Delmar Gardens on the Green, Chesterfield, MO

The Essentials

Summary

Across 7 inspections from June 2019 to November 2025, state surveyors documented 30 findings at Delmar Gardens on the Green; 29 have a recorded correction and 1 awaits one; CMS lists 2 enforcement actions in the window.

Inspections: 7; 2019–2025, complaint and standard
Findings: 30; Deficiencies cited by state inspectors
Corrected: 29; Of 30 findings, with a recorded correction date
Penalties: 2; 1 fine; payment not published, 1 closed

Findings by Year

Findings
Of which, actual harm (level G or above)

* Partial year, through October 1, 2026.

Findings by year
Year	Inspections	Findings	Of which, actual harm (level G or above)
2019	1	7	0
2020	0	0	0
2021	0	0	0
2022	0	0	0
2023	2	9	1
2024	1	11	1
2025	3	3	0
2026	0	0	0

What the Record Shows

29 of 30 findings have a recorded correction date.
CMS lists 2 enforcement actions in the window: 1 fine of $46,589, its payment not published; denial of payment imposed October 4, 2024, ended November 20, 2024.
5 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
The latest standard inspection, October 4, 2024, recorded 11 findings (most serious: Level G).

What to Ask About

Infection Control, Cited in Three Inspections
Investigating Alleged Violations, Cited in Two Inspections
Help With Daily Living, Cited in Two Inspections
Quality of Care, Cited in Two Inspections
Accident Hazards and Supervision, Cited in Two Inspections
Kitchen and Food Safety, Cited in Two Inspections
Pressure Injury Care, No Recorded Correction

Report at a Glance

Facility: Delmar Gardens on the Green
Address: 15197 Clayton Road, Chesterfield, MO 63017
CMS Certification Number: 265156
Provider Type: Skilled nursing facility and nursing facility
Certified Beds: 120
Ownership: For profit - Corporation
Record Window: June 25, 2019 to October 1, 2026

Chronology

Inspection History

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

Nov 262025
Complaint investigation
1 finding
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for morePast Non-Compliance
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Jul 72025
Complaint investigation
1 finding
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Aug 21, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Apr 72025
Complaint investigation
1 finding
- F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected May 6, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Oct 42024
Standard health inspection
11 findings
The same visit included a complaint investigation.
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level GActual harmCorrected Nov 11, 2024
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level ENo actual harm, potential for moreCorrected Nov 11, 2024
- F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level ENo actual harm, potential for moreCorrected Nov 11, 2024
- F625Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.Level ENo actual harm, potential for moreCorrected Nov 11, 2024
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected Nov 11, 2024
- F759Ensure medication error rates are not 5 percent or greater.Level ENo actual harm, potential for moreCorrected Nov 11, 2024
- F761Ensure 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.Level ENo actual harm, potential for moreCorrected Nov 11, 2024
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Nov 20, 2024
- F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Nov 11, 2024
- F569Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.Level DNo actual harm, potential for moreCorrected Apr 17, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Mar 18, 2024
Enforcement Action
Civil money penalty, $46,589 imposed October 4, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of October 4, 2024, the nearest before the penalty date.
Enforcement Action
Denial of payment imposed October 4, 2024. Status: Closed, November 20, 2024. CMS does not tie a penalty to a survey; listed with the standard health inspection of October 4, 2024, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Oct 112023
Complaint investigation
3 findings
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level GActual harmCorrected Nov 10, 2023
- F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Nov 10, 2023
- F699Provide care or services that was trauma informed and/or culturally competent.Level DNo actual harm, potential for moreCorrected Nov 10, 2023
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Apr 52023
Standard health inspection
6 findings
- F568Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.Level ENo actual harm, potential for moreCorrected May 12, 2023
- F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected May 12, 2023
- F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Level DNo actual harm, potential for moreCorrected May 12, 2023
- F584Honor 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.Level DNo actual harm, potential for moreCorrected May 12, 2023
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected May 12, 2023
- F577Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.Level CPotential for minimal harmCorrected May 12, 2023
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Jun 252019
Standard health inspection
7 findings
- F658Ensure services provided by the nursing facility meet professional standards of quality.Level ENo actual harm, potential for moreCorrected Aug 8, 2019
- F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Level ENo actual harm, potential for moreCorrected Aug 8, 2019
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Aug 8, 2019
- F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Aug 12, 2019
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Aug 12, 2019
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Aug 8, 2019
- F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Level DNo actual harm, potential for moreCorrected Aug 8, 2019
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

Context

Patterns Worth Examining

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1
Infection Control, Cited in Three Inspections
Inspectors cited F880 in June 2019, April 2023 and October 2024. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
19232324252525F880 across all 7 inspections, oldest to newest
2
Investigating Alleged Violations, Cited in Two Inspections
Inspectors cited F610 in October 2023 and April 2025. This citation covers how the home responds to and investigates an allegation of abuse, neglect or mistreatment. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
19232324252525F610 across all 7 inspections, oldest to newest
3
Help With Daily Living, Cited in Two Inspections
Inspectors cited F677 in June 2019 and April 2023. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
19232324252525F677 across all 7 inspections, oldest to newest
4
Quality of Care, Cited in Two Inspections
Inspectors cited F684 in October 2024 and July 2025. This citation covers whether residents receive the treatment their orders, preferences and goals call for. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
19232324252525F684 across all 7 inspections, oldest to newest
5
Accident Hazards and Supervision, Cited in Two Inspections
Inspectors cited F689 in June 2019 and October 2024. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
19232324252525F689 across all 7 inspections, oldest to newest
6
Kitchen and Food Safety, Cited in Two Inspections
Inspectors cited F812 in June 2019 and October 2024. This citation covers how food is stored, prepared and served. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
19232324252525F812 across all 7 inspections, oldest to newest
7
Pressure Injury Care, No Recorded Correction
F686 was cited in November 2025. This citation covers how the home prevents and treats pressure injuries (bedsores). The most serious was level D (no actual harm, potential for more). The November 2025 citation has no recorded correction date; its status reads “Past Non-Compliance.” The record does not show whether the problem was fixed.
19232324252525F686 across all 7 inspections, oldest to newest

For Your Next Visit

Questions to Ask on Your Visit

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

01
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in three inspections, most seriously at level E.
02
When an allegation is made, who investigates it, and how are residents protected in the meantime?
Investigating Alleged Violations: cited in two inspections, most seriously at level D.
03
How long do residents usually wait for help with bathing, dressing or the bathroom, and how is that tracked?
Help With Daily Living: cited in two inspections, most seriously at level D.
04
How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?
Quality of Care: cited in two inspections, most seriously at level G.
05
What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?
Accident Hazards and Supervision: cited in two inspections, most seriously at level D.
06
May we see the kitchen, and what do your own sanitation checks look like week to week?
Kitchen and Food Safety: cited in two inspections, most seriously at level E.
07
How often are residents checked for pressure injuries and repositioned, and who is responsible for it?
Pressure Injury Care: cited in one inspections, most seriously at level D. The November 26, 2025 citation has no recorded correction date.
08
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.
09
What led to the 2024 fine, and has it been paid?
A $46,589 civil money penalty was imposed October 4, 2024. CMS publishes the fine, not whether it has been paid. The record holds two enforcement actions in the window.

The Evidence

Sources and Coverage

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Missouri state survey agency.

Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Missouri state survey agency
Inspection Jun 25, 2019 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Missouri state survey agency
Inspection Apr 5, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Missouri state survey agency
Inspection Oct 11, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Missouri state survey agency
Inspection Oct 4, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Missouri state survey agency
Inspection Apr 7, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Missouri state survey agency
Inspection Jul 7, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Missouri state survey agency
Inspection Nov 26, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Penalties, Provider Data Catalog
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
View Dataset ↗
Provider Information, Provider Data Catalog
Centers for Medicare & Medicaid Services · 265156
Published Oct 1, 2026 · Retrieved Nov 1, 2026
View Dataset ↗

Coverage

Record windowJune 25, 2019 – October 1, 2026

CMS publishes about three inspection cycles; inspections before June 2019 are not in this release.
CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.

What This Report Cannot Tell You

Complaints not investigated onsite: Allegations screened out by the state before an onsite visit are not published.
Complaint allegations: CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
Facility-reported incidents: Self-reported incidents appear only if they led to an inspection.
Follow-up visits: CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
Fire safety inspections: Published by CMS separately and not included in this record yet.
Staffing levels and ownership history: Published by CMS separately and not included in this record.
Whether fines were paid: CMS publishes the fines imposed, not whether or when they were paid.

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.