Overland Park, KS

Delmar Gardens Of Overland Park

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

12100 W 109th Street, Overland Park, KS

(913) 469-4210

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Delmar Gardens

Operator or chain grouping

Approved since

1989-03-20

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.54

Registered nurse staffing

LPN hours / resident day

0.54

Licensed practical nurse staffing

Aide hours / resident day

2.24

Nurse aide staffing

Weekend hours

2.53

Weekend nurse staffing

RN turnover

21%

Annual RN turnover

Total nurse turnover

42%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	3.7	1.8 1.9 pts worse	1.9 1.8 pts worse	Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days	1.9	2.2 0.3 pts better	1.8 0.1 pts worse	Long Stay · 20240701-20250630
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	60.5%	91.8% 31.3 pts worse	93.4% 32.9 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	80.7%	95.5% 14.8 pts worse	95.5% 14.8 pts worse	Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury	3.9%	4.4% 0.5 pts better	3.3% 0.6 pts worse	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	2.4%	5.0% 2.6 pts better	5.4% 3 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication	22.3%	23.2% 0.9 pts better	19.6% 2.7 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication	14.2%	19.8% 5.6 pts better	16.7% 2.5 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	13.1%	18.4% 5.3 pts better	16.3% 3.2 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased	21.2%	18.8% 2.4 pts worse	14.9% 6.3 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.7%	1.8% 0.1 pts better	1.0% 0.7 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection	4.9%	3.1% 1.8 pts worse	1.7% 3.2 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	27.6%	23.2% 4.4 pts worse	19.8% 7.8 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers	4.5%	4.6% 0.1 pts better	5.1% 0.6 pts better	Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	13.4%	75.6% 62.2 pts worse	81.7% 68.3 pts worse	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit	4.1%	11.7% 7.6 pts better	12.0% 7.9 pts better	Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication	4.8%	2.2% 2.6 pts worse	1.6% 3.2 pts worse	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	27.1%	73.5% 46.4 pts worse	79.7% 52.6 pts worse	Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission	23.7%	23.0% 0.7 pts worse	23.9% 0.2 pts better	Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-03-13 · Fire 2024-03-13

33 health deficiencies

Top issue: Resident Rights (9 deficiencies)

13 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Cycle 2 Health 2022-09-15 · Fire 2022-09-15

12 health deficiencies

Top issue: Pharmacy Service (4 deficiencies)

3 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 3 Health 2021-04-15 · Fire 2021-04-15

8 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

12 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-03-13

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2024-04-24

F · Potential for more than minimal harm 2024-03-13

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2024-05-23

F · Potential for more than minimal harm 2024-03-13

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2024-04-24

F · Potential for more than minimal harm 2024-03-13

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 2024-05-23

F · Potential for more than minimal harm 2024-03-13

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-05-23

F · Potential for more than minimal harm 2024-03-13

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-05-23

F · Potential for more than minimal harm 2024-03-13

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2024-04-22

F · Potential for more than minimal harm 2024-03-13

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-04-24

F · Potential for more than minimal harm 2024-03-13

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-05-23

F · Potential for more than minimal harm 2024-03-13

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 2024-05-24

F · Potential for more than minimal harm 2024-03-13

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2024-05-23

F · Potential for more than minimal harm 2024-03-13

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-04-22

F · Potential for more than minimal harm 2024-03-13

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-05-23

F · Potential for more than minimal harm 2022-09-15

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-11-30

F · Potential for more than minimal harm 2022-09-15

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2022-11-30

F · Potential for more than minimal harm 2022-09-15

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2022-11-30

F · Potential for more than minimal harm 2021-04-15

K354 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Corrected 2021-07-20

F · Potential for more than minimal harm 2021-04-15

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2021-07-20

F · Potential for more than minimal harm 2021-04-15

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2021-07-20

F · Potential for more than minimal harm 2021-04-15

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2021-07-20

F · Potential for more than minimal harm 2021-04-15

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2021-07-20

F · Potential for more than minimal harm 2021-04-15

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2021-07-20

E · Potential for more than minimal harm 2021-04-15

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2021-07-20

E · Potential for more than minimal harm 2021-04-15

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2021-07-20

E · Potential for more than minimal harm 2021-04-15

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2021-07-20

E · Potential for more than minimal harm 2021-04-15

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2021-07-20

E · Potential for more than minimal harm 2021-04-15

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2021-07-20

E · Potential for more than minimal harm 2021-04-15

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 2021-07-20

Inspection history

Recent health citations

F · Potential for more than minimal harm 2024-03-13

F882 · Infection Control Deficiencies

Health

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Corrected 2024-04-26

F · Potential for more than minimal harm 2024-03-13

F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Corrected 2024-04-26

F · Potential for more than minimal harm 2024-03-13

F947 · Nursing and Physician Services Deficiencies

Health

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Corrected 2024-04-26

E · Potential for more than minimal harm 2024-03-13

F565 · Resident Rights Deficiencies

Health

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected 2024-04-26

E · Potential for more than minimal harm 2024-03-13

F585 · Resident Rights Deficiencies

Health

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected 2024-04-26

E · Potential for more than minimal harm 2024-03-13

F636 · Resident Assessment and Care Planning Deficiencies

Health

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Corrected 2024-04-26

E · Potential for more than minimal harm 2024-03-13

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 2024-04-26

E · Potential for more than minimal harm 2024-03-13

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 2024-04-26

E · Potential for more than minimal harm 2024-03-13

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-04-26

E · Potential for more than minimal harm 2024-03-13