Delmar Gardens of O'Fallon
7068 South Outer 364, O Fallon, MO 63368 · St. Charles County · 198 certified beds · avg 161 residents/day · certified since Dec 15, 2004
Part of chain: DELMAR GARDENS (12 facilities, chain avg rating 2.8★)
2/5
Health inspection rating (on-site)
1
Serious findings on record
$0
Fines, last 3 years
4.91
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5
⚠ The most recent standard health inspection was more than 2 years ago — conditions may have changed.
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Mar 19, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 11, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (39)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Feb 5, 2026 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. · from a complaint |
| Mar 19, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Aug 23, 2024 | E · Potential for harm, repeated | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · from a complaint |
| May 14, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| May 14, 2024 | E · Potential for harm, repeated | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| May 14, 2024 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| May 14, 2024 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| May 14, 2024 | E · Potential for harm, repeated | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| May 14, 2024 | E · Potential for harm, repeated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| May 14, 2024 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| May 14, 2024 | E · Potential for harm, repeated | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| May 14, 2024 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| May 14, 2024 | E · Potential for harm, repeated | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. |
| May 14, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| May 14, 2024 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| May 14, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| May 14, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| May 14, 2024 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| May 14, 2024 | D · Potential for harm, one-off | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. |
| May 14, 2024 | B · Minimal risk, repeated | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
| Mar 14, 2024 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Oct 27, 2022 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Oct 27, 2022 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Oct 27, 2022 | E · Potential for harm, repeated | The facility did not update each resident's care assessment at least once every 3 months. These regular check-ins keep the resident's care plan matched to their current condition. |
| Oct 27, 2022 | D · Potential for harm, one-off | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Oct 27, 2022 | D · Potential for harm, one-off | The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. |
| Oct 27, 2022 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Oct 16, 2019 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Oct 16, 2019 | E · Potential for harm, repeated | The facility did not treat residents with respect and dignity, or did not let them keep and use their own personal belongings. |
| Oct 16, 2019 | E · Potential for harm, repeated | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. |
| Oct 16, 2019 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Oct 16, 2019 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Oct 16, 2019 | E · Potential for harm, repeated | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Oct 16, 2019 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. |
| Oct 16, 2019 | E · Potential for harm, repeated | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Oct 16, 2019 | E · Potential for harm, repeated | The facility did not serve meals and snacks at times that fit residents' needs, preferences, and requests, or did not offer nourishing alternatives for residents who want to eat outside scheduled meal times. |
| Oct 16, 2019 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Oct 16, 2019 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Oct 16, 2019 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (6 → 17).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2019 | 12 | 0 | F |
| 2022 | 6 | 0 | F |
| 2024 | 19 | 0 | F |
| 2025 | 1 | 1 | G ▲ |
| 2026 | 1 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Missouri avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.91 | 3.66 | 3.95 | top 10% in Missouri; top 15% in the U.S. |
| Registered Nurse hours | 0.44 | 0.49 | 0.69 | top 46% in Missouri; bottom 28% in the U.S. |
| Weekend total nurse staffing | 4.79 | 3.22 | 3.50 | top 6% in Missouri; top 8% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.28 | 0.33 | 0.48 | top 45% in Missouri; bottom 28% in the U.S. |
| Total nursing staff turnover (%) | 42.7 | 56.0 | 45.8 | top 17% in Missouri; top 44% in the U.S. |
| RN turnover (%) | 14.3 | 47.8 | 42.9 | top 7% in Missouri; top 7% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.20, RN 0.37, weekend 4.11. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 3/5 · short-stay residents: 5/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Delmar Gardens Enterprises INC | Organization | 5% or Greater Direct Ownership Interest | 100% | 09/24/2004 |
| Gabe Grossberg and George Grossberg, Trustees of the Henry and Barbara | Organization | 5% or Greater Indirect Ownership Interest | 8% | 09/24/2004 |
| George Grossberg and Gabe Grossberg, Trustees of the Henry and Barbara | Organization | 5% or Greater Indirect Ownership Interest | 8% | 09/24/2004 |
| Goldberg-Nom LLC | Organization | 5% or Greater Indirect Ownership Interest | 25% | 09/24/2004 |
| Grossberg, Gabe | Individual | 5% or Greater Indirect Ownership Interest | 16% | 09/24/2004 |
| Grossberg, George | Individual | 5% or Greater Indirect Ownership Interest | 11% | 09/24/2004 |
| Non-Gst Family Trust Est U/W of Israel Goldberg Fbo Janice Bitanski | Organization | 5% or Greater Indirect Ownership Interest | 6% | 04/10/2013 |
| Non-Gst Family Trust Established U/W of Israel Goldberg Fbo Harry Zvi | Organization | 5% or Greater Indirect Ownership Interest | 6% | 04/10/2013 |
| Non-Gstfamily Trust Est U/W Israel Goldberg Fbo Diane Fredman | Organization | 5% or Greater Indirect Ownership Interest | 6% | 04/10/2013 |
| Delmar Gardens Management Services INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 04/01/2005 |
| Grossberg, Gabe | Individual | Corporate Officer | NOT APPLICABLE | 09/24/2004 |
| Marx, Kenneth | Individual | Corporate Officer | NOT APPLICABLE | 06/11/2019 |
| Oppenheimer, Howard | Individual | Corporate Officer | NOT APPLICABLE | 09/24/2004 |
| Reiter, Teresa | Individual | W-2 Managing Employee | NOT APPLICABLE | 09/24/2004 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What is your current medication error rate, and what have you changed to bring errors down?"
- "How is pest control handled here, and when was the last treatment or inspection?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Sunterra Springs Dardenne Prairie | 2.0 mi | Dardenne Prairie, MO | ★★☆☆☆ | 2/5 | |
| Garden View Care Center | 3.1 mi | O Fallon, MO | ★☆☆☆☆ | 1/5 | abuse |
| Cottages of Lake St Louis | 3.5 mi | Lake Saint Louis, MO | ★★★★☆ | 4/5 | |
| Abbey Senior Health | 3.7 mi | O Fallon, MO | ★★★☆☆ | 2/5 | abuse |
| Lutheran Senior Services at Breeze Park | 4.2 mi | Saint Charles, MO | ★★★★☆ | 3/5 | |
| St Peters Post Acute | 6.2 mi | Saint Peters, MO | ★☆☆☆☆ | 1/5 | |
| Ignite Medical Resort St Peters | 6.2 mi | Saint Peters, MO | —/5 | ||
| St Peters Rehab and Healthcare Center | 6.3 mi | Saint Peters, MO | ★☆☆☆☆ | 1/5 | abuseSFF |
| McClay Senior Care | 7.1 mi | Saint Peters, MO | ★★★☆☆ | 3/5 | |
| Aspen Point Health and Rehabilitation | 10.3 mi | Saint Charles, MO | ★☆☆☆☆ | 1/5 | |
| NHC Healthcare, St Charles | 10.3 mi | Saint Charles, MO | ★★★★☆ | 4/5 | |
| Delmar Gardens of Chesterfield | 11.2 mi | Chesterfield, MO | ★★★☆☆ | 3/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 265792.