Delmar Gardens on the Green
15197 Clayton Road, Chesterfield, MO 63017 · St. Louis County · 120 certified beds · avg 83 residents/day · certified since Feb 22, 1982
Part of chain: DELMAR GARDENS (12 facilities, chain avg rating 2.8★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 2/5
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 · Oct 4, 2024 · F-0684
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
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: Nov 11, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 11, 2023 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
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: Nov 10, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (30)
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 |
|---|---|---|
| Nov 26, 2025 | 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 |
| Jul 7, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Apr 7, 2025 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Oct 4, 2024 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Oct 4, 2024 | E · Potential for harm, repeated | 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. |
| Oct 4, 2024 | E · Potential for harm, repeated | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Oct 4, 2024 | E · Potential for harm, 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. |
| Oct 4, 2024 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Oct 4, 2024 | E · Potential for harm, repeated | 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. |
| Oct 4, 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. |
| Oct 4, 2024 | E · Potential for harm, repeated | 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 4, 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. · from a complaint |
| Oct 4, 2024 | D · Potential for harm, one-off | The facility did not properly notify residents about the balance of money it holds for them, or failed to return those funds when a resident was discharged, evicted, or died. |
| Oct 4, 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. · from a complaint |
| Oct 11, 2023 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Oct 11, 2023 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Oct 11, 2023 | D · Potential for harm, one-off | The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. · from a complaint |
| Apr 5, 2023 | E · Potential for harm, repeated | The facility did not properly hold, secure, and manage residents' personal money that was deposited with it for safekeeping. Facilities holding residents' funds must keep careful, honest accounts. |
| Apr 5, 2023 | 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. |
| Apr 5, 2023 | D · Potential for harm, one-off | 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. |
| Apr 5, 2023 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Apr 5, 2023 | D · Potential for harm, one-off | 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. |
| Apr 5, 2023 | C · Minimal risk, facility-wide | The facility did not make its inspection results easy for residents to see, or made it hard for residents to contact advocacy agencies like the ombudsman. |
| Jun 25, 2019 | 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. |
| Jun 25, 2019 | E · Potential for harm, repeated | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Jun 25, 2019 | E · Potential for harm, repeated | 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. |
| Jun 25, 2019 | 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. |
| Jun 25, 2019 | D · Potential for harm, one-off | 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. |
| Jun 25, 2019 | 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. |
| Jun 25, 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. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (6 → 11).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2019 | 7 | 0 | E |
| 2023 | 9 | 1 | G ▲ |
| 2024 | 11 | 1 | G ▲ |
| 2025 | 3 | 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)
1 fine totaling $46,589, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Oct 4, 2024 | Fine | $46,589 |
| Oct 4, 2024 | Payment Denial | 8 days from Nov 12, 2024 |
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) | 4.37 | 3.66 | 3.95 | top 21% in Missouri; top 27% in the U.S. |
| Registered Nurse hours | 0.34 | 0.49 | 0.69 | bottom 36% in Missouri; bottom 14% in the U.S. |
| Weekend total nurse staffing | 4.17 | 3.22 | 3.50 | top 14% in Missouri; top 18% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.17 | 0.33 | 0.48 | bottom 20% in Missouri; bottom 8% in the U.S. |
| Total nursing staff turnover (%) | 57.7 | 56.0 | 45.8 | bottom 46% in Missouri; bottom 20% in the U.S. |
| RN turnover (%) | 70.0 | 47.8 | 42.9 | bottom 19% in Missouri; bottom 12% 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 4.38, RN 0.34, weekend 4.19. Staffing rating: 2/5.
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: 1/5 · long-stay residents: 1/5 · short-stay residents: 2/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Delmar Gardens Enterprises INC | Organization | 5% or Greater Direct Ownership Interest | 100% | 03/07/2003 |
| Gabe Grossberg and George Grossberg, Trustees of the Henry and Barbara | Organization | 5% or Greater Indirect Ownership Interest | 8% | 03/07/2003 |
| George Grossberg and Gabe Grossberg, Trustees of the Henry and Barbara | Organization | 5% or Greater Indirect Ownership Interest | 8% | 03/07/2003 |
| Goldberg-Nom LLC | Organization | 5% or Greater Indirect Ownership Interest | 25% | 03/07/2003 |
| Grossberg, Gabe | Individual | 5% or Greater Indirect Ownership Interest | 16% | 03/07/2003 |
| Grossberg, George | Individual | 5% or Greater Indirect Ownership Interest | 11% | 03/07/2003 |
| 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 |
| Church, Vicky | Individual | W-2 Managing Employee | NOT APPLICABLE | 04/01/2005 |
| Delmar Gardens Management Services INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 04/01/2005 |
| Grossberg, Gabe | Individual | Corporate Officer | NOT APPLICABLE | 03/07/2003 |
| Marx, Kenneth | Individual | W-2 Managing Employee | NOT APPLICABLE | 05/01/2022 |
| Marx, Kenneth | Individual | Corporate Officer | NOT APPLICABLE | 06/11/2019 |
| Oppenheimer, Howard | Individual | Corporate Officer | NOT APPLICABLE | 03/07/2003 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "If you ever planned to discharge or transfer my family member, how much written notice would we receive and how could we appeal?"
- "If my family member goes to the hospital, how long will you hold their bed, and will we get that in writing?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "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 |
|---|---|---|---|---|---|
| Manchester Rehab and Healthcare Center | 2.1 mi | Ballwin, MO | ★☆☆☆☆ | 2/5 | |
| Garden View Care Center of Chesterfield | 2.6 mi | Chesterfield, MO | ★★★★☆ | 4/5 | |
| Lutheran Senior Services at Meramec Bluffs | 2.8 mi | Ballwin, MO | ★★★★★ | 5/5 | |
| Athene Nursing and Rehabilitation | 2.9 mi | Town and Country, MO | ★☆☆☆☆ | 1/5 | abuse |
| Ellisville Rehabilitation and Nursing | 2.9 mi | Ellisville, MO | ★☆☆☆☆ | 1/5 | abuseSFF |
| Mason Pointe Care Center | 2.9 mi | Chesterfield, MO | ★★★★★ | 5/5 | |
| Delmar Gardens West | 2.9 mi | Town and Country, MO | ★★☆☆☆ | 3/5 | |
| Delmar Gardens of Chesterfield | 3.0 mi | Chesterfield, MO | ★★★☆☆ | 3/5 | |
| Friendship Village Chesterfield | 3.8 mi | Chesterfield, MO | ★★★★★ | 4/5 | |
| Brooking Park | 3.8 mi | Chesterfield, MO | ★★★☆☆ | 3/5 | |
| Westchester House, the | 4.0 mi | Chesterfield, MO | ★★☆☆☆ | 2/5 | |
| Aegis Health and Rehabilitation | 4.4 mi | Wildwood, MO | ★☆☆☆☆ | 1/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 265156.