Your report for Delhaven Manor
Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- MissouriAbove 54% of peers479 rated homes · average 2.5★
- St. Louis City CountyAbove 83% of peers13 rated homes · average 1.6★
- United StatesAbove only 41% of peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point3★+0.2 vs MO avg
- StaffingCan add or remove a star—
- Quality measuresCan add or remove a star4★+1.3 vs MO avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles3★Above only 45% of peersMO avg2.8★U.S. avg2.8★
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover—No dataMO avg2.1★U.S. avg2.9★
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments4★Above 71% of peersMO avg2.7★U.S. avg3.6★
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff—hrsNo dataMO avg3.47Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only—hrsNo dataMO avg0.46Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better—No dataMO avg57%RN turnover—
The share of nursing staff who left within the past year, from the same payroll data.
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$73,048Above only 17% of peersMO avg$37,310Fines · denials1 · 1
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthOct 2019 – Nov 2024
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Nov 13, 2024Cycle 1worst F · no actual harm
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Jan 8, 2025
- F569Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.Resident RightsD · isolatedCorrected Dec 25, 2024
- F570Assure the security of all personal funds of residents deposited with the facility.Resident RightsE · patternCorrected Dec 25, 2024
- F574The resident has the right to receive notices in a format and a language he or she understands.Resident RightsC · widespreadCorrected Dec 25, 2024
- F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Dec 25, 2024
- F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Dec 25, 2024
- F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Dec 25, 2024
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Dec 25, 2024
Aug 14, 2024Cycle 2worst E · no actual harm
- F839Employ staff that are licensed, certified, or registered in accordance with state laws.AdministrationE · patternCorrected Aug 21, 2024
- F850Hire a qualified full-time social worker in a facility with more than 120 beds.AdministrationE · patternCorrected Aug 21, 2024
Jul 10, 2024Cycle 2worst J · immediate jeopardy
- F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Quality of Life and CareJ · isolatedCorrected Aug 2, 2024
Jun 17, 2024Cycle 2worst E · no actual harm$73,048, payment denial
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Jun 28, 2024
- F839Employ staff that are licensed, certified, or registered in accordance with state laws.AdministrationE · patternCorrected Aug 21, 2024
- F850Hire a qualified full-time social worker in a facility with more than 120 beds.AdministrationE · patternCorrected Aug 21, 2024
Apr 19, 2024Cycle 2worst D · no actual harm
- F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected May 24, 2024
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected May 24, 2024
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected May 24, 2024
Feb 23, 2024Cycle 2worst D · no actual harm
- F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Quality of Life and CareD · isolatedCorrected Mar 25, 2024
- F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Mar 25, 2024
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Mar 25, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Mar 25, 2024
Aug 25, 2023Cycle 3worst E · no actual harm
- F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Nursing and Physician ServicesE · patternCorrected Aug 26, 2023
Jun 30, 2023Cycle 2worst E · no actual harm
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningE · patternCorrected Aug 5, 2023
- F568Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.Resident RightsD · isolatedCorrected Aug 5, 2023
- F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningD · isolatedCorrected Aug 5, 2023
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Aug 5, 2023
- 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.Quality of Life and CareD · isolatedCorrected Aug 5, 2023
- F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Aug 5, 2023
- F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Nursing and Physician ServicesE · patternCorrected Aug 26, 2023
- 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.Pharmacy ServiceD · isolatedCorrected Aug 5, 2023
- F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Aug 5, 2023
Apr 27, 2023Cycle 3worst D · no actual harm
- F660Plan the resident's discharge to meet the resident's goals and needs.Resident Assessment and Care PlanningD · isolatedCorrected May 16, 2023
Oct 11, 2019Cycle 3worst E · no actual harm
- F567Honor the resident's right to manage his or her financial affairs.Resident RightsE · patternCorrected Nov 25, 2019
- F568Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.Resident RightsE · patternCorrected Nov 25, 2019
- F570Assure the security of all personal funds of residents deposited with the facility.Resident RightsE · patternCorrected Nov 25, 2019
- 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.Resident RightsB · patternCorrected Nov 25, 2019
- F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Nov 25, 2019
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningE · patternCorrected Nov 25, 2019
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningE · patternCorrected Nov 25, 2019
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Nov 25, 2019
- F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareE · patternCorrected Nov 25, 2019
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected Nov 25, 2019
- F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Nov 25, 2019
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected Nov 25, 2019
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Nov 25, 2019
- F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.AdministrationE · patternCorrected Nov 25, 2019
- Notify the resident or the residentâs representative in writing how long the nursing home will hold the residentâs bed in cases of transfer to a hospital or therapeutic leave.Resident RightsB · patternCorrected Nov 25, 2019
- F919Make sure that a working call system is available in each resident's bathroom and bathing area.EnvironmentalE · patternCorrected Nov 25, 2019
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined—hrs
- Registered nursesRN hours only—hrs
- Licensed practical nursesLPN hours—hrs
- Nurse aidesCNA hours—hrs
- Weekend nursingAll staff on Saturdays and Sundays—hrs
- Missouri average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better—MO avg 57%
- RN turnoverRegistered nurses only—Not ranked by CMS
- Administrators who leftIn the past year—
- Occupancy156 certified beds—MO avg 72%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $73,048In fines
- 1Fine
- 1Payment denial
- $37,310MO avg in fines
Actions on record
- Jun 17, 2024Civil money penalty$73,048
- Jun 17, 2024Denial of payment for new admissionsfrom Aug 16, 2024
Ownership
As filed with CMSStructure
- Ownership type
- For profit - Corporation
- Chain
- Circle B Enterprises29 facilities in the chain2.3★ chain average
- Certification
- Medicare and Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
- Circle B Enterprises Holding Company INC
- Agh1 LLC
- Sovereign Healthcare Group LLC
- Donald Bedell
- Thomas Jackson
- Christopher Labonte
- Donald Bedell
- Todd Beaird
- Donald Bedell
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 265392 · 5460 DELMAR BLVD, SAINT LOUIS, MO, 63112.
- Percentiles compare this facility with every rated nursing home in Missouri and St. Louis City County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.









