Cycle 1
Health 2025-03-19 · Fire 2025-03-19
8 health deficiencies
Top issue: Resident Rights (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Lenexa, KS
Westchester Village Of Lenexa
3-star overall rating with 4-star inspections with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
8505 Pflumm Road, Lenexa, KS
(913) 307-2000
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
34
Certified beds
Average residents
34
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pivotal Health Care
Operator or chain grouping
Approved since
2013-06-27
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 facilities
Chain averages 4 overall / 4 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.12
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.46
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
3.03
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.62
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.58
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
4.08
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.86
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
1.13
CMS adjusted RN staffing hours
Adjusted total hours
4.65
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
62%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
66%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,593
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.26
Composite VBP score used to determine payment impact.
Payment multiplier
0.9841
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.01
Baseline 21.92% · Performance 21.67% · Measure score 0.01 · Achievement 0 · Improvement 0.01
Healthcare-associated infections
4.04
Baseline 6.35% · Performance 6.63% · Measure score 4.04 · Achievement 4.04 · Improvement 0
Total nurse turnover
0
Baseline 50.00% · Performance 72.97% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
6.46
Baseline 4.59 hours · Performance 4.92 hours · Measure score 6.46 · Achievement 6.46 · Improvement 2.24
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.21% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 82 · Observed rate 10.98% · Lower 95% interval 6.8% |
| Discharge to community | 46.84% |
50.57%
3.7 pts worse
|
No Different than the National Rate · Eligible stays 73 · Observed rate 43.84% · Lower 95% interval 37.68% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 93.65% |
95.27%
1.6 pts worse
|
Numerator 59 · Denominator 63 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 63 |
| Discharge self-care score | 40% |
53.69%
13.7 pts worse
|
Numerator 20 · Denominator 50 |
| Discharge mobility score | 36% |
50.94%
14.9 pts worse
|
Numerator 18 · Denominator 50 |
| Pressure ulcers or injuries, new or worsened | 1.59% |
2.29%
0.7 pts better
|
Numerator 1 · Denominator 63 · Adjusted rate 1.7% |
| Healthcare-associated infections requiring hospitalization | 6.63% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 68 · Observed rate 4.41% · Lower 95% interval 3.6% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 105 |
| Staff flu vaccination coverage | 9.84% |
42%
32.2 pts worse
|
Numerator 12 · Denominator 122 |
| Discharge function score | 36% |
56.45%
20.5 pts worse
|
Numerator 18 · Denominator 50 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 90.91% |
96.28%
5.4 pts worse
|
Numerator 30 · Denominator 33 |
| Resident COVID-19 vaccinations up to date | 34.29% |
25.2%
9.1 pts better
|
Numerator 12 · Denominator 35 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.8
About the same
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.0 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
2.2
0.2 pts better
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.0 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.5% |
91.8%
5.7 pts better
|
93.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.2% · Q2 100.0% · 4Q avg 97.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 84.0% |
95.5%
11.5 pts worse
|
95.5%
11.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 84.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.6% |
4.4%
4.2 pts worse
|
3.3%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 8.7% · 4Q avg 8.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
5.6%
5.6 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 4.7% |
5.0%
0.3 pts better
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.4% |
23.2%
6.8 pts better
|
19.6%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.0% |
19.8%
19.8 pts better
|
16.7%
16.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 36.3% |
18.4%
17.9 pts worse
|
16.3%
20 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 36.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.6% |
18.8%
3.8 pts worse
|
14.9%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.4% |
1.8%
2.6 pts worse
|
1.0%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 4.5% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 9.0% |
3.1%
5.9 pts worse
|
1.7%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 4.3% · 4Q avg 9.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.4% |
23.2%
8.2 pts worse
|
19.8%
11.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 29.2% · 4Q avg 31.4% |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
4.6%
0.9 pts better
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 4.8% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.3% |
75.6%
15.7 pts better
|
81.7%
9.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 81.1% · Q2 92.9% · Q3 95.6% · Q4 94.0% · 4Q avg 91.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.9% |
11.7%
0.2 pts worse
|
12.0%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.9% · Observed 11.1% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
2.2%
0.5 pts better
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 1.7% · Q3 1.5% · Q4 1.7% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.6% |
73.5%
9.1 pts better
|
79.7%
2.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.4% |
23.0%
1.6 pts better
|
23.9%
2.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.4% · Observed 19.0% · Expected 21.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-12 · Fire 2023-07-12
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2021-12-30 · Fire 2021-12-30
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
14 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-01
E · Potential for more than minimal harm
2025-03-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-05-01
D · Potential for more than minimal harm
2025-03-19
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-05-01
F · Potential for more than minimal harm
2023-07-12
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-09-14
F · Potential for more than minimal harm
2023-07-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-09-14
F · Potential for more than minimal harm
2023-07-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-14
F · Potential for more than minimal harm
2023-07-12
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-09-14
F · Potential for more than minimal harm
2023-07-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-14
E · Potential for more than minimal harm
2023-07-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-09-14
D · Potential for more than minimal harm
2023-07-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-14
D · Potential for more than minimal harm
2023-07-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-14
D · Potential for more than minimal harm
2023-07-12
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-09-14
D · Potential for more than minimal harm
2023-07-12
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-09-14
F · Potential for more than minimal harm
2021-12-30
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2022-02-17
F · Potential for more than minimal harm
2021-12-30
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-02-17
F · Potential for more than minimal harm
2021-12-30
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-02-17
F · Potential for more than minimal harm
2021-12-30
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2022-02-17
F · Potential for more than minimal harm
2021-12-30
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2022-02-17
F · Potential for more than minimal harm
2021-12-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-02-17
F · Potential for more than minimal harm
2021-12-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-02-17
F · Potential for more than minimal harm
2021-12-30
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-02-17
F · Potential for more than minimal harm
2021-12-30
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-02-17
F · Potential for more than minimal harm
2021-12-30
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-02-17
F · Potential for more than minimal harm
2021-12-30
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-02-17
F · Potential for more than minimal harm
2021-12-30
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-02-17
E · Potential for more than minimal harm
2021-12-30
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-02-17
E · Potential for more than minimal harm
2021-12-30
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2022-02-17
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-03-19
F942 · Resident Rights Deficiencies
Health
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-19
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-19
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-19
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-19
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-19
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-19
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-19
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-05-02
E · Potential for more than minimal harm
2023-07-12
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-07-20
D · Potential for more than minimal harm
2023-07-12
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-07-20
D · Potential for more than minimal harm
2023-07-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-20
D · Potential for more than minimal harm
2023-07-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-20
D · Potential for more than minimal harm
2023-07-12
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-07-20
D · Potential for more than minimal harm
2023-07-12
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-07-20
D · Potential for more than minimal harm
2023-07-12
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-07-20
D · Potential for more than minimal harm
2021-12-30
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-01-30
D · Potential for more than minimal harm
2021-12-30
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2022-01-30
D · Potential for more than minimal harm
2021-12-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-01-30
D · Potential for more than minimal harm
2021-12-30
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-01-30
D · Potential for more than minimal harm
2021-12-30
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-01-30
D · Potential for more than minimal harm
2021-12-30
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-01-30
D · Potential for more than minimal harm
2021-12-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-01-30
Penalties and ownership
What sits behind the stars
Ownership
Scenic Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Scenic Development LLC
5% Or Greater Direct Ownership Interest · Organization
Wsg LLC
5% Or Greater Indirect Ownership Interest · Organization
Poky - 5r LLC
5% Or Greater Indirect Ownership Interest · Organization
Cadet Investment LLC
5% Or Greater Indirect Ownership Interest · Organization
Howard, Steven
5% Or Greater Indirect Ownership Interest · Individual
Anderson, Marlene
5% Or Greater Indirect Ownership Interest · Individual
Anderson, Wayne
5% Or Greater Indirect Ownership Interest · Individual
Abby, Amber
Operational/Managerial Control · Individual
Anderson, Jordan
Operational/Managerial Control · Individual
Gulledge, Scott
Operational/Managerial Control · Individual
Gulledge, Travis
Operational/Managerial Control · Individual
Martin, Caroline
Operational/Managerial Control · Individual
Pivotal Health Care LLC
Operational/Managerial Control · Organization
Scenic Development LLC
Operational/Managerial Control · Organization
Wood, Gilbert
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Lakeview Village
Lenexa, KS
3-star overall rating with 2-star inspections with $35,619 in total fines with 12 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Shawnee Gardens Healthcare & Rehab Center
Shawnee, KS
1-star overall rating with 1-star inspections with abuse icon flag with $94,968 in total fines with 24 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Delmar Gardens Of Lenexa
Lenexa, KS
4-star overall rating with 5-star inspections with 7 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
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