Map showing the location of Delmar Gardens Of Overland Park in OVERLAND PARK, Kansas
12100 W 109TH STREET, OVERLAND PARK, KS, 66210

Overall Score

CMS Five-Star Quality Rating
1/5Much below averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • KansasLowest tier among peers294 rated homes · average 3.0★
  • Johnson CountyLowest tier among peers35 rated homes · average 2.7★
  • United StatesLowest tier among peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point1★−1.8 vs KS avg
  • StaffingCan add or remove a star3★−0.4 vs KS avg
  • Quality measuresCan add or remove a star3★−0.1 vs KS avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersKS avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover3★Above only 24% of peersKS avg3.4★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments3★Above only 35% of peersKS avg3.1★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff3.32hrsAbove only 13% of peersKS avg4.07Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.54hrsAbove only 32% of peersKS avg0.71Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better42%Above 67% of peersKS avg50%RN turnover21%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$23,261Above only 25% of peersKS avg$21,017Fines · denials4 · 0
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
53citations
3inspection dates
1actual harm (G–I)
0immediate jeopardy (J–L)
Mar 13, 2024most recent

Citations by monthApr 2021 – Mar 2024

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Mar 13, 202433 citationsCycle 1worst F · no actual harm
  1. F585Honor 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.Resident RightsE · patternCorrected Apr 26, 2024
  2. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Apr 26, 2024
  3. Ensure each resident’s drug regimen must be free from unnecessary drugs.Pharmacy ServiceD · isolatedCorrected Apr 26, 2024
  4. F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Apr 26, 2024
  5. F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningD · isolatedCorrected Apr 26, 2024
  6. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Apr 26, 2024
  7. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Apr 26, 2024
  8. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Apr 26, 2024
  9. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Apr 26, 2024
  10. F688Provide 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.Quality of Life and CareD · isolatedCorrected Apr 26, 2024
  11. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Apr 26, 2024
  12. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Apr 26, 2024
  13. F697Provide safe, appropriate pain management for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Apr 26, 2024
  14. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected Apr 26, 2024
  15. F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceD · isolatedCorrected Apr 26, 2024
  16. F758Implement 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.Pharmacy ServiceD · isolatedCorrected Apr 26, 2024
  17. F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Nutrition and DietaryD · isolatedCorrected Apr 26, 2024
  18. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Apr 26, 2024
  19. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Apr 26, 2024
  20. F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Infection ControlF · widespreadCorrected Apr 26, 2024
  21. F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlD · isolatedCorrected Apr 26, 2024
  22. F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.Freedom from Abuse, Neglect, and ExploitationF · widespreadCorrected Apr 26, 2024
  23. F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Nursing and Physician ServicesF · widespreadCorrected Apr 26, 2024
  24. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Apr 26, 2024
  25. F553Allow resident to participate in the development and implementation of his or her person-centered plan of care.Resident RightsD · isolatedCorrected Apr 26, 2024
  26. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Apr 26, 2024
  27. F565Honor the resident's right to organize and participate in resident/family groups in the facility.Resident RightsE · patternCorrected Apr 26, 2024
  28. F576Ensure residents have reasonable access to and privacy in their use of communication methods.Resident RightsD · isolatedCorrected Apr 26, 2024
  29. F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Resident RightsD · isolatedCorrected Apr 26, 2024
  30. 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.Resident RightsD · isolatedCorrected Apr 26, 2024
  31. F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsD · isolatedCorrected Apr 26, 2024
  32. F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Resident Assessment and Care PlanningE · patternCorrected Apr 26, 2024
  33. F637Assess the resident when there is a significant change in conditionResident Assessment and Care PlanningD · isolatedCorrected Apr 26, 2024
Sep 15, 202212 citationsCycle 2worst E · no actual harm
  1. F585Honor 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.Resident RightsE · patternCorrected Oct 21, 2022
  2. F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Quality of Life and CareD · isolatedCorrected Oct 21, 2022
  3. F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceD · isolatedCorrected Oct 21, 2022
  4. F758Implement 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.Pharmacy ServiceD · isolatedCorrected Oct 21, 2022
  5. F761Ensure 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.Pharmacy ServiceE · patternCorrected Oct 21, 2022
  6. F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected Oct 21, 2022
  7. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Oct 21, 2022
  8. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Oct 21, 2022
  9. Ensure each resident’s drug regimen must be free from unnecessary drugs.Pharmacy ServiceD · isolatedCorrected Oct 21, 2022
  10. F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Oct 21, 2022
  11. F675Honor each resident's preferences, choices, values and beliefs.Quality of Life and CareE · patternCorrected Oct 21, 2022
  12. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Oct 21, 2022
Apr 15, 20218 citationsCycle 3worst G · actual harm
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected May 7, 2021
  2. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected May 7, 2021
  3. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareG · isolatedCorrected May 7, 2021
  4. F761Ensure 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.Pharmacy ServiceD · isolatedCorrected May 7, 2021
  5. F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.EnvironmentalD · isolatedCorrected May 7, 2021
  6. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected May 7, 2021
  7. F693Ensure 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.Quality of Life and CareD · isolatedCorrected May 7, 2021
  8. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected May 7, 2021

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined3.32hrsAbove only 13% of peers−0.75 vs KS avg
  • Registered nursesRN hours only0.54hrsAbove only 32% of peers−0.17 vs KS avg
  • Licensed practical nursesLPN hours0.54hrs
  • Nurse aidesCNA hours2.24hrs
  • Weekend nursingAll staff on Saturdays and Sundays2.53hrs
  • Kansas average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better42%Above 67% of peersKS avg 50%
  • RN turnoverRegistered nurses only21%Not ranked by CMS
  • Administrators who leftIn the past year0Stable leadership
  • Occupancy120 certified beds · ~97 residents a day81%Above only 39% of peersKS avg 82%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $23,261In fines
  • 4Fines
  • 0Payment denials
  • $21,017KS avg in fines
Above only 25% of peersFewer fines than 25% of rated homes in Kansas

Actions on record

  1. Feb 20, 2024Civil money penalty$6,369
  2. Feb 12, 2024Civil money penalty$5,790
  3. Jan 22, 2024Civil money penalty$5,698
  4. Dec 26, 2023Civil money penalty$5,404

Ownership

As filed with CMS

Structure

Ownership type
For profit - Limited Liability company
Chain
Delmar Gardens14 facilities in the chain2.9★ chain average
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Delmar Gardens Enterprises INC
Indirect owners (5%+)
  • Gabe Grossberg and George Grossberg, Trustees of the Henry and Barbara
  • George Grossberg and Gabe Grossberg, Trustees of the Henry and Barbara
  • Goldberg-Nom LLC
  • Non-Gst Family Trust Est U/W of Israel Goldberg Fbo Janice Bitanski
  • Non-Gst Family Trust Established U/W of Israel Goldberg Fbo Harry Zvi
  • Non-Gstfamily Trust Est U/W Israel Goldberg Fbo Diane Fredman
  • Gabe Grossberg
  • George Grossberg
Operational or managerial control
  • Delmar Gardens Management Services INC
Corporate officers
  • Gabe Grossberg
  • Kenneth Marx
  • Howard Oppenheimer
Managing employees
  • Tammy Conekin
  • Amanda Hill

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 175182 · 12100 W 109TH STREET, OVERLAND PARK, KS, 66210.
  • Percentiles compare this facility with every rated nursing home in Kansas and Johnson County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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