A list of the most recent deficiencies for Westchester Village of Lenexa. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-08-21 | 2023-09-14 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-21 | 2023-09-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-21 | 2023-09-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-21 | 2023-09-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-08-21 | 2023-09-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-08-21 | 2023-09-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-21 | 2023-09-14 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-08-21 | 2023-09-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-21 | 2023-09-14 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-08-21 | 2023-09-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-12 | 2023-07-20 | N |
| Provide activities to meet all resident's needs. | Health | 2023-07-12 | 2023-07-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-12 | 2023-07-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-12 | 2023-07-20 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-07-12 | 2023-07-20 | N |
| 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. | Health | 2023-07-12 | 2023-07-20 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-07-12 | 2023-07-20 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-01-19 | 2022-02-17 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-01-19 | 2022-02-17 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-01-19 | 2022-02-17 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2022-01-19 | 2022-02-17 | N |
| 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. | Fire Safety | 2022-01-19 | 2022-02-17 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-01-19 | 2022-02-17 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-01-19 | 2022-02-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-01-19 | 2022-02-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-19 | 2022-02-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-01-19 | 2022-02-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-01-19 | 2022-02-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-01-19 | 2022-02-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-01-19 | 2022-02-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-01-19 | 2022-02-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-12-30 | 2022-01-30 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-12-30 | 2022-01-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-30 | 2022-01-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-30 | 2022-01-30 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-12-30 | 2022-01-30 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-12-30 | 2022-01-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-30 | 2022-01-30 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2020-01-22 | 2020-02-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-01-22 | 2020-02-22 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-01-22 | 2020-02-22 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2020-01-22 | 2020-02-22 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-01-22 | 2020-02-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-22 | 2020-02-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-01-22 | 2020-02-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-01-22 | 2020-02-03 | N |
