Facility WatchInspection records for every certified US nursing home
Delmar Gardens of Overland Park
12100 W 109th Street Overland Park, KS 66210 (913) 469-4210
CCN
175182
Certified beds
120
Ownership
For profit - Limited Liability company
Chain
Delmar Gardens
Nurse staffing
3.92
Total nurse staffing hours per resident per day, case-mix adjusted
Registered nurses: 0.59 hours per resident per day
Nursing staff turnover: 40% a year
Derived by CMS from the Payroll-Based Journal and refreshed quarterly.
Inspection history
Inspected January 28, 2026
4 citations · Health
D
F0684No actual harm with potential for more than minimal harm · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected March 12, 2026
D
F0695No actual harm with potential for more than minimal harm · Isolated
Provide safe and appropriate respiratory care for a resident when needed.
Deficient, Provider has date of correction · corrected March 12, 2026
D
F0699No actual harm with potential for more than minimal harm · Isolated
Provide care or services that was trauma informed and/or culturally competent.
Deficient, Provider has date of correction · corrected March 12, 2026
F
F0812No actual harm with potential for more than minimal harm · Widespread
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected March 12, 2026
Inspected March 13, 2024
33 citations · from a complaint investigation · Health
D
F0550No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Deficient, Provider has date of correction · corrected April 26, 2024
D
F0553No actual harm with potential for more than minimal harm · Isolated
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Deficient, Provider has date of correction · corrected April 26, 2024
D
F0558No actual harm with potential for more than minimal harm · Isolated
Reasonably accommodate the needs and preferences of each resident.
Deficient, Provider has date of correction · corrected April 26, 2024
D
F0576No actual harm with potential for more than minimal harm · Isolated
Ensure residents have reasonable access to and privacy in their use of communication methods.
Deficient, Provider has date of correction · corrected April 26, 2024
D
F0582No actual harm with potential for more than minimal harm · Isolated
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Deficient, Provider has date of correction · corrected April 26, 2024
D
F0623No actual harm with potential for more than minimal harm · Isolated
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Deficient, Provider has date of correction · corrected April 26, 2024
D
F0625No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected April 26, 2024
D
F0637No actual harm with potential for more than minimal harm · Isolated
Assess the resident when there is a significant change in condition
Deficient, Provider has date of correction · corrected April 26, 2024
D
F0641No actual harm with potential for more than minimal harm · Isolated
Ensure each resident receives an accurate assessment.
Deficient, Provider has date of correction · corrected April 26, 2024
D
F0655No actual harm with potential for more than minimal harm · Isolated
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Deficient, Provider has date of correction · corrected April 26, 2024
D
F0656No actual harm with potential for more than minimal harm · Isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected April 26, 2024
D
F0657No actual harm with potential for more than minimal harm · Isolated
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Deficient, Provider has date of correction · corrected April 26, 2024
D
F0677No actual harm with potential for more than minimal harm · Isolated
Provide care and assistance to perform activities of daily living for any resident who is unable.
Deficient, Provider has date of correction · corrected April 26, 2024
D
F0684No actual harm with potential for more than minimal harm · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected April 26, 2024
D
F0686No actual harm with potential for more than minimal harm · Isolated
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has date of correction · corrected April 26, 2024
D
F0688No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected April 26, 2024
D
F0695No actual harm with potential for more than minimal harm · Isolated
Provide safe and appropriate respiratory care for a resident when needed.
Deficient, Provider has date of correction · corrected April 26, 2024
D
F0697No actual harm with potential for more than minimal harm · Isolated
Provide safe, appropriate pain management for a resident who requires such services.
Deficient, Provider has date of correction · corrected April 26, 2024
D
F0756No actual harm with potential for more than minimal harm · Isolated
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Deficient, Provider has date of correction · corrected April 26, 2024
D
F0757No actual harm with potential for more than minimal harm · Isolated
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Deficient, Provider has date of correction · corrected April 26, 2024
D
F0758No actual harm with potential for more than minimal harm · Isolated
Implement 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.
Deficient, Provider has date of correction · corrected April 26, 2024
D
F0806No actual harm with potential for more than minimal harm · Isolated
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Deficient, Provider has date of correction · corrected April 26, 2024
D
F0883No actual harm with potential for more than minimal harm · Isolated
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Deficient, Provider has date of correction · corrected April 26, 2024
E
F0565No actual harm with potential for more than minimal harm · Pattern
Honor the resident's right to organize and participate in resident/family groups in the facility.
Deficient, Provider has date of correction · corrected April 26, 2024
E
F0585No actual harm with potential for more than minimal harm · Pattern
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.
Deficient, Provider has date of correction · corrected April 26, 2024
E
F0636No actual harm with potential for more than minimal harm · Pattern
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Deficient, Provider has date of correction · corrected April 26, 2024
E
F0689No actual harm with potential for more than minimal harm · Pattern
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected April 26, 2024
E
F0755No actual harm with potential for more than minimal harm · Pattern
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected April 26, 2024
E
F0812No actual harm with potential for more than minimal harm · Pattern
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected April 26, 2024
E
F0880No actual harm with potential for more than minimal harm · Pattern
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected April 26, 2024
F
F0882No actual harm with potential for more than minimal harm · Widespread
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Deficient, Provider has date of correction · corrected April 26, 2024
F
F0943No actual harm with potential for more than minimal harm · Widespread
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Deficient, Provider has date of correction · corrected April 26, 2024
F
F0947No actual harm with potential for more than minimal harm · Widespread
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Deficient, Provider has date of correction · corrected April 26, 2024
Inspected September 15, 2022
12 citations · Health
D
F0550No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Deficient, Provider has date of correction · corrected October 21, 2022
D
F0641No actual harm with potential for more than minimal harm · Isolated
Ensure each resident receives an accurate assessment.
Deficient, Provider has date of correction · corrected October 21, 2022
D
F0740No actual harm with potential for more than minimal harm · Isolated
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Deficient, Provider has date of correction · corrected October 21, 2022
D
F0756No actual harm with potential for more than minimal harm · Isolated
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Deficient, Provider has date of correction · corrected October 21, 2022
D
F0757No actual harm with potential for more than minimal harm · Isolated
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Deficient, Provider has date of correction · corrected October 21, 2022
D
F0758No actual harm with potential for more than minimal harm · Isolated
Implement 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.
Deficient, Provider has date of correction · corrected October 21, 2022
E
F0585No actual harm with potential for more than minimal harm · Pattern
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.
Deficient, Provider has date of correction · corrected October 21, 2022
E
F0675No actual harm with potential for more than minimal harm · Pattern
Honor each resident's preferences, choices, values and beliefs.
Deficient, Provider has date of correction · corrected October 21, 2022
E
F0689No actual harm with potential for more than minimal harm · Pattern
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected October 21, 2022
E
F0761No actual harm with potential for more than minimal harm · Pattern
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.
Deficient, Provider has date of correction · corrected October 21, 2022
E
F0804No actual harm with potential for more than minimal harm · Pattern
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Deficient, Provider has date of correction · corrected October 21, 2022
E
F0812No actual harm with potential for more than minimal harm · Pattern
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected October 21, 2022