01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-03-19 | 8 | 2025-03-19 | 3 |
| Cycle 2 | 2023-07-12 | 7 | 2023-07-12 | 10 |
| Cycle 3 | 2021-12-30 | 7 | 2021-12-30 | 14 |
CMS CCN 1755362026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Westchester Village Of Lenexa
8505 Pflumm Road · Lenexa, KS 66215 · Johnson County
Certified beds34CMS provider file
Recent citation rows49current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
49 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 11 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-03-19 · HEALTHF0550Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2025-05-02 · complaint2025-03-19 · HEALTHF0580Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Correction field: Deficient, Provider has date of correction · 2025-05-02 · complaint2025-03-19 · HEALTHF0625Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-05-02 · complaint2025-03-19 · HEALTHF0686Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2025-05-02 · complaint2025-03-19 · HEALTHF0690Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Correction field: Deficient, Provider has date of correction · 2025-05-02 · complaint2025-03-19 · HEALTHF0757Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Correction field: Deficient, Provider has date of correction · 2025-05-02 · complaint2025-03-19 · HEALTHF0883Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Correction field: Deficient, Provider has date of correction · 2025-05-02 · complaint2025-03-19 · HEALTHF0942Severity F · widespread; potential for more than minimal harm
Resident Rights Deficiencies
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Correction field: Deficient, Provider has date of correction · 2025-05-02 · complaint2025-03-19 · FIREK0324Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2025-05-012025-03-19 · FIREK0363Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Correction field: Deficient, Provider has date of correction · 2025-05-012025-03-19 · FIREK0372Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has date of correction · 2025-05-012023-07-12 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2023-07-202023-07-12 · HEALTHF0679Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
Correction field: Deficient, Provider has date of correction · 2023-07-202023-07-12 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2023-07-202023-07-12 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2023-07-202023-07-12 · HEALTHF0692Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Correction field: Deficient, Provider has date of correction · 2023-07-202023-07-12 · HEALTHF0758Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2023-07-202023-07-12 · HEALTHF0883Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Correction field: Deficient, Provider has date of correction · 2023-07-202023-07-12 · FIREK0211Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Correction field: Deficient, Provider has date of correction · 2023-09-142023-07-12 · FIREK0324Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2023-09-142023-07-12 · FIREK0353Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2023-09-142023-07-12 · FIREK0363Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Correction field: Deficient, Provider has date of correction · 2023-09-142023-07-12 · FIREK0372Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has date of correction · 2023-09-142023-07-12 · FIREK0511Severity D · isolated; potential for more than minimal harm
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Correction field: Deficient, Provider has date of correction · 2023-09-1403 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- SCENIC DEVELOPMENT LLCOrganization · DIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 12/16/2017
- SCENIC HOLDINGS LLCOrganization · DIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 12/31/2019
- 3RK, LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 01/01/2021
- 5 R CATTLE, LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 12/16/2017
- CADET INVESTMENT LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 12/16/2017
- LMRAY, LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 12/16/2017
- POKY - 5R LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 12/31/2019
- POKY FEEDERS INCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 12/16/2017
- WSG LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 12/16/2017
- ANDERSON, JORDANIndividual · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 10/01/2021
- ANDERSON, MARLENEIndividual · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 12/16/2017
- ANDERSON, WAYNEIndividual · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 12/16/2017
- GULLEDGE, SCOTTIndividual · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 12/16/2017
- GULLEDGE, TRAVISIndividual · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 10/01/2021
- HOWARD, STEVENIndividual · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 12/16/2017
- WOOD, GILBERTIndividual · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 12/16/2017
- PIVOTAL HEALTH CARE LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/16/2017
- SCENIC DEVELOPMENT LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/16/2017
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours5.11per resident day
RN hours1.22per resident day
Weekend nurse hours4.80per resident day
Staff turnover57.8%CMS reported field
06 / LOCAL RECORDS
Open the Lenexa ledger →