Delmar Gardens North

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

50.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 120 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 25.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 59 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.19 therapist hours per resident per day in 2026Q1 — more than 19% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 14% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 240 beds and averages 177.3 residents a day — about 74% occupied, or roughly 63 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.56 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.18 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.55 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.27 hrs/resident/day on weekends vs 3.68 on weekdays — 11% thinner on weekends. RN hours go from 0.21 to 0.11 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 43% is about the same as the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

34 citations, most serious first. The 13 most serious are shown; the remaining 21 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-02-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an environment as free of accident hazards as possible and to provide supervision and assistance to prevent falls for five of seven sampled residents (Residents #1, #3, #4, #5 and #6) by not implementing care planned fall interventions. On 12/31/24 Certified Nurse Aide (CNA) A failed to place Resident #1's bed in a low position. Resident #1 was found screaming and hanging off the bed holding onto the grab rail. A nurse assisted the resident to the floor. The resident sustained bilateral (both sides) fractured femurs (thighbones). The facility failed to complete post fall neurological (neuro) assessments (a series of questions and tests to check brain, spinal cord, and nerve function) as ordered by the physician and in accordance with the facility's policy for seven out of seven sampled residents (Residents #1, #3, #4, #5 #6 and #7), and failed to complete post fall follow-up documentation each shift for 72 hours after falls for…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-11-02 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure staff followed their Abuse, Neglect and Exploitation, Freedom From policy by failing to immediately notify the Administrator/Designee or Director of Nurses (DON)/Designee and promptly begin an investigation regarding one resident's allegation on 10/24/23 around 4:30 P.M. to 5:00 P.M., of being slapped or hit in the face/mouth by Certified Nursing Assistant (CNA) A. In addition, the facility failed to ensure CNA A was immediately suspended from work pending the results of an investigation. CNA A continued to work on 10/24/23 until 10:38 P.M., returned to the facility on [DATE], and worked from 6:34 A.M. until 3:27 P.M., before being suspended from work. Six residents were sampled and problems were identified with one (Resident #3). The census was 145. Review of the facility's Abuse, Neglect and Exploitation, Freedom From policy dated 1/2019 and last revised 9/2022, showed: -Resident Safety Position Statement, included the following: -It is the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-11-02 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure staff followed their Condition Change, of the Resident policy. On the morning of 10/9/23, Nurse O (the day shift nurse) documented the night shift nurse reported at shift change one resident had a low blood pressure (BP), the physician was notified and gave orders to encourage fluids. The night shift nurse failed to document in the progress notes and/or on an SBAR (Situation, Background, Assessment, and Recommendation, assessment tool) communication form, the date or time the resident's BP was low, what the BP was, or the physician's order. In addition, Nurse O failed to document on-going assessments/monitoring of the resident throughout the day. On 10/9/23 at 5:00 P.M., the resident's family visited and requested the resident be sent to the hospital. The resident was admitted to the hospital on [DATE], with a temperature of 102.2 Fahrenheit (F) and a diagnoses of urosepsis (a blood infection caused by a urinary tract infection (UTI)) and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-11-17 · tag F0550 — failed to protect resident dignity and rights — pattern
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure all residents were treated with dignity and respect, ensuring their comfort, privacy, and personal rights are always upheld, when staff did not knock or announce their presence before entering the rooms of Residents #36, #50, #72, and #84, violating their right to privacy, when Residents #1, #2 and #28 were not provided with call lights within reach, limiting their ability to communicate their needs promptly and when staff failed to adjust the dining room temperature to a comfortable level, compromising their comfort for Residents #26, #72, #145, and #164. This affected the dignity standards to guarantee residents' physical comfort, autonomy, and respect in daily care for nine of 36 sampled residents. The census was 171. Review of the facility's undated Resident Right policy, showed:-Dignity and Respect: Resident has the right to expect the surroundings are safe, clean, and comfortable;-Privacy and Confidentiality: Resident has the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-11-17 · tag F0761 — failed to label and store drugs safely — pattern
  Ensure 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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to maintain a clean or organized medication cart and storage rooms within the facility. Four out of seven carts were checked. Staff failed to ensure proper storage and labels on medications on four Certified Medication Technician (CMT) medication carts. The census was 171. Review of the facility's Medication Storage Policy, dated December 2021, showed:-Drugs and medications are to be stored in the original container in which they were received;-Only the charge nurse or medication nurse has access to the narcotics keys,-Now discontinued, outdated, or deteriorated drugs or medications will be stored in the facility over thirty (30) days.-Medications which require refrigeration are kept in the refrigerator in the locked medication room. Drugs stored under the refrigeration are stored separately from food, -Compartments and areas containing drugs are locked when not in use or when left unattended. Such areas included drawers, cabinets, rooms, refrigerators, carts and boxes. 1. Observation of the 100-hall medication…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-11-17 · tag F0628 — isolated
  Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's Against Medical Advice (AMA) discharge was documented in the medical record and appropriate information was communicated to the resident and/or responsible party. The facility also failed to maintain a copy of a signed AMA discharge form for one of three residents reviewed for voluntary and involuntary discharge procedures (Resident #178). The census was 171. Review of facility's admission Agreement, showed: -You may voluntarily end this admission Agreement and leave our facility at any time by giving us seven days advance written notice. If you leave against the advice of your physician, you agree to assume full responsibility of all results that follow. You also agree to pay all outstanding charges before you leave. If you die while in our facility, we will honor your wishes and provide assistance to your Resident Representative or to whomever is responsible for making all funeral arrangements.Review of Resident #178's medical…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-11-17 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to document assessments and failed to contact the resident's physician regarding a change of condition for one sampled resident (Resident #11). The sample was 36. The census was 171. Review of the facility's policy, Following Physician's Orders, dated 6/29/21, showed:-Purpose: It is the policy of the community to ensure that all Licensed Professional Nurses (LPNs) Registered Nurses (RNs) and other healthcare professionals, follow physicians in accordance with State, Federal regulations and their respective practice acts.-Procedure: All physicians orders will be followed as prescribed and if not followed, the reason shall be recorded on the resident's medical record;--If an order is questionable according to the seven Rights of Medications Administration, a clarification order will be obtained;--All physician or other health care professional's verbal, telephone or written orders will be immediately entered by the nurse obtaining the order. Review of the facility's policy, Wound Management for the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-11-17 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 2 of 6 sampled residents the facility identified with a catheter (medical device to allow for voiding) received appropriate catheter care. The facility failed to ensure one resident's catheter was stored properly while the resident was in bed (Resident #2) and failed to ensure one resident received proper catheter care (Resident #55). The sample was 36. The census was 171. Review of the facility's catheter care policy, dated 3/2021, showed:-Purpose: To keep indwelling catheter free of discharge and/or crusting which can cause infections;-Procedure: Check tubing for positioning. Coil on bed. Attach catheter bag to bed frame only.-Male catheter procedure: Apply gloves. Place protective pad or towel under the resident. Avoid unnecessary exposure. Moisten wash cloth with soap and water. Clean the catheter from the opening of the urethra outward four (4) inches, or farther if needed. Do not pull on the catheter. If the male is…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-11-17 · tag F0693 — failed to provide proper feeding-tube care — isolated
  Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure two residents received gastrostomy tube (a tube surgically inserted into the abdomen, used for liquid nutrition, fluids and medications) feedings at the specified times ordered by the physician (Residents #1 and #55). The sample was 36. The census was 171. Review of the facility's Tube Feeding policy, revised June 2021, showed:-Purpose: to deliver a continuous, regulated drip feeding to gastrostomy tube (g-tube) fed residents using an enteral pump;-Procedure: -Equipment: Enteral pump, enteral feeding bag and administration set; prescribed feeding; and a pole; -Review the physician's orders; The order should specify the amount and type of formula, and the flow rate. Review of the facility's Following Physician Orders policy, dated 6/29/21, showed:-Purpose: It is the policy of the community to ensure that all licensed professional nurses and other healthcare professionals, follow physician orders in accordance to state and federal…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-12-26 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide activities of daily living (ADL) care assistance for a dependent resident (Resident #1), during the evening shift on 12/3/24 and the overnight shift from 12/3/24 to 12/4/24. The sample was five. The census was 172. The Administrator was notified on 12/26/24, of the past non-compliance. The facility disciplined various staff members who failed to provide ADL care to the resident. The facility in-serviced current employees on the topics of rounding on residents, customer service, abuse and neglect, and grooming. The deficiency was corrected on 12/11/24. Review of Resident #1's Medical Record showed: -Diagnoses included Alzheimer's disease, diabetes and major depressive disorder; -Cognitively intact; -Resident required two staff members assistance with ADLs. Review of the resident's care plan, in use at the time of the investigation, showed: -Problem: The resident refuses to shower at times; -Goal: The resident will allow staff to assist him/her…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Potential for harm · Dcited before2024-07-26 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to prevent further potential abuse, neglect or mistreatment by not investigating an injury of unknown origin for one of three sampled residents (Resident #1). The census was 95. Review of the facility's Injury of Unknown Source - Investigative Protocol policy, undated, showed: -Purpose: The following indicators of abuse/neglect are provided to help determine if abuse/neglect should be suspected. Staff are mandated to report suspected abuse; -Indicators of physical abuse may include injuries of an unknown source; -The attached worksheet and directions are offered to assist facilities in their internal investigation. If a logical/reasonable explanation of the source of the injury cannot be determined, notify your local state agency within 2 hours of discovery. Review of the facility's when to initiate an investigation document, undated, showed: -Contact Administrator and Nursing Administration immediately for the following events included for injury, actual or suspected. Examples included bruise of unknown…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-07-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to ensure the residents' environment remained free of accident hazards by keeping an un-secured plastic container filled with insulin (used to control high blood sugar) pens (a small lightweight pen that is prefilled with insulin to inject under a person's skin) of 13 residents (Residents #2, #4, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15 and #16) on un-attended, unsupervised treatment/medication carts. The facility also had an open plastic tray with auto shield duo pen needles (needles used to inject insulin from the insulin pen) and lancets (a small device with a needle used to prick the surface of the skin to obtain a blood sample) with a sharps container (used to discard used lancets and auto shield duo pen needles) which had an unsecured plastic lid on top of the un-attended, un-supervised treatment/medication carts. The sample size was 16. The census was 95. Review of the facility's Storage of Drugs policy, undated, showed: -Compartments and areas containing drugs are locked when not in use or when left…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-07-26 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, staff failed to demonstrate proper use of hand hygiene and proper infection control during wound care for two of three sampled residents (Residents #2 and #4). The census was 95. Review of the facility's Infection Control Policy, dated 12/2016, showed: -Purpose: The community has established and maintains an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections; -Develop prevention, surveillance, and control measures to protect residents and personnel from healthcare-associated infections; -Develop specific policies and procedures governing such activities as surveillance, standard and transmission based precautions, hand hygiene procedures to be followed by staff involved in direct resident contact, aseptic technique, outbreak investigation, wound care, catheter care, etc. to be followed to prevent the spread of…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$39,299 in federal fines across 1 penalty. 1 Medicare payment denial on record.

• $39,299 — penalty dated 2025-02-10
• Medicare payment denial — starting 2023-12-07 for 9 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to DELMAR GARDENS — 12 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 16 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted.

8 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

About 77% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $2.6M paid to related parties — landlords or management companies under common ownership — equal to about 14% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in MO