Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
DELMAR GARDENS WEST
TOWN AND COUNTRY, MO · 321 certified beds · Last Life Safety survey April 11, 2025
CMS Certification Number 265105 · first certified February 1972
Ownership
Operated by DELMAR GARDENS · For profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within MO
22 citations — more than 58% 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
The latest survey found 6 citations; the earlier surveys in the window averaged 8. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: June 2026 to December 2026. This facility’s last Life Safety survey was April 2025. 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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3 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.
Emergency preparedness
2 of the 22 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
9 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 22 Life Safety citations above. The Physical Environment Index
- F-0584 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.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
How that compares
Compared with the median facility in MO, and nationally. Surveyors differ markedly between states, so the MO figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 22 |
| Median facility in MO | 18 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| January 15, 2020 | 5 |
| November 17, 2023 | 11 |
| April 11, 2025 | 6 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | 3 | 2025-04-11 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 2 | 2025-04-11 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2025-04-11 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 2 | 2025-04-11 |
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2025-04-11 |
| E-0030 | List the names and contact information of those in the facility. | 1 | 2023-11-17 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 1 | 2023-11-17 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2020-01-15 |
What the citations cover
- Smoke Deficiencies 7
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Miscellaneous Deficiencies 4
- Egress Deficiencies 3
- Other 4
| Category | Citations |
|---|---|
| Smoke Deficiencies | 7 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Miscellaneous Deficiencies | 4 |
| Egress Deficiencies | 3 |
| Services Deficiencies | 2 |
| Emergency Preparedness Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
April 11, 2025 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (May 13, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (May 13, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (May 13, 2025) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (May 13, 2025) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (May 13, 2025) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (May 13, 2025) |
November 17, 2023 — 11 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (December 26, 2023) |
| E-0030 | List the names and contact information of those in the facility. | Deficient, Provider has date of correction (December 26, 2023) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (December 26, 2023) |
| K-0222 | Add 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. | Deficient, Provider has date of correction (December 26, 2023) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (December 26, 2023) |
| K-0351 | Install an approved automatic sprinkler system. | Waiver has been granted (February 29, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Waiver has been granted (February 29, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (December 26, 2023) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (December 26, 2023) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (December 26, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (December 26, 2023) |
January 15, 2020 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (February 21, 2020) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (February 21, 2020) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (February 21, 2020) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (February 21, 2020) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (February 21, 2020) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.