DELMAR GARDENS OF LENEXA
Address
9701 MONROVIA ST
LENEXA, KS 66215
(913) 492-1130
Nursing Home Ratings
Health Inspections | |
Quality Measures | |
Nursing Staff | |
R.N. Staff Only | |
Overall Rating |
Percent of Beds Occupied
Number of Residents and Certified Beds
- Residents: 194
- Certified Beds: 250
This Facility Accepts
- Medicare
- Medicaid
Operational Details
- Operated By For Profit - Corporation
- Offers Both Resident and Family Counseling Services
- This Facility is Part of a Chain or Franchise
Resident Services
The information below lists services this facility has provided for residents from October through December 2010. During this period, the most common type of service provided was "Very High Rehabilitation". To get a better idea of the types of services that are commonly performed, compare the "Percent of Service Days" column below. These services are based on submitted claims to Medicare and do not provide a complete overview of all the services provided by Delmar Gardens of Lenexa. For more information read our guide on how nursing facilities are reimbursed, types of services, and ADL index scores.
Resident Services | Resident Conditions | Percent of Service Days |
Ultra-High Rehabilitation
- At least one rehabilitation discipline five days/week
- A second rehabilitation discipline three days/week
ADL Index Range: 11-16 | 2.7% |
ADL Index Range: 6-10 | 10.1% |
Total Percent: | 12.8% |
Very High Rehabilitation
- At least one rehabilitation discipline five days/week
ADL Index Range: 11-16 | 10.7% |
ADL Index Range: 6-10 | 29.1% |
ADL Index Range: 0-5 | 5.0% |
Total Percent: | 44.8% |
High Rehabilitation
- At least one rehabilitation discipline five days/week
ADL Index Range: 11-16 | 5.3% |
ADL Index Range: 6-10 | 7.1% |
ADL Index Range: 0-5 | 4.5% |
Total Percent: | 16.9% |
Medium Rehabilitation
- Five days any combination of three rehabilitation disciplines
ADL Index Range: 6-10 | 4.5% |
Total Percent: | 4.5% |
Special Care High
- Comatose
- Septicemia
- Diabetes with daily injections and a change of order two or more days
- Quadriplegia with ADL score greater or equal to 5
- Chronic Obstructive Pulmonary Disease (COPD) and shortness of breath when lying flat
- Fever with pneumonia, or vomiting, or weight loss, or feeding tube
- Parenteral/IV feedings
- Respiratory therapy for 7 days
- Activities of Daily Living (ADL) score of 2 or more
ADL Index Range: 6-10 - No Signs of depression | 5.3% |
Total Percent: | 5.3% |
Special Care Low
- Cerebral palsy, multiple sclerosis, or Parkinson's disease with ADL score greater or equal to 5
- Respiratory failure and oxygen therapy while a resident
- Feeding tube where calories >= 51% or calories are in the range of 26-50% and fluid >= 501 mL)
- Ulcers: 2 or more stage II or 1 or more stage III or IV pressure ulcers
- Ulcers: 2 or more venous or arterial ulcers
- Ulcers: 1 stage II pressure ulcer and 1 venous or arterial ulcer with 2 or more skin care treatments
- Foot infection/diabetic foot ulcer/open lesions of foot with treatment
- Radiation therapy while a resident
- Dialysis while a resident
- Activities of Daily Living (ADL) score of 2 or more
ADL Index Range: 6-10 - No Signs of depression | 9.5% |
Total Percent: | 9.5% |
Clinically Complex
- Pneumonia, hemiplegia with ADL score >=5
- Surgical wounds or open lesions with treatment
- Burns
- Chemotherapy while a resident
- Oxygen therapy while a resident
- IV medications or transfusions while a resident
- Extensive Services, Special Care High or Special Care Low qualifier and ADL score of 0 or 1
ADL Index Range: 0-1 - No Signs of depression | 1.5% |
Total Percent: | 1.5% |
Behavioral Symptoms and Cognitive Performance
- Cognitive impairment BIMS score less than or equal to 9
- CPS great than or equal to 3
- Hallucinations or delusions
- Physical or verbal behavioral symptoms toward others
- Other behavioral symptoms
- Rejection of care or wandering
- Activities of Daily Living (ADL) score of 5 or less
ADL Index Range: 2-5 - Less restorative nursing | 1.2% |
Total Percent: | 1.2% |
Reduced Physical Function
- Urinary and/or bowel training program
- Passive and/or active range of motion (ROM)
- Amputation/prosthesis training
- Dressing or grooming training
- Eating or swallowing training
- Transfer training
- Splint or brace assistance
- Bed mobility and/or walking training
- Communication training
ADL Index Range: 6-10 - Less restorative nursing | 0.3% |
ADL Index Range: 2-5 - Less restorative nursing | 3.3% |
Total Percent: | 3.6% |
Rating Details For Delmar Gardens of Lenexa
Nursing Staff -
The nursing staff is the most important part of what determines the quality of care and comfort of a resident in a nursing home. Government regulations set expectations on time spent with each resident based on the services being provided. The breakdown below lists the nursing types (RN, LPN, LVN, CNA) and a comparison of the reported and expected hours per resident per day.
Nursing Hours Per Resident Per Day | Reported | Expected |
Registered Nurse (RN) Hours | 31 Minutes | 1 Hour and 11 Minutes |
Licensed Practical/Vocational Nurse (LPN/LVN) Hours | 28 Minutes | 42 Minutes |
Certified Nursing Assistant (CNA) Hours | 2 Hours and 27 Minutes | 2 Hours and 20 Minutes |
Total Licensed Nurse Hours | 59 Minutes | 1 Hour and 52 Minutes |
Total Nurse Hours | 3 Hours and 26 Minutes | 4 Hours and 12 Minutes |
Quality of Care -
Medicare determines quality of care ratings for nursing facilities by surveying several "quality measures", which are broken down into long-term and short-term stay residents, as well as if the action is preventive or if there is a deficiency in the quality of care. State averages for Kansas are also provided for comparison purposes. Note: Figures below are averaged over the past nine months.
This Facility | Kansas Average |
Long-Term Stay Preventive Actions
Percent of Long-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination | 70% | 91% |
Percent of Long-Stay Residents Given Influenza Vaccination During the Flu Season | 67% | 93% |
Long-Term Stay Deficiencies
Percent of Long-Stay Residents Who Have/Had a Catheter Inserted and Left in Their Bladder | 7% | 6% |
Percent of Long-Stay Residents Who Were Physically Restrained | 1% | 3% |
Percent of Long-Stay Residents Who Had a Urinary Tract Infection | 14% | 10% |
Percent of Long-Stay Residents Who Spend Most of Their Time in Bed or in a Chair | - | 3% |
Percent of Low-Risk Long-Stay Residents Who Have Pressure Sores | 1% | 4% |
Percent of Long-Stay Residents Whose Ability to Move About in and Around Their Room Got Worse | 9% | 11% |
Percent of Long-Stay Residents Who Lose Too Much Weight | 8% | 8% |
Percent of Long-Stay Residents Who Have Moderate to Severe Pain | 2% | 4% |
Percent of Long-Stay Residents Whose Need for Help with Daily Activities Has Increased | 10% | 14% |
Percent of Low-Risk Long-Stay Residents Who Lose Control of Their Bowels or Bladder | 46% | 44% |
Percent of Long-Stay Residents Who Are More Depressed or Anxious | 11% | 17% |
Percent of High-Risk Long-Stay Residents Who Have Pressure Sores | 11% | 10% |
Short-Term Stay Preventive Actions
Percent of Short-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination | 71% | 82% |
Percent of Short-Stay Residents Given Influenza Vaccination During the Flu Season | 76% | 86% |
Short-Term Stay Deficiencies
Percent of Short-Stay Residents Who Have Delirium | 5% | 4% |
Percent of Short-Stay Residents Who Have Pressure Sores | 9% | 10% |
Percent of Short-Stay Residents Who Had Moderate to Severe Pain | 37% | 20% |
Health Inspection Details -
All Medicare and/or Medicaid certified nursing home must undergo health inspections on average once a year, but may be more frequent if the facility is peforming poorly. These inspections cover most aspects of life in a nursing home, and are broken down into deficiencies types, which including: Pharmacy Service, Administration, Resident Rights, Nutrition and Dietary, Resident Assessment, Environmental, and Mistreatment. Below are the list of deficiencies found by inspectors in the past few years along with the degree of harm and how many residents may have been affected. Note: The most recent health survey was on 05/26/2010.
Degree of Harm
- - Potential for Minimal Harm
- - Minimal Harm or Potential for Harm
- - Resident Harmed
- - Immediate Jeopardy to Resident Health
Residents Affected
- - Isolated
- - Some Residents
- - Many Residents
Deficiencies Found By Inspectors | Degree of Harm | Residents Affected |
Administration
Get Proof That a Nurse Aide Has the Training and Skills That the State Requires.
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Have Licensed, Certified, or Registered Staff to Give Needed Services.
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Environmental
Provide Needed Housekeeping and Maintenance.
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Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents.
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Nutrition and Dietary
Store, Cook, and Give out Food in a Safe and Clean Way.
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Pharmacy Service
1) Make Sure That Residents Who Take Drugs Are Not Given Too Many Doses or for Too Long; 2) Make Sure That the Use of Drugs is Carefully Watched; or 3) Stop or Change Drugs That Cause Unwanted Effects.
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Have Drugs and Other Similar Products Available, Which Are Needed Every Day and in Emergencies, and Give Them out Properly.
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At Least Once a Month, Have a Licensed Pharmacist Check the Drugs That Each Resident Takes.
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Quality Care
Provide Activities to Meet the Needs of Each Resident.
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Provide Social Services for Related Medical Problems to Help Each Resident Achieve the Highest Possible Quality of Life.
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Give Professional Services That Meet a Professional Standard of Quality.
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Properly Care for Residents Needing Special Services, Including: Injections, Colostomy, Ureostomy, Ileostomy, Tracheostomy Care, Tracheal Suctioning, Respiratory Care, Foot Care, and Prostheses.
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Give Professional Services That Meet a Professional Standard of Quality.
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Resident Assessment
Make a Complete Assessment That Covers All Questions for Areas That Are Listed in Official Regulations.
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Check and Update (If Needed) Each Resident's Assessment Every 3 Months.
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Develop a Complete Care Plan That Meets All of a Resident's Needs, with Timetables and Actions That Can Be Measured.
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1) Develop a Complete Care Plan Within 7 Days of Each Resident's Admission; 2) Prepare a Care Plan with the Care Team, Including the Primary Nurse, Doctor, Resident or Resident's Family or Representative; or 3) Check and Update the Care Plan.
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Keep Assessments Completed in the Preceding 15 Months in the Resident's Active Record.
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1) Develop a Complete Care Plan Within 7 Days of Each Resident's Admission; 2) Prepare a Care Plan with the Care Team, Including the Primary Nurse, Doctor, Resident or Resident's Family or Representative; or 3) Check and Update the Care Plan.
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Resident Rights
Tell Each Resident Who Can Get Medicaid Benefits About 1) Which Items and Services Medicaid Covers and Which the Resident Must Pay For; or 2) How to Apply for Medicaid, Along with the Names and Addresses of State Groups That Can Help.
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Deficiencies from Complaints and Incidents
The table below lists incident reports by the nursing staff or administration for Delmar Gardens of Lenexa, as well as complaints by residents or their family in the previous three years.
Degree of Harm
- - Potential for Minimal Harm
- - Minimal Harm or Potential for Harm
- - Resident Harmed
- - Immediate Jeopardy to Resident Health
Residents Affected
- - Isolated
- - Some Residents
- - Many Residents
Formal Complaints | Degree of Harm | Residents Affected |
Environmental
Make Sure That a Working Call System is Available in Each Resident's Room or Bathroom and Bathing Area.
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Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents.
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Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents.
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Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents.
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Mistreatment
Protect Residents from Mistreatment, Neglect, And/Or Theft of Personal Property.
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Nutrition and Dietary
Store, Cook, and Give out Food in a Safe and Clean Way.
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Pharmacy Service
Properly Mark Drugs and Other Similar Products.
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1) Make Sure That Residents Who Take Drugs Are Not Given Too Many Doses or for Too Long; 2) Make Sure That the Use of Drugs is Carefully Watched; or 3) Stop or Change Drugs That Cause Unwanted Effects.
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Quality Care
Give Each Resident Care and Services to Get or Keep the Highest Quality of Life Possible.
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Make Sure That Each Resident Who Enters the Nursing Home Without a Catheter is Not Given a Catheter, Unless It is Necessary.
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Give Residents Proper Treatment to Prevent New Bed (Pressure) Sores or Heal Existing Bed Sores.
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Develop/Implement Required Procedures for the Administration of Immunizations.
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Make Sure That Each Resident Who Enters the Nursing Home Without a Catheter is Not Given a Catheter, Unless It is Necessary.
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Make Sure That Residents Who Cannot Care for Themselves Receive Help with Eating/Drinking, Grooming and Hygiene.
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Resident Assessment
Make a Complete Assessment That Covers All Questions for Areas That Are Listed in Official Regulations.
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Develop a Complete Care Plan That Meets All of a Resident's Needs, with Timetables and Actions That Can Be Measured.
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Develop a Complete Care Plan That Meets All of a Resident's Needs, with Timetables and Actions That Can Be Measured.
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1) Develop a Complete Care Plan Within 7 Days of Each Resident's Admission; 2) Prepare a Care Plan with the Care Team, Including the Primary Nurse, Doctor, Resident or Resident's Family or Representative; or 3) Check and Update the Care Plan.
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Make a Complete Assessment That Covers All Questions for Areas That Are Listed in Official Regulations.
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Resident Rights
Tell Each Resident Who Can Get Medicaid Benefits About 1) Which Items and Services Medicaid Covers and Which the Resident Must Pay For; or 2) How to Apply for Medicaid, Along with the Names and Addresses of State Groups That Can Help.
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Fire Safety
Nursing homes certified by Medicare and/or Medicaid are required to have fire safety inspections to meet Life Safety Code (LSC) standards. Below is a list of deficiencies that Delmar Gardens of Lenexa had in recent fire safety inspections. This information can be used to see if all standards were met, the degree of harm, the number of residents affected, and the date when deficiencies were corrected. Note: The most recent fire safety survey was on 03/15/2010.
Degree of Harm
- - Potential for Minimal Harm
- - Minimal Harm or Potential for Harm
- - Resident Harmed
- - Immediate Jeopardy to Resident Health
Residents Affected
- - Isolated
- - Some Residents
- - Many Residents
Deficiencies Found By Inspectors | Degree of Harm | Residents Affected |
Automatic Sprinkler Systems
Automatic Sprinkler Systems That Have Been Maintained in Working Order.
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Back-Up Procedures in Place for a Faulty Automatic Sprinkler System.
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An Approved Automatic Sprinkler System Connected to the Fire Alarm System.
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Automatic Sprinkler Systems That Have Been Maintained in Working Order.
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Building Construction
Approved Construction Type or Materials.
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Building Service Equipment
Properly Constructed Linen or Trash Chutes.
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Corridor Walls and Doors
Corridor and Hallway Doors That Block Smoke.
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Corridor and Hallway Doors That Block Smoke.
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Corridor and Hallway Doors That Block Smoke.
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Electrical
Properly Installed Electrical Wiring and Equipment.
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Properly Installed Electrical Wiring and Equipment.
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Emergency Plans and Fire Drills
Record of Quarterly Fire Drills for Each Shift Under Varying Conditions.
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Record of Quarterly Fire Drills for Each Shift Under Varying Conditions.
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Exits and Egress
Exits That Are Accessible at All Times.
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Fire Alarm Systems
A Fire Alarm System That Can Be Heard Throughout the Facility.
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An Approved Installation, Maintenance and Testing Program for Fire Alarm Systems.
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An Approved Back-Up Procedure for a Faulty Fire Alarm System.
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Furnishings and Decorations
Restrictions on the Use of Highly Flammable Materials.
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Restrictions on the Use of Flammable Curtains.
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Hazardous Area
Construction That Can Resist Fire for One Hour or an Approved Fire Extinguishing System.
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Construction That Can Resist Fire for One Hour or an Approved Fire Extinguishing System.
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Medical Gases and Anesthetizing Areas
Proper Medical Gas Storage and Administration Areas.
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Smoke Compartmentation and Control
Walls or Barriers That Prevent Smoke from Passing Through and Would Resist Fire for at Least One Hour.
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Smoke Barrier Doors That Can Resist Smoke for at Least 20 Minutes.
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Smoke Barrier Doors That Can Resist Smoke for at Least 20 Minutes.
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Smoke Barrier Doors That Can Resist Smoke for at Least 20 Minutes.
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Smoking Regulations
Posted "No-Smoking" Signs in Areas Where Smoking is Not Permitted or Did Not Provide Ashtrays Where Smoking Was Allowed.
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