Delmar Gardens Of Lenexa
9701 Monrovia Street, Lenexa, KS 66215
Delmar Gardens Of Lenexa, a 222-bed for profit - corporation nursing facility in Lenexa, KS, holds a 4-star CMS overall rating - well above the 3.0-star national average, with nurse staffing below the national norm. No recent finding reached the actual-harm level.
CMS combines health inspections, nurse-staffing levels, and clinical quality measures into the overall star rating, read the components below; they often tell a sharper story than the headline.
Phone: 9134921130
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- 4 / 5
- Above average · CMS overall · nat'l 3.0
- 0.17
- Well below average · nurse hrs/day · nat'l 3.89
- 14
- Inspection findings
- $0
- Federal penalties (0)
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 175122
- Ownership
- For profit - Corporation
- Provider Type
- Medicare and Medicaid
- Beds
- 222
- Residents
- 175
- In Hospital
- No
- County
- Johnson
- Last Inspection
- Mar 27, 2024
Staffing Data
How the 0.17 total nursing hours per resident-day are staffed:
- RN Hours
- 0.02 (nat'l avg: 0.68)
- LPN Hours
- 0.04
- CNA Hours
- 0.11
- Total Nursing Hours
- 0.17 (nat'l avg: 3.89)
- PT Hours
- 0.05
What the CMS Record Reveals About Delmar Gardens Of Lenexa
Delmar Gardens Of Lenexa operates 222 certified beds in Lenexa, KS with approximately 175 residents currently in care, and carries a CMS overall rating of 4 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (5★), staffing levels (1★), and quality measures (2★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone, a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 14 deficiency records from recent surveys, all falling in the no-harm or minimal-harm bands of the CMS scope-and-severity grid. No fines or payment denials have been assessed against this provider, suggesting issues, if any, did not rise to the enforcement threshold. Staffing is reported at 0.17 total nursing hours per resident day (national average 3.89), with RN coverage at 0.02 per resident day, the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "For profit - Corporation" ownership and operating as a "Medicare and Medicaid" provider, Delmar Gardens Of Lenexa falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes, ratings and fines are lagging indicators of those upstream choices. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report, the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (14 most recent)
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.
Category: Pharmacy Service Deficiencies
Corrected: May 3, 2024
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.
Category: Quality of Life and Care Deficiencies
Corrected: May 3, 2024
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: May 3, 2024
PASARR screening for Mental disorders or Intellectual Disabilities
Category: Resident Assessment and Care Planning Deficiencies
Corrected: May 3, 2024
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.
Category: Resident Rights Deficiencies
Corrected: May 3, 2024
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category: Resident Rights Deficiencies
Corrected: May 3, 2024
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: May 3, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Nov 30, 2022
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 30, 2022
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 30, 2022
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.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 30, 2022
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Nov 30, 2022
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Nov 30, 2022
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 22, 2021
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 20.6% | Yes |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 1.4% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 2.2% | Yes |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 2.3% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 21.4% | Yes |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 5.2% | Yes |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 15.3% | Yes |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 2.2% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 6.9% | No |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 1.3% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 81.9% | No |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 13.2% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 85.0% | No |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 27.2% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 85.4% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 42.4% | No |
Penalty History
No penalties on record.
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Understanding Nursing Home Data
Frequently Asked Questions
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Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology - how this data is sourced, computed, and verified.
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