Delmar Gardens of Overland Park
12100 W 109th Street, Overland Park, KS 66210
Delmar Gardens of Overland Park is a nursing home in Overland Park, 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.
At a glance
- CMS overall star rating3 of 5
- Last standard health inspectionJanuary 28, 2026 (9 months ago)
- Health citations since September 15, 202250 (Kansas average 28)
- Fines in the past three years4, $23,261 in total
- CMS flagsNone listed by CMS
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CMS flags
CMS does not list this home as a Special Focus Facility or a candidate. CMS does not show an abuse icon for it. CMS lists no change of ownership in the past 12 months.
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.
Health inspection on June 30, 2026
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on July 30, 2026.
CMS update of May 27, 2026
Star rating
The CMS overall star rating changed from 1 of 5 to 3 of 5.
Star rating
The CMS health inspection star rating changed from 1 of 5 to 3 of 5.
CMS update of April 29, 2026
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
Health inspection on January 28, 2026
4 citationsCMS lists this as a standard inspection.
Show the 4 citations
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on March 12, 2026.
CMS has cited this home for F0812 3 times since 2022.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on March 12, 2026.
CMS has cited this home for F0684 2 times since 2024.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on March 12, 2026.
CMS has cited this home for F0695 2 times since 2024.
Citation F0699. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care or services that was trauma informed and/or culturally competent.
CMS lists it as corrected on March 12, 2026.
Fire safety inspection on January 28, 2026
11 citationsCMS lists this as a standard inspection.
Show the 11 citations
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 April 8, 2026.
CMS has cited this home for K0291 2 times since 2024.
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 April 8, 2026.
CMS has cited this home for K0345 2 times since 2024.
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 April 8, 2026.
CMS has cited this home for K0712 3 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 April 8, 2026.
CMS has cited this home for K0918 2 times since 2024.
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 April 8, 2026.
Citation K0321. Severity E: potential for more than minimal harm, pattern.
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 April 8, 2026.
CMS has cited this home for K0321 2 times since 2024.
Citation K0353. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on April 8, 2026.
CMS has cited this home for K0353 3 times since 2022.
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on April 8, 2026.
CMS has cited this home for K0363 2 times since 2024.
Citation K0372. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on April 8, 2026.
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 April 8, 2026.
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 April 8, 2026.
CMS has cited this home for K0920 3 times since 2022.
CMS update of November 20, 2025
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
CMS update of July 30, 2025
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
CMS update of April 30, 2025
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 staffing star rating changed from 1 of 5 to 2 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 September 26, 2024
Fine
CMS changed the fine from January 22, 2024 from $5,645 to $5,697.
CMS update of July 31, 2024
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
CMS update of June 26, 2024
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5.
CMS update of April 25, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
Health inspection on March 13, 2024
33 citationsCMS lists this as a standard inspection and a complaint inspection.
Show the 33 citations
Citation F0882. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
CMS lists it as corrected on April 26, 2024.
Citation F0943. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
CMS lists it as corrected on April 26, 2024.
Citation F0947. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
CMS lists it as corrected on April 26, 2024.
Citation F0565. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to organize and participate in resident/family groups in the facility.
CMS lists it as corrected on April 26, 2024.
Citation F0585. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on April 26, 2024.
CMS has cited this home for F0585 2 times since 2022.
Citation F0636. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
CMS lists it as corrected on April 26, 2024.
Citation F0689. Severity E: potential for more than minimal harm, pattern.
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 April 26, 2024.
CMS has cited this home for F0689 2 times since 2022.
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 April 26, 2024.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on April 26, 2024.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on April 26, 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 April 26, 2024.
CMS has cited this home for F0550 2 times since 2022.
Citation F0553. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
CMS lists it as corrected on April 26, 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 26, 2024.
Citation F0576. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure residents have reasonable access to and privacy in their use of communication methods.
CMS lists it as corrected on April 26, 2024.
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 26, 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 April 26, 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 April 26, 2024.
Citation F0637. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Assess the resident when there is a significant change in condition
CMS lists it as corrected on April 26, 2024.
Citation F0641. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on April 26, 2024.
CMS has cited this home for F0641 2 times since 2022.
Citation F0655. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS lists it as corrected on April 26, 2024.
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 April 26, 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 April 26, 2024.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on April 26, 2024.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on April 26, 2024.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on April 26, 2024.
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 April 26, 2024.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on April 26, 2024.
Citation F0697. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate pain management for a resident who requires such services.
CMS lists it as corrected on April 26, 2024.
Citation F0756. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on April 26, 2024.
CMS has cited this home for F0756 2 times since 2022.
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 26, 2024.
CMS has cited this home for F0757 2 times since 2022.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on April 26, 2024.
CMS has cited this home for F0758 2 times since 2022.
Citation F0806. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
CMS lists it as corrected on April 26, 2024.
Citation F0883. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on April 26, 2024.
Fire safety inspection on March 13, 2024
13 citationsCMS lists this as a standard inspection.
Show the 13 citations
Citation E0004. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop and maintain an Emergency Preparedness Program (EP).
CMS lists it as corrected on April 24, 2024.
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 May 23, 2024.
Citation K0293. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have properly located and lighted "Exit" signs.
CMS lists it as corrected on April 24, 2024.
Citation K0321. Severity F: potential for more than minimal harm, widespread.
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 May 23, 2024.
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 May 23, 2024.
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 23, 2024.
Citation K0355. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on April 22, 2024.
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 April 24, 2024.
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 May 23, 2024.
Citation K0741. Severity F: potential for more than minimal harm, widespread.
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 24, 2024.
Citation K0914. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
CMS lists it as corrected on May 23, 2024.
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 April 22, 2024.
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 May 23, 2024.
February 20, 2024
FineCMS fine of $6,369 on February 20, 2024.
February 12, 2024
FineCMS fine of $5,790 on February 12, 2024.
January 22, 2024
FineCMS fine of $5,698 on January 22, 2024.
December 26, 2023
FineCMS fine of $5,404 on December 26, 2023.
Health inspection on September 15, 2022
12 citationsCMS lists this as a standard inspection.
Show the 12 citations
Citation F0585. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on October 21, 2022.
Citation F0675. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor each resident's preferences, choices, values and beliefs.
CMS lists it as corrected on October 21, 2022.
Citation F0689. Severity E: potential for more than minimal harm, pattern.
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 October 21, 2022.
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 October 21, 2022.
Citation F0804. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS lists it as corrected on October 21, 2022.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on October 21, 2022.
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 October 21, 2022.
Citation F0641. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on October 21, 2022.
Citation F0740. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
CMS lists it as corrected on October 21, 2022.
Citation F0756. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on October 21, 2022.
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 October 21, 2022.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on October 21, 2022.
Fire safety inspection on September 15, 2022
3 citationsCMS lists this as a standard inspection.
Show the 3 citations
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 November 30, 2022.
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 November 30, 2022.
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 November 30, 2022.
CMS star ratings
- 3 of 5CMS overall star rating
- 3 of 5CMS health inspection star rating
- 4 of 5CMS staffing star rating
- 3 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (913) 469-4210
- Last standard health inspection
- January 28, 2026 (9 months ago)
- Certified beds
- 120
- Residents per day, on average
- 101
- Ownership type
- For profit - Limited Liability company
- Legal business name
- Delmar Gardens of Overland Park Operating LLC
- Chain
- Delmar Gardens
- Takes part in
- Medicare and Medicaid
More health citations than the Kansas average (50 vs 28).
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
Show 5 more
- 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 Overland Park last inspected?
CMS lists January 28, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Delmar Gardens of Overland Park have?
CMS lists 50 health citations since September 15, 2022. CMS also calls these deficiencies.
Has Delmar Gardens of Overland Park been fined?
CMS lists 4 fines in the past three years, $23,261 in total.
What is the CMS star rating of Delmar Gardens of Overland Park?
Its CMS overall star rating is 3 of 5.
Is Delmar Gardens of Overland Park a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.
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- Overland Park Post Acute
- Shawnee Post Acute Rehabilitation Center
- Stratford Commons Rehab & Health Care Center
- Swan Health at Overland Park