Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

DELMAR GARDENS SOUTH

SAINT LOUIS, MO · 184 certified beds · Last Life Safety survey September 17, 2024

CMS Certification Number 265310 · first certified April 1987

Ownership

Operated by DELMAR GARDENS · For profit - Corporation

No change of ownership on CMS record since January 1, 2016, when the records begin.

14
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
3
Tags cited more than once
Across separate surveys
8
Inspection & testing records
Of the citations on file

Position within MO

14 citations — more than 37% of the 487 certified nursing homes in MO. Compared within MO rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Holding steadyabout the same at the latest survey as at its earlier surveys in the window.

The latest survey found 5 citations; the earlier surveys in the window averaged 4.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Well past the typical window (November 2025 to June 2026), and past the point by which nine in ten MO facilities have been surveyed. This facility’s last Life Safety survey was September 2024. Facilities in MO are typically surveyed 14–21 months after the last one (median 17), measured over 567 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Physical environment (health survey)

5 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 14 Life Safety citations above. The Physical Environment Index

  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  • F-0919 Make sure that a working call system is available in each resident's bathroom and bathing area.

How that compares

Citations on file over three years

Compared with the median facility in MO, and nationally. Surveyors differ markedly between states, so the MO figure is the meaningful one.

This facility14MO median18National median11
Citations on file over three years, compared
MeasureCitations
This facility14
Median facility in MO18
Median facility nationally11

Survey history

Citations at each Life Safety survey
42019-1052023-0752024-09
Citations at each Life Safety survey
Survey dateCitations
October 24, 20194
July 8, 20235
September 17, 20245

Most-cited tags

Most-cited tags at this facility
K-09183K-03722K-02112K-02931K-03631K-01611K-03511K-03531
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0918Have generator or other power source capable of supplying service within 10 seconds.32024-09-17
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.22024-09-17
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.22024-09-17
K-0293Have properly located and lighted "Exit" signs.12023-07-08
K-0363Install corridor and hallway doors that block smoke.12019-10-24
K-0161Use approved construction type or materials.12024-09-17
K-0351Install an approved automatic sprinkler system.12019-10-24
K-0353Inspect, test, and maintain automatic sprinkler systems.12024-09-17

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 5
  • Gas, Vacuum, and Electrical Systems Deficiencies 4
  • Egress Deficiencies 3
  • Construction Deficiencies 1
  • Other 1
Citations by CMS category
CategoryCitations
Smoke Deficiencies5
Gas, Vacuum, and Electrical Systems Deficiencies4
Egress Deficiencies3
Construction Deficiencies1
Services Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

September 17, 2024 — 5 citations

Citations issued on September 17, 2024
TagWhat the surveyor checksStatus
K-0161Use approved construction type or materials.Deficient, Provider has date of correction (October 10, 2024)
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.Deficient, Provider has date of correction (October 8, 2024)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (October 10, 2024)
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (October 8, 2024)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (October 1, 2024)

July 8, 2023 — 5 citations

Citations issued on July 8, 2023
TagWhat the surveyor checksStatus
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.Deficient, Provider has date of correction (August 12, 2023)
K-0293Have properly located and lighted "Exit" signs.Deficient, Provider has date of correction (August 12, 2023)
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (August 12, 2023)
K-0511Have properly installed electrical wiring and gas equipment.Deficient, Provider has date of correction (August 12, 2023)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (August 12, 2023)

October 24, 2019 — 4 citations

Citations issued on October 24, 2019
TagWhat the surveyor checksStatus
K-0351Install an approved automatic sprinkler system.Deficient, Provider has date of correction (December 6, 2019)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (December 6, 2019)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (December 6, 2019)
K-0919Meet requirements for the use of electrical equipment.Deficient, Provider has date of correction (December 6, 2019)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.