Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

DELMAR GARDENS OF LENEXA

LENEXA, KS · 222 certified beds · Last Life Safety survey March 27, 2024

CMS Certification Number 175122 · first certified January 1981

Ownership

Operated by DELMAR GARDENS · For profit - Limited Liability company

No change of ownership on CMS record since January 1, 2016, when the records begin.

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within KS

43 citations — more than 90% of the 296 certified nursing homes in KS. Compared within KS rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 12 citations; the earlier surveys in the window averaged 15.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Well past the typical window (November 2025 to January 2026), and past the point by which nine in ten KS facilities have been surveyed. This facility’s last Life Safety survey was March 2024. Facilities in KS are typically surveyed 20–22 months after the last one (median 21), measured over 298 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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8 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

2 of the 43 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 43 Life Safety citations above. The Physical Environment Index

F-0880 Provide and implement an infection prevention and control program.
F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

How that compares

Citations on file over three years

Compared with the median facility in KS, and nationally. Surveyors differ markedly between states, so the KS figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	43
Median facility in KS	27
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
May 24, 2021	10
October 24, 2022	21
March 27, 2024	12

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0353	Inspect, test, and maintain automatic sprinkler systems.	3	2024-03-27
K-0511	Have properly installed electrical wiring and gas equipment.	3	2024-03-27
K-0923	Have proper medical gas storage and administration areas.	3	2024-03-27
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	3	2024-03-27
K-0920	Ensure proper usage of power strips and extension cords.	2	2024-03-27
K-0222	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.	2	2024-03-27
K-0363	Install corridor and hallway doors that block smoke.	2	2024-03-27
K-0324	Provide properly protected cooking facilities.	2	2024-03-27

What the citations cover

Citations by CMS category

Smoke Deficiencies 19
Gas, Vacuum, and Electrical Systems Deficiencies 9
Egress Deficiencies 5
Miscellaneous Deficiencies 4
Other 6

Citations by CMS category
Category	Citations
Smoke Deficiencies	19
Gas, Vacuum, and Electrical Systems Deficiencies	9
Egress Deficiencies	5
Miscellaneous Deficiencies	4
Services Deficiencies	3
Emergency Preparedness Deficiencies	2
Construction Deficiencies	1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

March 27, 2024 — 12 citations

Citations issued on March 27, 2024
Tag	What the surveyor checks	Status
K-0222	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.	Deficient, Provider has date of correction (May 22, 2024)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (May 22, 2024)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (May 22, 2024)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (May 22, 2024)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (May 22, 2024)
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	Deficient, Provider has date of correction (May 22, 2024)
K-0511	Have properly installed electrical wiring and gas equipment.	Deficient, Provider has date of correction (May 22, 2024)
K-0741	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	Deficient, Provider has date of correction (May 22, 2024)
K-0753	Have restrictions on the use of highly flammable decorations.	Deficient, Provider has date of correction (May 22, 2024)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (May 22, 2024)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (May 22, 2024)
K-0923	Have proper medical gas storage and administration areas.	Deficient, Provider has date of correction (May 22, 2024)

October 24, 2022 — 21 citations

Citations issued on October 24, 2022
Tag	What the surveyor checks	Status
E-0006	Conduct risk assessment and an All-Hazards approach.	Deficient, Provider has date of correction (January 11, 2023)
E-0013	Develop Emergency Preparedness policies and procedures.	Deficient, Provider has date of correction (January 11, 2023)
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Waiver has been granted (January 11, 2023)
K-0222	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.	Deficient, Provider has date of correction (January 11, 2023)
K-0255	Ensure that suites are correctly sub-divided by noncombustible or limited-combustible construction.	Waiver has been granted (January 11, 2023)
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	Deficient, Provider has date of correction (January 11, 2023)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (January 11, 2023)
K-0343	Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.	Deficient, Provider has date of correction (January 11, 2023)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (January 11, 2023)
K-0346	Follow proper procedures when the fire alarm was out of service for more than 4 hours.	Deficient, Provider has date of correction (January 11, 2023)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (January 11, 2023)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (January 11, 2023)
K-0362	Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.	Deficient, Provider has date of correction (January 11, 2023)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (January 11, 2023)
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	Deficient, Provider has date of correction (January 11, 2023)
K-0374	Install smoke barrier doors that can resist smoke for at least 20 minutes.	Deficient, Provider has date of correction (January 11, 2023)
K-0511	Have properly installed electrical wiring and gas equipment.	Deficient, Provider has date of correction (January 11, 2023)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (January 11, 2023)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (January 11, 2023)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (January 11, 2023)
K-0923	Have proper medical gas storage and administration areas.	Deficient, Provider has date of correction (January 11, 2023)

May 24, 2021 — 10 citations

Citations issued on May 24, 2021
Tag	What the surveyor checks	Status
K-0161	Use approved construction type or materials.	Deficient, Provider has date of correction (August 26, 2021)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (August 26, 2021)
K-0347	Properly provide smoke detection systems in areas open to corridors.	Deficient, Provider has date of correction (August 26, 2021)
K-0351	Install an approved automatic sprinkler system.	Deficient, Provider has date of correction (August 26, 2021)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (August 26, 2021)
K-0511	Have properly installed electrical wiring and gas equipment.	Deficient, Provider has date of correction (August 26, 2021)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (August 26, 2021)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Waiver has been granted (July 28, 2021)
K-0923	Have proper medical gas storage and administration areas.	Deficient, Provider has date of correction (August 26, 2021)
K-0926	Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.	Deficient, Provider has date of correction (August 26, 2021)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.