7 health deficiencies
Top issue: Resident Rights (3 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Lenexa, KS
4-star overall rating with 5-star inspections with 7 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
9701 Monrovia Street, Lenexa, KS
(913) 492-1130
Overall
4 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
222
Certified beds
Average residents
175
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Delmar Gardens
Operator or chain grouping
Approved since
1981-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
13 facilities
Chain averages 3 overall / 3 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.02
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.04
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
0.11
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
0.17
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
0.05
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
0.25
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.02
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.02
CMS adjusted RN staffing hours
Adjusted total hours
0.20
CMS adjusted total nurse staffing hours
Case-mix index
1.14
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Program rank
9,239
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.33
Composite VBP score used to determine payment impact.
Payment multiplier
0.9834
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 22.54% · Performance 23.87% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.48% · Performance 8.15% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.62
Baseline 26.67% · Performance 36.61% · Measure score 6.62 · Achievement 6.62 · Improvement 0
Adjusted total nurse staffing
3.11
Baseline 3.46 hours · Performance 3.96 hours · Measure score 3.11 · Achievement 3.11 · Improvement 1.67
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.41% |
10.72%
2.7 pts worse
|
No Different than the National Rate · Eligible stays 140 · Observed rate 19.29% · Lower 95% interval 10.3% |
| Discharge to community | 47.59% |
50.57%
3 pts worse
|
No Different than the National Rate · Eligible stays 109 · Observed rate 40.37% · Lower 95% interval 38.48% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 70 · Denominator 70 |
| Falls with major injury | 1.43% |
0.77%
0.7 pts worse
|
Numerator 1 · Denominator 70 |
| Discharge self-care score | 45.24% |
53.69%
8.4 pts worse
|
Numerator 19 · Denominator 42 |
| Discharge mobility score | 23.81% |
50.94%
27.1 pts worse
|
Numerator 10 · Denominator 42 |
| Pressure ulcers or injuries, new or worsened | 1.43% |
2.29%
0.9 pts better
|
Numerator 1 · Denominator 70 · Adjusted rate 1.76% |
| Healthcare-associated infections requiring hospitalization | 8.15% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 74 · Observed rate 10.81% · Lower 95% interval 4.39% |
| Staff COVID-19 vaccination coverage | 82.78% |
8.2%
74.6 pts better
|
Numerator 173 · Denominator 209 |
| Staff flu vaccination coverage | 2.58% |
42%
39.4 pts worse
|
Numerator 10 · Denominator 388 |
| Discharge function score | 21.43% |
56.45%
35 pts worse
|
Numerator 9 · Denominator 42 |
| Transfer of health information to provider | 92.31% |
95.95%
3.6 pts worse
|
Numerator 24 · Denominator 26 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 25 · Denominator 25 |
| Resident COVID-19 vaccinations up to date | 84.21% |
25.2%
59 pts better
|
Numerator 32 · Denominator 38 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.3 |
1.8
1.5 pts worse
|
1.9
1.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 3.0 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
2.2
1.3 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 81.9% |
91.8%
9.9 pts worse
|
93.4%
11.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 79.4% · Q2 77.7% · Q3 84.8% · Q4 85.8% · 4Q avg 81.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 85.0% |
95.5%
10.5 pts worse
|
95.5%
10.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 85.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.3% |
4.4%
2.1 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.0% · Q3 2.2% · Q4 2.8% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.3% |
5.6%
4.3 pts better
|
11.4%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.7% · Q3 1.6% · Q4 0.8% · 4Q avg 1.3% |
| Percentage of long-stay residents who lose too much weight | 6.9% |
5.0%
1.9 pts worse
|
5.4%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 10.3% · Q3 5.4% · Q4 10.1% · 4Q avg 6.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.2% |
23.2%
10 pts better
|
19.6%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 11.9% · Q3 12.3% · Q4 13.5% · 4Q avg 13.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.3% |
19.8%
4.5 pts better
|
16.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 17.2% · Q3 11.1% · Q4 16.9% · 4Q avg 15.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 21.4% |
18.4%
3 pts worse
|
16.3%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.2% · Q2 23.6% · Q3 20.5% · Q4 13.6% · 4Q avg 21.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.6% |
18.8%
1.8 pts worse
|
14.9%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 21.2% · Q3 16.8% · Q4 18.7% · 4Q avg 20.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
1.8%
0.4 pts better
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.7% · Q3 1.4% · Q4 1.4% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
3.1%
0.9 pts better
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 4.8% · Q3 0.0% · Q4 1.4% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.2% |
23.2%
4 pts worse
|
19.8%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.5% · Q2 21.7% · Q3 36.8% · Q4 30.7% · 4Q avg 27.2% |
| Percentage of long-stay residents with pressure ulcers | 5.2% |
4.6%
0.6 pts worse
|
5.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 6.8% · Q3 3.9% · Q4 5.0% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.4% |
75.6%
9.8 pts better
|
81.7%
3.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.7% · Q2 83.8% · Q3 83.7% · Q4 83.9% · 4Q avg 85.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.9% |
11.7%
0.2 pts worse
|
12.0%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.9% · Observed 12.9% · Expected 12.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.2% |
2.2%
About the same
|
1.6%
0.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 2.0% · Q3 1.8% · Q4 3.4% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 42.4% |
73.5%
31.1 pts worse
|
79.7%
37.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 42.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 37.7% |
23.0%
14.7 pts worse
|
23.9%
13.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 37.7% · Observed 40.0% · Expected 25.3% · Used in QM five-star |
Survey summary
Top issue: Resident Rights (3 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
21 fire-safety deficiencies
Top issue: Smoke (10 deficiencies)
Top issue: Quality of Life and Care (1 deficiency)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-05-22
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-22
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-05-22
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-22
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-05-22
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-05-22
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-05-22
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-05-22
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-05-22
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-05-22
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-05-22
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-05-22
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2023-01-11
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-01-11
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-01-11
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-01-11
Fire Safety
Ensure that suites are correctly sub-divided by noncombustible or limited-combustible construction.
Corrected 2023-01-11
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-01-11
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2023-01-11
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-01-11
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-01-11
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-11
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-01-11
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-01-11
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-01-11
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-01-11
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-01-11
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-11
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-01-11
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-01-11
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-01-11
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-01-11
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-01-11
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-08-26
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2021-08-26
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-08-26
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-07-28
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2021-08-26
Fire Safety
Use approved construction type or materials.
Corrected 2021-08-26
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2021-08-26
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-08-26
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-08-26
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-08-26
Inspection history
Health
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.
Corrected 2024-05-03
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-05-03
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-05-03
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-05-03
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-05-03
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-05-03
Health
Provide 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.
Corrected 2024-05-03
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-11-30
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-11-30
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-11-30
Health
Provide 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.
Corrected 2022-11-30
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-11-30
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2022-11-30
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2021-06-22
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
W-2 Managing Employee · Individual
Operational/Managerial Control · Organization
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
Nearby options
Lenexa, KS
3-star overall rating with 2-star inspections with $35,619 in total fines with 12 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
Overland Park, KS
1-star overall rating with 1-star inspections with $23,261 in total fines with 33 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
Lenexa, KS
3-star overall rating with 4-star inspections with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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