Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Westchester Village Of Lenexa during CMS and state inspections, most recent first.
Agency CNAs and a CMA provided care without documented completion of required resident rights training, and the facility could not produce a policy on staff education requirements.
Staff did not ensure a resident was properly clothed while his room door was open, resulting in his bare leg and thigh being visible from the hallway. The resident, who had cognitive and mobility impairments and required assistance with dressing, was observed in this state while staff were providing care. Facility policy and staff interviews confirmed that privacy measures, such as closing doors during personal care, were not followed.
Two residents experienced missed or abnormal clinical results—one with multiple missed or undocumented daily weights and significant weight gains related to CHF, and another with repeated blood glucose readings above ordered parameters for diabetes—without timely physician notification or documentation, contrary to physician orders and facility policy.
A resident with multiple risk factors for pressure ulcers, including impaired cognition and incontinence, was observed lying in bed with heels directly on the mattress, despite physician orders and a care plan requiring heel offloading and use of a low air loss mattress. Staff interviews revealed confusion about responsibility for ensuring heel offloading, and the intervention was not consistently implemented, increasing the risk for pressure ulcer development.
A resident with a suprapubic catheter was repeatedly observed with catheter tubing dragging on the floor, despite care plan directives and staff knowledge that tubing should be secured and off the floor. The facility could not provide a catheter care policy, and staff interviews confirmed the expectation for proper catheter management was not met.
Surveyors found that the facility did not follow physician orders for medication administration and monitoring for three residents, including missing dosing instructions for a topical pain reliever, failing to document or notify the physician about significant weight changes and high blood glucose readings, and incorrectly transcribing an anticoagulant order, resulting in improper dosing.
A resident who had provided signed consent for the PCV20 vaccine did not receive the vaccination, and there was no documentation of administration, refusal, or medical contraindication. Facility policy required assessment and timely administration of the vaccine, but the process was not completed as required.
Agency Staff Lacked Required Resident Rights Training
Penalty
Summary
The facility failed to ensure that agency staff, including several Certified Nurse Aides (CNAs) and a Certified Medication Aide (CMA), received the required training on resident rights. During a review of training records, the facility was unable to provide documentation that these agency staff members had completed resident rights training. Additionally, the facility did not provide a policy related to required staff education. This lack of documentation and policy meant that staff who provided care in the facility may not have been properly educated on resident rights, as required.
Failure to Maintain Resident Dignity and Privacy During Personal Care
Penalty
Summary
Staff failed to ensure that a resident was appropriately clothed while his room door was open, resulting in his bare thigh and leg being visible from the hallway. Observations confirmed that the resident was lying in bed on his back while staff assisted him to sit on the side of the bed, and his exposed leg could be seen through the open door. Interviews with staff, including a CNA, a licensed nurse, and an administrative nurse, confirmed that facility policy and staff training require doors to be closed and privacy to be maintained when residents are not fully dressed. The resident involved had a history of cognitive communication deficits, difficulty walking, and required assistance with activities of daily living such as dressing and transfers. Despite being alert and oriented with some forgetfulness and confusion, the resident was dependent on staff for upper body dressing and mobility support. Facility policy emphasized the importance of maintaining resident dignity and privacy, including closing doors and curtains during personal care, but these procedures were not followed during the incident.
Failure to Notify Physician of Significant Clinical Changes
Penalty
Summary
The facility failed to ensure timely physician notification regarding significant clinical changes for two residents. For one resident with diagnoses including diabetes mellitus, congestive heart failure (CHF), and dementia, there were multiple instances where daily weights were either missed, refused, or not documented, as well as several occasions where the resident experienced weight gains exceeding the physician-ordered threshold of two pounds in 24 hours. Despite these occurrences, the clinical record lacked documentation that the physician was notified about the missed weights or the weight gains outside the ordered parameters, as required by the resident's care plan and physician orders. Another resident with diabetes mellitus and hypertension had physician orders for blood glucose (BG) monitoring, with instructions to notify the physician if BG levels were less than 70 or greater than 350. Over a 75-day period, this resident's BG readings exceeded 350 on 26 occasions. However, there was no documentation in the clinical record that the physician was notified of these out-of-parameter BG results, nor was there evidence of physician response as required by facility policy and the resident's care plan. Interviews with nursing staff and administrative personnel confirmed that the expectation was for nurses to notify physicians of missed or abnormal clinical results and to document both the notification and the physician's response in the resident's record. The facility's own policy emphasized timely communication of significant changes in resident status. The lack of physician notification and documentation for both residents constituted a failure to follow physician orders and facility policy.
Failure to Offload Heels for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that a resident's heels were properly offloaded while in bed, as required by physician orders and the resident's care plan, to prevent the development of pressure ulcers. Observations on two separate occasions showed the resident lying in bed with heels directly on the mattress, despite orders for offloading and the use of a low air loss mattress. The resident's care plan and medical record documented multiple risk factors for pressure ulcers, including impaired cognition, incontinence, dependence on staff for activities of daily living, and a Braden Scale score indicating risk. The care plan specifically included interventions such as offloading heels and weekly skin assessments, and the physician's orders required offloading of both heels every shift and application of skin protectant. Interviews with staff revealed confusion regarding responsibility for ensuring the resident's heels were floated, with some staff indicating it was the charge nurse's responsibility and others stating all nursing staff could perform the task. The task was documented on the Treatment Administration Record (TAR) for the charge nurse to verify completion. Despite these documented interventions and staff awareness, the resident's heels were not consistently offloaded, placing the resident at increased risk for pressure ulcer development.
Failure to Maintain Catheter Tubing Off the Floor
Penalty
Summary
Surveyors observed that a resident with a suprapubic catheter had catheter tubing dragging on the floor on multiple occasions while seated in a wheelchair in common areas. The resident's care plan required catheter care each shift, use of a dignity bag, and keeping the catheter bag off the floor. Staff interviews confirmed that catheter tubing should not be on the floor and should be secured, but observations showed this was not followed. The facility was unable to provide a policy for catheter care during the survey. The resident involved had a history of neurogenic bladder, hydroureter, diabetes mellitus, hypertension, and other conditions requiring significant assistance with activities of daily living. The resident was alert and oriented, used a wheelchair for mobility, and had a suprapubic catheter due to urinary retention. Documentation indicated the resident was at risk for pressure ulcers and required staff assistance for mobility and repositioning. Despite these needs and care plan directives, the catheter tubing was not properly managed, leading to the identified deficiency.
Failure to Follow Physician Orders and Ensure Accurate Medication Administration
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary drugs and that physician orders were followed as prescribed. For one resident with diagnoses including diabetes mellitus, congestive heart failure, and dementia, the facility did not provide dosing instructions for as-needed Voltaren gel and did not consistently obtain or document daily weights as ordered to monitor for fluid overload. There were multiple instances where weights were not recorded, or the resident gained more than two pounds in 24 hours without physician notification or documentation of follow-up, despite clear orders and care plan requirements. Another resident with diabetes mellitus and hypertension had physician orders for blood glucose (BG) monitoring before meals and at bedtime, with instructions to notify the physician if BG was less than 70 or greater than 350. Over a 75-day period, this resident had BG readings above 350 on 26 occasions, but there was no documentation that the physician was notified as required. The care plan specified that nursing staff should administer diabetic medication as ordered and monitor for side effects, but the lack of notification and documentation indicated the order was not followed. A third resident with multiple diagnoses, including hypertension, hemiplegia, and venous insufficiency, was prescribed warfarin with a specific dosing schedule based on therapeutic drug monitoring. The order was transcribed incorrectly, resulting in the resident receiving the wrong dose on certain days. This error was identified after subsequent lab results showed subtherapeutic levels, and the physician had to reorder the correct dosing schedule. The facility's process for verifying and double-checking medication orders was not consistently implemented, leading to the administration of an incorrect anticoagulant dose.
Failure to Administer Pneumococcal Vaccine After Consent Obtained
Penalty
Summary
The facility failed to administer the Pneumococcal Conjugate Vaccine (PCV20) to a resident after obtaining a signed consent for vaccination. Review of the resident's clinical record showed no documentation that the vaccine was given, nor was there a physician-documented contraindication. The facility's policy required that all residents be assessed for eligibility and offered the pneumococcal vaccine series within thirty days of admission, with proper documentation of administration or refusal. In this case, the required documentation and administration did not occur after consent was obtained. Interviews with administrative nursing staff revealed that the process for obtaining consent and ordering the vaccine involved including the consent form in the admission packet and having the charge nurse responsible for ensuring the vaccine was ordered and administered. Despite these procedures, the vaccine was not given to the resident, and there was no record of refusal or contraindication. This lapse was identified during a review of a sample of residents for immunization status.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 863 citations issued within 25 miles in the last 12 months — including the 23 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lenexa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakeview Village | 0.8 mi | ★★★★★ | 15 | 0 |
| Shawnee Gardens Healthcare & Rehab Center | 1.5 mi | ★★★★★ | 2 | 0 |
| Delmar Gardens Of Lenexa | 1.8 mi | ★★★★★ | 10 | 0 |
| Garden Terrace At Overland Park | 2.1 mi | ★★★★★ | 4 | 2 |
| Delmar Gardens Of Overland Park | 3 mi | ★★★★★ | 15 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.