Delmar Gardens of O'Fallon

In the surveyor’s words

From the most serious findings on record at Delmar Gardens of O'Fallon, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Sep 15, 2021

  Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #1), in a review of 15 sampled residents, was free from abuse when Resident #2 entered his/her room and stabbed Resident #1 repeatedly with a knife as Resident #1 sat in his/her power chair. Resident #1 was totally dependent on two staff for transfer with a mechanical lift and the resident did not walk. Resident #2 had conflict with Resident #1 prior and was aggressive with the resident. Resident #2 did not like the light coming from Resident #1's television. The night before the stabbing, Resident #2 entered Resident #1's room, threw his/her covers off while he/she was in bed, turned of his/her television and threw his/her remote control against the wall. […]

• Actual harm, isolatedF689Mar 19, 2025

  Based on observation, interview, and record review, the facility failed to safely transfer one resident (Resident #1), in a review of two sampled residents who transferred with a sit-to-stand lift. Staff identified Resident #1 was fatigued in the evening, and during transfer with the sit-to-stand lift, the resident's legs would not support his/her weight sufficiently. On the evening of 03/05/25, staff transported the resident in a sit-to-stand lift from his/her bathroom to his/her bed. Staff reported the resident's legs began to give way and the resident began to slide out of the lift sling (a sling that was positioned around the resident's back and under his/her arms), during a transport in the lift from the toilet to the bed. […]

• Actual harm, isolatedF689Sep 15, 2021

  Based on observation, interview, and record review, the facility failed to provide protective oversight for two(Resident #3 and #15) of 19 sampled residents. Facility failed to review, revise, and/or add interventions to one of Resident #15's care plan to prevent further falls. Resident experienced multiple falls with minor injuries including abrasions, skin tears, and bruises. One of resident's falls resulted in major injury, including a fracture of the cervical spine vertebrae (neck) which required hospitalization . Facility failed to address interventions following the major injury and the resident continued to fall. Facility's staff were unfamiliar with resident and were unaware he/she had history of falling and required closer observation. […]

• No harm, potential for more than minimal, widespreadF880Jul 30, 2026

  Based on observation, interview, and record review, the facility failed to implement policies to monitor the water system and monitor for Legionella (a bacterium that can cause a serious type of pneumonia called Legionnaires' Disease, a bacterial disease commonly associated with water-based aerosols, in persons at risk) control that included specific control parameters based on the Center for Disease Control and Prevention (CDC) and American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRAE) standards and failed to develop procedures consistent with CDC guidelines to test residents with healthcare-associated pneumonia (pneumonia with onset 48 hours after admission) for Legionnaires' disease. […]

• No harm, potential for more than minimal, widespreadF812May 14, 2024

  Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in accordance with professional standards for food service safety. Staff failed to label, date, and seal opened food items. Staff failed to store food items per manufacturer's label instructions, store food items off the floor, and store food items in an area separate from resident medications and related items. Staff failed to discard food items that were expired or showed visible signs of deterioration. Staff failed to properly clean ice machines, properly store ice scoops, and ensure an air gap was present at each ice machine drain. […]