Westchester Village of Lenexa
8505 Pflumm Road, Lenexa, KS 66215
Westchester Village of Lenexa is a nursing home in Lenexa, Kansas. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating5 of 5
- Last standard health inspectionMarch 19, 2025 (1 year ago)
- Health citations since December 30, 202122 (Kansas average 28)
- Fines in the past three yearsNone listed by CMS
- CMS flagsNone listed by CMS
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One email per CMS update, only when something changed: a new citation, a fine, a star rating change, a new owner. Early access follows one home per address.
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CMS flags
CMS does not list this home as a Special Focus Facility or a candidate. CMS does not show an abuse icon for it. CMS lists no change of ownership in the past 12 months.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS overall star rating changed from 4 of 5 to 5 of 5.
Star rating
The CMS staffing star rating changed from 4 of 5 to 5 of 5.
CMS update of April 29, 2026
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 1 of 5 to 2 of 5.
CMS update of February 25, 2026
Star rating
The CMS overall star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 1 of 5.
Health inspection on March 19, 2025
8 citationsCMS lists this as a standard inspection and a complaint inspection.
Show the 8 citations
Citation F0942. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
CMS lists it as corrected on May 2, 2025.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on May 2, 2025.
CMS has cited this home for F0550 2 times since 2021.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on May 2, 2025.
Citation F0625. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on May 2, 2025.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on May 2, 2025.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on May 2, 2025.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on May 2, 2025.
CMS has cited this home for F0757 2 times since 2021.
Citation F0883. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on May 2, 2025.
CMS has cited this home for F0883 2 times since 2023.
Fire safety inspection on March 19, 2025
3 citationsCMS lists this as a standard inspection.
Show the 3 citations
Citation K0324. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on May 1, 2025.
CMS has cited this home for K0324 2 times since 2023.
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on May 1, 2025.
CMS has cited this home for K0363 2 times since 2023.
Citation K0372. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on May 1, 2025.
CMS has cited this home for K0372 3 times since 2021.
CMS update of February 26, 2025
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
CMS update of July 31, 2024
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
CMS update of January 31, 2024
Star rating
The CMS overall star rating changed from 5 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
Health inspection on July 12, 2023
7 citationsCMS lists this as a standard inspection.
Show the 7 citations
Citation F0679. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide activities to meet all resident's needs.
CMS lists it as corrected on July 20, 2023.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on July 20, 2023.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on July 20, 2023.
CMS has cited this home for F0684 2 times since 2021.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on July 20, 2023.
CMS has cited this home for F0689 2 times since 2021.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on July 20, 2023.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 20, 2023.
Citation F0883. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on July 20, 2023.
Fire safety inspection on July 12, 2023
10 citationsCMS lists this as a standard inspection.
Show the 10 citations
Citation K0211. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on September 14, 2023.
Citation K0372. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on September 14, 2023.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on September 14, 2023.
CMS has cited this home for K0712 2 times since 2021.
Citation K0914. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
CMS lists it as corrected on September 14, 2023.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on September 14, 2023.
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on September 14, 2023.
Citation K0324. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on September 14, 2023.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on September 14, 2023.
CMS has cited this home for K0353 2 times since 2021.
Citation K0511. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on September 14, 2023.
CMS has cited this home for K0511 2 times since 2021.
Citation K0923. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on September 14, 2023.
Health inspection on December 30, 2021
7 citationsCMS lists this as a standard inspection.
Show the 7 citations
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on January 30, 2022.
Citation F0661. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
CMS lists it as corrected on January 30, 2022.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on January 30, 2022.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on January 30, 2022.
Citation F0756. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on January 30, 2022.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on January 30, 2022.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on January 30, 2022.
Fire safety inspection on December 30, 2021
14 citationsCMS lists this as a standard inspection.
Show the 14 citations
Citation E0004. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop and maintain an Emergency Preparedness Program (EP).
CMS lists it as corrected on February 17, 2022.
Citation E0024. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish policies and procedures for volunteers.
CMS lists it as corrected on February 17, 2022.
Citation E0041. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Implement emergency and standby power systems.
CMS lists it as corrected on February 17, 2022.
Citation K0131. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Meet requirements for sections of health care facilities separated by fire resistive construction.
CMS lists it as corrected on February 17, 2022.
Citation K0222. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on February 17, 2022.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on February 17, 2022.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on February 17, 2022.
Citation K0372. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on February 17, 2022.
Citation K0511. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on February 17, 2022.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on February 17, 2022.
Citation K0761. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on February 17, 2022.
Citation K0920. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on February 17, 2022.
Citation K0291. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on February 17, 2022.
Citation K0300. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Meet other general requirements that are deficient.
CMS lists it as corrected on February 17, 2022.
CMS star ratings
- 5 of 5CMS overall star rating
- 4 of 5CMS health inspection star rating
- 5 of 5CMS staffing star rating
- 2 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (913) 307-2000
- Last standard health inspection
- March 19, 2025 (1 year ago)
- Certified beds
- 34
- Residents per day, on average
- 27.5
- Ownership type
- For profit - Corporation
- Legal business name
- Ccrc of Lenexa LLC
- Chain
- Pivotal Health Care
- Takes part in
- Medicare and Medicaid
Fewer health citations than the Kansas average (22 vs 28).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- SCENIC DEVELOPMENT LLCDirect ownership interest · not applicable · since 12/16/2017
- SCENIC HOLDINGS LLCDirect ownership interest · not applicable · since 12/31/2019
- 3RK, LLCIndirect ownership interest · not applicable · since 01/01/2021
- 5 R CATTLE, LLCIndirect ownership interest · not applicable · since 12/16/2017
- CADET INVESTMENT LLCIndirect ownership interest · not applicable · since 12/16/2017
Show 19 more
- LMRAY, LLCIndirect ownership interest · not applicable · since 12/16/2017
- POKY - 5R LLCIndirect ownership interest · not applicable · since 12/31/2019
- POKY FEEDERS INCIndirect ownership interest · not applicable · since 12/16/2017
- WSG LLCIndirect ownership interest · not applicable · since 12/16/2017
- ANDERSON, JORDANIndirect ownership interest · not applicable · since 10/01/2021
- ANDERSON, MARLENEIndirect ownership interest · not applicable · since 12/16/2017
- ANDERSON, WAYNEIndirect ownership interest · not applicable · since 12/16/2017
- GULLEDGE, SCOTTIndirect ownership interest · not applicable · since 12/16/2017
- GULLEDGE, TRAVISIndirect ownership interest · not applicable · since 10/01/2021
- HOWARD, STEVENIndirect ownership interest · not applicable · since 12/16/2017
- WOOD, GILBERTIndirect ownership interest · not applicable · since 12/16/2017
- PIVOTAL HEALTH CARE LLCOperational/managerial control · not applicable · since 12/16/2017
- SCENIC DEVELOPMENT LLCOperational/managerial control · not applicable · since 12/16/2017
- ANDERSON, JORDANOperational/managerial control · not applicable · since 01/01/2025
- FRANS, CLAYTONOperational/managerial control · not applicable · since 05/02/2026
- GULLEDGE, SCOTTOperational/managerial control · not applicable · since 12/16/2017
- GULLEDGE, TRAVISOperational/managerial control · not applicable · since 01/01/2025
- MARTIN, CAROLINEOperational/managerial control · not applicable · since 02/06/2023
- WOOD, GILBERTOperational/managerial control · not applicable · since 12/16/2017
Questions
When was Westchester Village of Lenexa last inspected?
CMS lists March 19, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Westchester Village of Lenexa have?
CMS lists 22 health citations since December 30, 2021. CMS also calls these deficiencies.
Has Westchester Village of Lenexa been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Westchester Village of Lenexa?
Its CMS overall star rating is 5 of 5.
Is Westchester Village of Lenexa a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.