Cycle 1
Health 2024-03-27 · Fire 2024-03-27
7 health deficiencies
Top issue: Resident Rights (3 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Lenexa, KS
Delmar Gardens Of Lenexa
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
Facility snapshot
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
Staffing
Hours and turnover
RN hours / resident day
0.02
Registered nurse staffing
LPN hours / resident day
0.04
Licensed practical nurse staffing
Aide hours / resident day
0.11
Nurse aide staffing
Weekend hours
0.25
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-10-24 · Fire 2022-10-24
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
21 fire-safety deficiencies
Top issue: Smoke (10 deficiencies)
Cycle 3
Health 2021-05-24 · Fire 2021-05-24
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-03-27
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-05-22
F · Potential for more than minimal harm
2024-03-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-22
F · Potential for more than minimal harm
2024-03-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-05-22
F · Potential for more than minimal harm
2024-03-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-22
E · Potential for more than minimal harm
2024-03-27
K222 · Egress Deficiencies
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
E · Potential for more than minimal harm
2024-03-27
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-05-22
E · Potential for more than minimal harm
2024-03-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-05-22
D · Potential for more than minimal harm
2024-03-27
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-05-22
D · Potential for more than minimal harm
2024-03-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-05-22
D · Potential for more than minimal harm
2024-03-27
K741 · Miscellaneous Deficiencies
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
D · Potential for more than minimal harm
2024-03-27
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-05-22
D · Potential for more than minimal harm
2024-03-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-05-22
F · Potential for more than minimal harm
2022-10-24
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2023-01-11
F · Potential for more than minimal harm
2022-10-24
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-01-11
F · Potential for more than minimal harm
2022-10-24
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-01-11
F · Potential for more than minimal harm
2022-10-24
K222 · Egress Deficiencies
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
F · Potential for more than minimal harm
2022-10-24
K255 · Egress Deficiencies
Fire Safety
Ensure that suites are correctly sub-divided by noncombustible or limited-combustible construction.
Corrected 2023-01-11
F · Potential for more than minimal harm
2022-10-24
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-01-11
F · Potential for more than minimal harm
2022-10-24
K343 · Smoke Deficiencies
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
F · Potential for more than minimal harm
2022-10-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-01-11
F · Potential for more than minimal harm
2022-10-24
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-01-11
F · Potential for more than minimal harm
2022-10-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-11
F · Potential for more than minimal harm
2022-10-24
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-01-11
F · Potential for more than minimal harm
2022-10-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-01-11
F · Potential for more than minimal harm
2022-10-24
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-01-11
F · Potential for more than minimal harm
2022-10-24
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-01-11
F · Potential for more than minimal harm
2022-10-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-01-11
F · Potential for more than minimal harm
2022-10-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-11
F · Potential for more than minimal harm
2022-10-24
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-01-11
F · Potential for more than minimal harm
2022-10-24
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-01-11
E · Potential for more than minimal harm
2022-10-24
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-01-11
D · Potential for more than minimal harm
2022-10-24
K321 · Smoke Deficiencies
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
D · Potential for more than minimal harm
2022-10-24
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-01-11
F · Potential for more than minimal harm
2021-05-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-08-26
F · Potential for more than minimal harm
2021-05-24
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2021-08-26
F · Potential for more than minimal harm
2021-05-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-08-26
F · Potential for more than minimal harm
2021-05-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-07-28
F · Potential for more than minimal harm
2021-05-24
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2021-08-26
E · Potential for more than minimal harm
2021-05-24
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2021-08-26
E · Potential for more than minimal harm
2021-05-24
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2021-08-26
E · Potential for more than minimal harm
2021-05-24
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-08-26
E · Potential for more than minimal harm
2021-05-24
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-08-26
E · Potential for more than minimal harm
2021-05-24
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-08-26
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-03-27
F761 · Pharmacy Service Deficiencies
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
D · Potential for more than minimal harm
2024-03-27
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-03-27
F623 · Resident Rights Deficiencies
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
D · Potential for more than minimal harm
2024-03-27
F625 · Resident Rights Deficiencies
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
D · Potential for more than minimal harm
2024-03-27
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-03-27
F657 · Resident Assessment and Care Planning Deficiencies
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
D · Potential for more than minimal harm
2024-03-27
F688 · Quality of Life and Care Deficiencies
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
E · Potential for more than minimal harm
2022-10-24
F755 · Pharmacy Service Deficiencies
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
D · Potential for more than minimal harm
2022-10-24
F656 · Resident Assessment and Care Planning Deficiencies
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
D · Potential for more than minimal harm
2022-10-24
F657 · Resident Assessment and Care Planning Deficiencies
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
D · Potential for more than minimal harm
2022-10-24
F688 · Quality of Life and Care Deficiencies
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
D · Potential for more than minimal harm
2022-10-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-11-30
D · Potential for more than minimal harm
2022-10-24
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2022-11-30
D · Potential for more than minimal harm
2021-05-24
F690 · Quality of Life and Care Deficiencies
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
What sits behind the stars
Ownership
Delmar Gardens Enterprises Inc
5% Or Greater Direct Ownership Interest · Organization
Goldberg-Nom LLC
5% Or Greater Indirect Ownership Interest · Organization
Grossberg, Gabe
5% Or Greater Indirect Ownership Interest · Individual
Grossberg, George
5% Or Greater Indirect Ownership Interest · Individual
Gabe Grossberg And George Grossberg, Trustees Of The Henry And Barbara
5% Or Greater Indirect Ownership Interest · Organization
George Grossberg And Gabe Grossberg, Trustees Of The Henry And Barbara
5% Or Greater Indirect Ownership Interest · Organization
Non-Gst Family Trust Est U/W Of Israel Goldberg Fbo Janice Bitanski
5% Or Greater Indirect Ownership Interest · Organization
Non-Gst Family Trust Established U/W Of Israel Goldberg Fbo Harry Zvi
5% Or Greater Indirect Ownership Interest · Organization
Non-Gstfamily Trust Est U/W Israel Goldberg Fbo Diane Fredman
5% Or Greater Indirect Ownership Interest · Organization
Allen, Kathryn
W-2 Managing Employee · Individual
Delmar Gardens Management Services Inc
Operational/Managerial Control · Organization
Grossberg, Gabe
Corporate Officer · Individual
Marx, Kenneth
Corporate Officer · Individual
Oppenheimer, Howard
Corporate Officer · Individual
Rodgers, Lynn
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Lakeview Village
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
#2
Delmar Gardens Of Overland Park
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
#3
Westchester Village Of Lenexa
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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