Westchester Village Of Lenexa
Lenexa, Johnson County, Kansas · CCN 175536 · For-profit (Corporation) · part of Pivotal Health Care (9 facilities, chain average 3.9 stars)
CMS rates Westchester Village Of Lenexa 4 of 5 overall as of August 2026. 34 certified beds, 31 residents a day on average. 22 citations on record from the current inspection cycles; no fines on record.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★★★★☆ 4 of 5 |
|---|---|
| Health inspections | ★★★★☆ 4 of 5 |
| Staffing | ★★★★☆ 4 of 5 |
| Quality measures | ★★☆☆☆ 2 of 5 |
| Quality: long-stay / short-stay | 1 / 3 of 5 |
Staffing
| Total nurse staffing | 5.1138 hours per resident per day |
|---|---|
| Registered nurses | 1.22093 hours per resident per day |
| Weekend total | 4.80246 hours per resident per day |
| Nursing staff turnover | 57.8% (registered nurses 45.5%) |
| Administrators who left | 1 |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2025-03-19 complaint survey |
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. Resident Rights Deficiencies · tag F0942 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2025-05-02 |
| 2025-03-19 complaint survey |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · tag F0550 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-05-02 |
| 2025-03-19 complaint survey |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · tag F0580 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-05-02 |
| 2025-03-19 complaint survey |
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. Resident Rights Deficiencies · tag F0625 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-05-02 |
| 2025-03-19 complaint survey |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-05-02 |
| 2025-03-19 complaint survey |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · tag F0690 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-05-02 |
| 2025-03-19 complaint survey |
Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · tag F0757 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-05-02 |
| 2025-03-19 complaint survey |
Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · tag F0883 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-05-02 |
| 2023-07-12 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · tag F0679 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-07-20 |
| 2023-07-12 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · tag F0656 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-07-20 |
| 2023-07-12 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-07-20 |
| 2023-07-12 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-07-20 |
| 2023-07-12 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · tag F0692 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-07-20 |
| 2023-07-12 | 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. Pharmacy Service Deficiencies · tag F0758 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-07-20 |
| 2023-07-12 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · tag F0883 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-07-20 |
| 2021-12-30 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · tag F0550 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-01-30 |
| 2021-12-30 | Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Resident Assessment and Care Planning Deficiencies · tag F0661 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-01-30 |
| 2021-12-30 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-01-30 |
| 2021-12-30 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-01-30 |
| 2021-12-30 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies · tag F0756 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-01-30 |
| 2021-12-30 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · tag F0757 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-01-30 |
| 2021-12-30 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-01-30 |
Fines and payment denials
No fines or payment denials on record since 2023.
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Curana Health Of Missouri-Kansas LLC Organization | adp of the snf | — | 2023-03-01 |
| Pivotal Health Care LLC Organization | adp of the snf | — | 2025-04-28 |
| Summit Care, LLC Organization | adp of the snf | — | 2017-12-16 |
| Scenic Development LLC Organization | direct ownership interest | — | 2017-12-16 |
| Scenic Holdings LLC Organization | direct ownership interest | — | 2019-12-31 |
| 3rk, LLC Organization | indirect ownership interest | — | 2021-01-01 |
| 5 R Cattle, LLC Organization | indirect ownership interest | — | 2017-12-16 |
| Cadet Investment LLC Organization | indirect ownership interest | — | 2017-12-16 |
| Lmray, LLC Organization | indirect ownership interest | — | 2017-12-16 |
| Poky - 5r LLC Organization | indirect ownership interest | — | 2019-12-31 |
| Poky Feeders Inc. Organization | indirect ownership interest | — | 2017-12-16 |
| Wsg LLC Organization | indirect ownership interest | — | 2017-12-16 |
| Pivotal Health Care LLC Organization | operational/managerial control | — | 2017-12-16 |
| Scenic Development LLC Organization | operational/managerial control | — | 2017-12-16 |
| Frans, Clayton Individual | adp of the snf | — | 2026-05-02 |
| Gulledge, Scott Individual | adp of the snf | — | 2017-12-16 |
| Gulledge, Travis Individual | adp of the snf | — | 2025-01-01 |
| Martin, Caroline Individual | adp of the snf | — | 2023-02-06 |
| Anderson, Jordan Individual | indirect ownership interest | — | 2021-10-01 |
| Anderson, Marlene Individual | indirect ownership interest | — | 2017-12-16 |
| Anderson, Wayne Individual | indirect ownership interest | — | 2017-12-16 |
| Gulledge, Scott Individual | indirect ownership interest | — | 2017-12-16 |
| Gulledge, Travis Individual | indirect ownership interest | — | 2021-10-01 |
| Howard, Steven Individual | indirect ownership interest | — | 2017-12-16 |
| Wood, Gilbert Individual | indirect ownership interest | — | 2017-12-16 |
| Anderson, Jordan Individual | operational/managerial control | — | 2025-01-01 |
| Frans, Clayton Individual | operational/managerial control | — | 2026-05-02 |
| Gulledge, Scott Individual | operational/managerial control | — | 2017-12-16 |
| Gulledge, Travis Individual | operational/managerial control | — | 2025-01-01 |
| Martin, Caroline Individual | operational/managerial control | — | 2023-02-06 |
| Wood, Gilbert Individual | operational/managerial control | — | 2017-12-16 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Westchester Village Of Lenexa.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Johnson County.