Several residents were observed with unmet needs and improper care practices.
Deficiencies (11)
F557 Respect, Dignity/Right to have Personal Property: Facility failed to treat residents with respect and dignity, including incidents of staff laughing at residents and not assisting with toileting needs.
F561 Self-Determination: Facility failed to ensure residents' rights to self-determination and participation in care planning were respected.
F677 Treatment and Appearance: Facility failed to provide adequate oral hygiene, shaving, and nail care for residents.
F686 Treatment/Services to Prevent/Heal Pressure Ulcers: Facility failed to prevent and properly treat pressure ulcers in residents.
F689 Accidents: Facility failed to ensure adequate supervision and assistance to prevent resident accidents and injuries.
F690 Incontinence: Facility failed to maintain urinary catheter care and prevent urinary tract infections.
F725 Sufficient Staff: Facility failed to provide sufficient nursing staff to meet residents' needs and ensure quality care.
F758 Psychotropic Drugs: Facility failed to ensure proper use and monitoring of psychotropic medications.
F809 Food Procurement, Store/Prepare/Serve-Sanitary: Facility failed to maintain sanitary food storage and preparation areas.
F812 Food Service Sanitation: Facility failed to maintain proper food temperatures and storage conditions.
F880 Infection Prevention & Control: Facility failed to implement an effective infection control program to prevent spread of infections.
Report Facts
Certified census: 128
Total facility census: 183
Residents requiring assistance with transfers: 132
Residents requiring assistance with toileting: 118
Residents requiring assistance with dressing: 132
Residents requiring assistance with eating: 14
Residents requiring assistance with mobility: 118
Residents requiring assistance with bathing: 115
Residents requiring assistance with oral care: 132
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 |
Inspection Report
Life Safety
Deficiencies: 6
Date: Oct 16, 2019
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related fire safety regulations.
Findings
The facility failed to maintain exit pathways free of obstructions, ensure emergency illumination lighting was tested annually, and inspect the kitchen range hood in accordance with NFPA standards. No deficiencies were cited in the emergency preparedness investigation.
Deficiencies (6)
K211 Means of Egress - The facility failed to maintain exit pathways free of obstructions, including a 6 inch step down on an exit path from the 500 hall dining room to the back driveway.
K293 Exit Signage - The facility failed to ensure emergency illumination lighting was tested annually for 90 minutes as required, with no documentation of testing found.
K324 Cooking Facilities - The facility failed to inspect the kitchen range hood and wet chemical suppression system monthly as required by NFPA standards.
A2017 Range Hood Certification - The facility did not maintain certification and testing of the cooking range hood and extinguishing system at least twice annually as required.
A2037 Exit Requirements - The facility did not meet requirements for unobstructed exits remote from each other in an existing multi-story facility.
A2049 Exit Sign-Maintain/Illuminate - The facility failed to maintain all exit and directional signs clearly legible and electrically illuminated at all times.
Report Facts
Facility census: 183
Certified census: 128
Deficiencies cited: 6
Inspection Report
Abbreviated Survey
Census: 142
Deficiencies: 2
Date: Oct 30, 2018
Visit Reason
The abbreviated survey was conducted to investigate allegations of abuse, neglect, exploitation, or mistreatment involving injuries of unknown source to a resident.
Findings
The facility failed to report an injury of unknown origin for one resident as required by regulations. The investigation found bruising on the resident but no evidence of abuse, and the resident's care plan was updated accordingly.
Deficiencies (2)
F609 Reporting of Alleged Violations: The facility failed to report an injury of unknown origin for one resident within the required timeframe to the administrator and other officials.
A8023 Develop/Implement A/N Policies: The facility did not develop and implement written policies prohibiting mistreatment, neglect, abuse, and misappropriation of resident property, including reporting requirements.
Report Facts
Resident census: 142
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa L Ruiter | Administrator | Signed the report and plan of correction |
Inspection Report
Plan of Correction
Census: 54
Capacity: 136
Deficiencies: 9
Date: Sep 13, 2018
Visit Reason
The visit was a plan of correction submission following a prior inspection that identified deficiencies related to resident funds management, care planning, wound care, infection control, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including improper management of resident funds, failure to develop and implement baseline care plans timely, inadequate wound care and pressure sore prevention, insufficient infection control practices, and failure to maintain proper immunization records. The plan of correction outlines steps to address these deficiencies.
Deficiencies (9)
F567 Resident funds were not properly managed; the facility failed to maintain accurate accounting and safeguard resident personal funds as required.
F655 The facility failed to develop and implement baseline care plans within 48 hours of admission for residents, including necessary assessments and physician orders.
F677 The facility did not provide adequate perineal care and hygiene, resulting in risks for infection and skin breakdown.
F686 The facility failed to properly assess, document, and treat pressure ulcers and wounds according to professional standards.
F689 The facility failed to ensure adequate supervision and assistance to prevent accidents and injuries, including proper transfer techniques and weight bearing status monitoring.
F690 The facility failed to provide appropriate incontinence care and catheter care, increasing risk of infection and skin breakdown.
F812 The facility failed to maintain clean and safe food service areas, including proper cleaning of kitchen equipment and food storage areas.
F880 The facility failed to establish and maintain an effective infection prevention and control program, including hand hygiene and use of personal protective equipment.
F883 The facility failed to ensure residents received required influenza and pneumococcal vaccinations and maintain proper documentation of immunizations.
Report Facts
Facility licensed census: 136
Facility census at time of survey: 54
Residents affected by resident funds deficiency: 17
Residents sampled for care plan review: 27
Residents sampled for wound care review: 27
Residents sampled for immunization review: 54
Inspection Report
Plan of Correction
Census: 190
Capacity: 240
Deficiencies: 7
Date: Sep 13, 2018
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and other regulatory requirements, including fire safety, cooking facilities, corridor doors, and smoking regulations.
Findings
The facility failed to maintain exits free of locks, ensure cooking equipment compliance and cleanliness, maintain positive latching on kitchen doors, and properly maintain smoking areas. These deficiencies had the potential to affect residents, visitors, and staff.
Deficiencies (7)
K222 Egress Doors: The facility failed to maintain exits free of locks, making it difficult to open gates on the egress path. This affected the safety of residents and staff in the Division 300 dining room.
K324 Cooking Facilities: The facility failed to ensure cooking equipment was inspected, cleaned, and maintained according to NFPA 96. Grease buildup was observed on and around the fryer.
K363 Corridor Doors: The facility failed to ensure doors to the main kitchen were positive latching. Observations showed doors lacked means to positive latch in the frame.
K741 Smoking Regulations: The facility failed to maintain smoking areas free of fire hazards, with over 30 cigarettes found in mulch and dried leaves in designated smoking areas.
A2041 Door Locks: Door locks did not meet requirements to be opened from inside without a key or tool, violating NFPA 101 standards.
A2057 Ashtrays: Designated smoking areas lacked proper ashtrays for noncombustible material disposal, violating safety regulations.
A3001 Construction: The building was not substantially constructed and maintained according to applicable construction standards, affecting resident safety.
Report Facts
Facility capacity: 240
Census: 190
Certified beds: 136
Inspection Report
Complaint Investigation
Census: 117
Deficiencies: 2
Date: Jun 4, 2018
Visit Reason
The inspection was conducted in response to allegations of abuse involving resident-to-resident physical altercation at Delmar Gardens of O'Fallon.
Complaint Details
The complaint investigation was substantiated as the facility failed to report a resident-to-resident physical abuse incident involving Resident #20 and Resident #6. The administrator acknowledged not reporting the incident to the state agency because there was no injury.
Findings
The facility failed to report a witnessed incident of resident-to-resident physical abuse involving Resident #20 slapping Resident #6. The administrator did not report the incident to the state agency because there was no injury.
Deficiencies (2)
F609: The facility failed to report a witnessed incident of resident-to-resident physical abuse involving Resident #20 slapping Resident #6 within the required timeframe to the administrator and state officials.
A8025: The facility did not immediately report suspected abuse or neglect to the Department of Health and Senior Services or Department of Mental Health as required by regulation.
Report Facts
Certified census: 117
Date of injury/slap: May 19, 2018
Date of resident admission: Aug 18, 2012
Date of resident care plan review: Feb 13, 2018
Date of MDS assessment: May 12, 2018
Date of interview with administrator: Jun 5, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa L. Rutter | Administrator | Signed the statement of deficiencies and plan of correction; involved in interview regarding failure to report abuse |
Inspection Report
Complaint Investigation
Census: 117
Deficiencies: 6
Date: Mar 22, 2018
Visit Reason
The inspection was conducted due to complaints regarding housekeeping deficiencies and allegations of sexual abuse between residents.
Complaint Details
The complaint investigation substantiated that Resident #3 sexually abused Resident #4 on multiple occasions. The facility failed to report the incidents within the required timeframes and did not adequately protect Resident #4. The certified census was 117 at the time of investigation.
Findings
The facility failed to maintain a clean and comfortable environment as evidenced by multiple observations of soiled bathrooms and rooms. Additionally, the facility failed to protect a resident from sexual abuse by another resident and did not report the incident timely as required.
Deficiencies (6)
F584 The facility failed to maintain housekeeping services to ensure a clean and comfortable environment, with multiple observations of fecal matter and odors in resident bathrooms and rooms.
F600 The facility failed to ensure one resident was free from sexual abuse by another resident on multiple occasions and did not properly investigate or report the incidents.
F609 The facility failed to report alleged violations involving abuse, neglect, or exploitation within the required timeframes and failed to investigate and protect the resident.
A6012 All floors in the facility were not maintained in good repair and cleanliness as required by regulation.
A6041 Toilet rooms were not conveniently located, completely enclosed, or kept clean and in good repair, lacking proper waste receptacles.
A8023 The facility failed to develop and implement written policies prohibiting mistreatment, neglect, and abuse of residents, and failed to ensure staff compliance.
Report Facts
Certified census: 117
Deficiencies cited: 6
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