Delmar Gardens of Lenexa
9701 Monrovia Street, Lenexa, KS 66215
Delmar Gardens of Lenexa is a nursing home in Lenexa, Kansas. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 4 of 5CMS overall star rating
- 4 of 5CMS health inspection star rating
- 3 of 5CMS staffing star rating
- 2 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (913) 492-1130
- Last standard health inspection
- March 18, 2026 (7 months ago)
- Certified beds
- 222
- Residents per day, on average
- 163.8
- Ownership type
- For profit - Limited Liability company
- Legal business name
- Delmar Gardens of Lenexa Operating, LLC
- Chain
- Delmar Gardens
- Takes part in
- Medicare and Medicaid
Fewer health citations than the Kansas average (25 vs 28).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
CMS update of July 29, 2026
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
2 citations
Health inspection on June 8, 2026
CMS lists this as a complaint inspection.
Citation F0582. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
CMS lists it as corrected on June 26, 2026.
CMS has cited this home for F0582 2 times since 2026.
Citation F0627. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
CMS lists it as corrected on June 26, 2026.
CMS update of May 27, 2026
Star rating
The CMS overall star rating changed from 5 of 5 to 4 of 5.
Star rating
The CMS health inspection star rating changed from 5 of 5 to 4 of 5.
CMS update of April 29, 2026
Star rating
The CMS overall star rating changed from 4 of 5 to 5 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
10 citations
Health inspection on March 18, 2026
CMS lists this as a standard inspection.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on April 29, 2026.
CMS has cited this home for F0761 2 times since 2024.
Citation F0558. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on April 29, 2026.
Citation F0582. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
CMS lists it as corrected on April 29, 2026.
Citation F0583. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Keep residents' personal and medical records private and confidential.
CMS lists it as corrected on April 29, 2026.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on April 29, 2026.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on April 29, 2026.
Citation F0693. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
CMS lists it as corrected on April 29, 2026.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on April 29, 2026.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on April 29, 2026.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on April 29, 2026.
CMS update of February 25, 2026
Star rating
The CMS staffing star rating changed from 4 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 1 of 5 to 2 of 5.
Staffing
Total nurse staffing reported to CMS went from 3.7 to 0.2 hours per resident per day.
CMS update of July 30, 2025
Star rating
The CMS overall star rating changed from 5 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 1 of 5.
Health citation
CMS removed citation F0623 from the health inspection on March 27, 2024.
Health citation
CMS removed citation F0625 from the health inspection on March 27, 2024.
CMS update of April 30, 2025
Star rating
The CMS overall star rating changed from 4 of 5 to 5 of 5.
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 1 of 5 to 2 of 5.
CMS update of February 26, 2025
Star rating
The CMS health inspection star rating changed from 4 of 5 to 5 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
CMS update of October 30, 2024
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
CMS update of July 31, 2024
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
7 citations
Health inspection on March 27, 2024
CMS lists this as a standard inspection.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on May 3, 2024.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on May 3, 2024.
Citation F0623. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
CMS lists it as corrected on May 3, 2024.
Citation F0625. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on May 3, 2024.
Citation F0645. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
PASARR screening for Mental disorders or Intellectual Disabilities
CMS lists it as corrected on May 3, 2024.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on May 3, 2024.
CMS has cited this home for F0657 2 times since 2022.
Citation F0688. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on May 3, 2024.
CMS has cited this home for F0688 2 times since 2022.
12 citations
Fire safety inspection on March 27, 2024
CMS lists this as a standard inspection.
Citation K0324. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on May 22, 2024.
CMS has cited this home for K0324 2 times since 2021.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on May 22, 2024.
CMS has cited this home for K0353 3 times since 2021.
Citation K0363. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on May 22, 2024.
CMS has cited this home for K0363 2 times since 2022.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on May 22, 2024.
CMS has cited this home for K0918 3 times since 2021.
Citation K0222. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on May 22, 2024.
CMS has cited this home for K0222 2 times since 2022.
Citation K0511. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on May 22, 2024.
CMS has cited this home for K0511 3 times since 2021.
Citation K0920. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on May 22, 2024.
CMS has cited this home for K0920 2 times since 2022.
Citation K0355. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on May 22, 2024.
CMS has cited this home for K0355 2 times since 2022.
Citation K0372. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on May 22, 2024.
CMS has cited this home for K0372 2 times since 2022.
Citation K0741. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
CMS lists it as corrected on May 22, 2024.
Citation K0753. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have restrictions on the use of highly flammable decorations.
CMS lists it as corrected on May 22, 2024.
Citation K0923. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on May 22, 2024.
CMS has cited this home for K0923 3 times since 2021.
CMS update of January 31, 2024
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
6 citations
Health inspection on October 24, 2022
CMS lists this as a standard inspection.
Citation F0755. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on November 30, 2022.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on November 30, 2022.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on November 30, 2022.
Citation F0688. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on November 30, 2022.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on November 30, 2022.
Citation F0745. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide medically-related social services to help each resident achieve the highest possible quality of life.
CMS lists it as corrected on November 30, 2022.
21 citations
Fire safety inspection on October 24, 2022
CMS lists this as a standard inspection.
Citation E0006. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct risk assessment and an All-Hazards approach.
CMS lists it as corrected on January 11, 2023.
Citation E0013. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop Emergency Preparedness policies and procedures.
CMS lists it as corrected on January 11, 2023.
Citation K0211. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on January 11, 2023.
Citation K0222. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on January 11, 2023.
Citation K0255. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that suites are correctly sub-divided by noncombustible or limited-combustible construction.
CMS lists it as corrected on January 11, 2023.
Citation K0291. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on January 11, 2023.
Citation K0343. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
CMS lists it as corrected on January 11, 2023.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on January 11, 2023.
Citation K0346. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
CMS lists it as corrected on January 11, 2023.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on January 11, 2023.
Citation K0362. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
CMS lists it as corrected on January 11, 2023.
Citation K0363. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on January 11, 2023.
Citation K0372. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on January 11, 2023.
Citation K0511. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on January 11, 2023.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on January 11, 2023.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on January 11, 2023.
Citation K0920. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on January 11, 2023.
Citation K0923. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on January 11, 2023.
Citation K0374. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install smoke barrier doors that can resist smoke for at least 20 minutes.
CMS lists it as corrected on January 11, 2023.
Citation K0321. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on January 11, 2023.
Citation K0355. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on January 11, 2023.
10 citations
Fire safety inspection on May 24, 2021
CMS lists this as a standard inspection.
Citation K0324. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on August 26, 2021.
Citation K0347. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Properly provide smoke detection systems in areas open to corridors.
CMS lists it as corrected on August 26, 2021.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on August 26, 2021.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on July 28, 2021.
Citation K0926. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
CMS lists it as corrected on August 26, 2021.
Citation K0161. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Use approved construction type or materials.
CMS lists it as corrected on August 26, 2021.
Citation K0351. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install an approved automatic sprinkler system.
CMS lists it as corrected on August 26, 2021.
Citation K0511. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on August 26, 2021.
Citation K0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on August 26, 2021.
Citation K0923. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on August 26, 2021.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- DELMAR GARDENS ENTERPRISES INC5% or greater direct ownership interest · 100% · since 03/11/2003
- GABE GROSSBERG AND GEORGE GROSSBERG, TRUSTEES OF THE HENRY AND BARBARA5% or greater indirect ownership interest · 8% · since 03/11/2003
- GEORGE GROSSBERG AND GABE GROSSBERG, TRUSTEES OF THE HENRY AND BARBARA5% or greater indirect ownership interest · 8% · since 03/11/2003
- GOLDBERG-NOM LLC5% or greater indirect ownership interest · 25% · since 03/11/2003
- NON-GST FAMILY TRUST EST U/W OF ISRAEL GOLDBERG FBO JANICE BITANSKI5% or greater indirect ownership interest · 6% · since 04/10/2013
- NON-GST FAMILY TRUST ESTABLISHED U/W OF ISRAEL GOLDBERG FBO HARRY ZVI5% or greater indirect ownership interest · 6% · since 04/10/2013
- NON-GSTFAMILY TRUST EST U/W ISRAEL GOLDBERG FBO DIANE FREDMAN5% or greater indirect ownership interest · 6% · since 04/10/2013
- GROSSBERG, GABE5% or greater indirect ownership interest · 16% · since 03/11/2003
- GROSSBERG, GEORGE5% or greater indirect ownership interest · 11% · since 03/11/2003
- DELMAR GARDENS MANAGEMENT SERVICES INCOperational/managerial control · not applicable · since 04/01/2005
Questions
When was Delmar Gardens of Lenexa last inspected?
CMS lists March 18, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Delmar Gardens of Lenexa have?
CMS lists 25 health citations since October 24, 2022. CMS also calls these deficiencies.
Has Delmar Gardens of Lenexa been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Delmar Gardens of Lenexa?
Its CMS overall star rating is 4 of 5.
Is Delmar Gardens of Lenexa a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.