Westchester Village of Lenexa
Lenexa, Kansas · CCN 175536
10 surveys since 2014, 6 of them producing a finding at harm level or worse.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 87
- Surveys
- 10
- Harm or worse
- 6
- Immediate jeopardy
- 4
Findings at the most serious level CMS records.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 34
- Ownership
- For profit - Corporation
- Chain
- PIVOTAL HEALTH CARE
- County
- Johnson
- Medicare-certified since
- 2013
CMS ratings
- Overall
- 4
- Health inspection
- 4
- Staffing
- 4
- Quality measures
- 2
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded fewer weighted findings than most of its peer group.
Weighted by harm level, against 108 for-profit facilities with fewer than 66 beds in Kansas.
Last survey on record
Mar 19, 2025
600 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 5.11 | 3.78 |
| Registered-nurse hours per resident day | 1.22 | — |
| Annual nurse turnover | 57.8% | 50.0% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
No fines, payment denials or special-focus designation on the current CMS record.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D2090.9% | E14.5% | F14.5% |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F5502×
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- F6842×
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- F6892×
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F7572×
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- F8832×
Develop and implement policies and procedures for flu and pneumonia vaccinations.
In the surveyor’s words
From the most serious findings on record at Westchester Village of Lenexa, in the surveyor’s own words.
- No harm, potential for more than minimal, widespreadF942Mar 19, 2025
The facility identified a census of 26 residents. Based on record review and interviews, the facility failed to ensure agency staff received the required resident rights training. This placed the residents at risk for impaired care and decreased quality of life. Findings included: - On 03/19/25 at 08:40 AM a review of the training provided by the facility for agency Certified Nurse Aide (CNA) N, CNA O, CNA P, and Certified Medication Aide (CMA) R revealed the following: The facility was unable to provide documentation of CNA N had completed on resident rights training. The facility was unable to provide documentation of CNA O had completed on resident rights training. The facility was unable to provide documentation of CNA P had completed on resident rights training. […]
- No harm, potential for more than minimal, patternF679Jul 12, 2023
The facility identified a census of 35. The sample included 12 residents. Based on interview and record review, the facility failed to provide activities on the weekends which reflected the residents' interests, and preferences. This placed the residents at risk for boredom, isolation, and decreased quality of life. Findings included: - Review of the facility's activity calendars for April 2023 and May 2023 revealed each Saturday had activities of snacks and chat, and family visits except for 04/08/23 when an Easter egg hunt and a musical Yakety [NAME] Quartet was provided. The activity calendar for April, May, and June 2023 revealed no activities scheduled on any Sunday except afternoon church services. […]
- No harm, potential for more than minimal, isolatedF550Mar 19, 2025
The facility identified a census of 26 residents. The sample included 12 residents with one resident reviewed for dignity. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 19 was appropriately clothed when his bare thigh and leg were showing, and his door was left open. This deficient practice placed R19 at risk for impaired dignity and decreased psychosocial well-being. Findings included: - R19's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of cognitive communication deficient (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), difficulty in walking, hypertension (high blood pressure), transient ischemic attack (TIA - temporary episode of inadequate… […]
- No harm, potential for more than minimal, isolatedF580Mar 19, 2025
The facility identified a census of 26 residents. The sample included 12 residents. Based on record review, interview, and observation, the facility failed to ensure the physician was notified of Resident (R) 2's daily weights that were missed or notified related to weight gain which could lead to fluid overload. The facility further failed to notify R15's physician related to his blood sugar monitoring. This deficient practice placed the residents at risk for further decline and a delay in treatment. […]
- No harm, potential for more than minimal, isolatedF625Mar 19, 2025
The facility identified a census of 26 residents. The sample included 12 residents, with one resident sampled for discharge. Based on observation, record review, and interview, the facility failed to provide a bed hold with the required information to Resident (R) 7 or to their family representative when R7 was transferred to the hospital. This deficient practice placed R7 at risk for impaired ability to return to the facility or his same room. Finding include: - The electronic medical record (EMR) documented diagnoses of malnutrition (not enough calories to maintain), chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), hypertension (high blood pressure), depression (a… […]
Read 26 findings in full →The most serious and the most recent: 26 of 87 on record.
Every survey on record
FindingsAt actual harm or above
- Mar 19, 2025Standard and complaint8 findings
- Jul 12, 2023Standard7 findings
- Dec 30, 2021Standard7 findings
- Dec 1, 2020Infection control1 finding · 1 harm
- Feb 11, 2020Complaint1 finding · 1 harm
- Jan 22, 2020Standard and complaint5 findings
- Feb 9, 2019Standard6 findings
- Mar 22, 2018Standard and complaint8 findings
Show the 2 earlier surveys
- Jan 27, 2016Standard and complaint31 findings · 4 harm
- Oct 6, 2014Standard and complaint13 findings
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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