A list of the most recent deficiencies for Delmar Gardens of Lenexa. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-12-07 | 2023-01-11 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-12-07 | 2023-01-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-12-07 | 2023-01-11 | N |
| 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. | Fire Safety | 2022-12-07 | 2023-01-11 | N |
| Ensure that suites are correctly sub-divided by noncombustible or limited-combustible construction. | Fire Safety | 2022-12-07 | 2023-01-11 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-12-07 | 2023-01-11 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-12-07 | 2023-01-11 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2022-12-07 | 2023-01-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-07 | 2023-01-11 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-12-07 | 2023-01-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-07 | 2023-01-11 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-12-07 | 2023-01-11 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-12-07 | 2023-01-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-12-07 | 2023-01-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-12-07 | 2023-01-11 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-12-07 | 2023-01-11 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-12-07 | 2023-01-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-07 | 2023-01-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-07 | 2023-01-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-12-07 | 2023-01-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-12-07 | 2023-01-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-24 | 2022-11-30 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-10-24 | 2022-11-30 | N |
| 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. | Health | 2022-10-24 | 2022-11-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-24 | 2022-11-30 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-10-24 | 2022-11-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-10-24 | 2022-11-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-01 | 2022-01-05 | Y |
| Use approved construction type or materials. | Fire Safety | 2021-07-28 | 2021-08-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-07-28 | 2021-08-26 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2021-07-28 | 2021-08-26 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-07-28 | 2021-08-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-28 | 2021-08-26 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-07-28 | 2021-08-26 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-07-28 | 2021-08-26 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-07-28 | 2021-08-26 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2021-07-28 | 2021-08-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-07-28 | 2021-07-28 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-05-24 | 2021-06-22 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2019-09-23 | 2019-11-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-09-23 | 2019-11-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-23 | 2019-11-05 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-09-23 | 2019-11-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-23 | 2019-11-05 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-09-23 | 2019-11-05 | N |
| 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. | Health | 2019-09-23 | 2019-11-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-23 | 2019-11-05 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-09-23 | 2019-11-05 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-09-23 | 2019-11-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-23 | 2019-11-05 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-09-23 | 2019-11-05 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-09-23 | 2019-11-05 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2019-07-12 | 2019-08-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-12 | 2019-08-08 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-07-12 | 2019-08-08 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-07-12 | 2019-08-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-07-12 | 2019-08-08 | N |
