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Lakeview Village

13840 W 91st Terrace, Lenexa, KS 66215 · Non profit - Corporation · 158 certified beds · (913) 888-1900 Medicare & Medicaid certified

Call the home — (913) 888-1900 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)2 immediate-jeopardy citations CMS recorded as corrected before the inspection ended (past non-compliance)$27,841 in federal fines
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • a high payroll-based staffing rating (5/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • inspectors recorded 2 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $27,841 in federal fines (most recent 2025-04-22)
  • its payroll-based staffing score sits well above its independent inspection score

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 3 of 5

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
13830 SANTA FE Trail Dr Ste 106 · (913) 453-0290 · Call to confirm hours
Pharmacy
13715 West 109th Street · (913) 498-2121 · Call to confirm hours
Grocery
Hy-Vee0.7 mi
13400 W 87th St Pkwy · (913) 438-8308 · Call to confirm hours
Park
14006 W 92nd Ter · (913) 477-7100 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 4 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 to 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased27.8%17.9%15.4%worse
Long-stay residents who lose too much weight6.4%4.9%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%1.6%0.9%better
Long-stay residents with a urinary tract infection0.6%2.9%2.0%better
Long-stay residents with depressive symptoms5.1%6.5%6.5%better
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury3.6%4.3%3.3%typical
Long-stay residents whose ability to walk worsened24.0%16.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication31.2%23.2%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%95.5%95.3%typical
Long-stay residents with pressure ulcers4.5%4.4%4.7%typical
Long-stay residents with worsening bladder/bowel control31.0%22.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table1.7%18.1%17.1%better
Short-stay residents who newly got an antipsychotic medication0.3%1.9%1.4%better
Short-stay residents given the seasonal flu vaccine97.3%73.8%79.4%better
Short-stay residents rehospitalized after admission32.5%22.4%22.6%worse
Short-stay residents with an outpatient ER visit8.9%11.5%12.0%better
Long-stay hospitalizations per 1,000 resident days2.151.801.67worse
Long-stay outpatient ER visits per 1,000 resident days1.412.131.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

51.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 519 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

51.5%U.S. median 51.5%
Got home and stayed home
11.7%U.S. median 10.7%
Went back to hospital
88.7%U.S. median 56.6%
Met the expected recovery
1.46U.S. median 0.31
Therapy hours / resident / day
0.64hours / resident / day
Physical therapy
0.63hours / resident / day
Occupational therapy
0.19hours / resident / day
Speech therapy

Met the expected recovery: 88.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 292 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 1.46 therapist hours per resident per day in 2026Q1 — more than 99% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 5% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF51.5%CMS range 48.1–55.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.7%CMS range 9.3–13.710.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge88.7%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge79.8%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge82.9%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified96.5%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting98.1%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge98.9%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.3%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.8%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization4.6%CMS range 2.9–7.07.1%Oct 2023–Sep 2024better than U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.741.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

1.07
RN hours/ resident / day
0.82
LPN hours/ resident / day
3.97
Aide hours/ resident / day
5.86
Total nurse hours/ resident / day
0.75
RN hoursweekends
41.1%
Total nursing turnover
29.6%
RN turnover

How full it usually is: this home is certified for 158 beds and averages 114.8 residents a day — about 73% occupied, or roughly 43 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.86 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.07 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.97 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 5.53 hrs/resident/day on weekends vs 5.99 on weekdays — 8% thinner on weekends. RN hours go from 1.19 to 0.75 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 41% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

8
deficiencies at the latest standard inspection (2026-04-22)
11
at the previous standard inspection (2024-06-05)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

26 citations, most serious first. The 12 most serious are shown; the remaining 14 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2025-04-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 128 residents. The sample included three residents, with three residents reviewed for elopement (when a cognitively impaired resident leaves the facility without the knowledge or supervision of staff). Based on observations, record review, and interviews, the facility failed to ensure staff provided adequate supervision to prevent an elopement for Resident (R) 1 and further failed to provide a thorough search in response to a WanderGuard (sensors that monitor doors and a technology platform that sends safety alerts in real-time) alert. On 04/13/25 at 07:15 PM, R1 who was severely cognitively impaired and at high risk for elopement, set off the WanderGuard alert system. Staff responded to the alarm 36 seconds later but did not see R1. Staff started searching for R1 but did not immediately open the staircase door and search the staircase where the WanderGuard alert system sounded. By the time the staff searched the staircase, R1 had exited the building through the staircase and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Immediate jeopardy · Jcited before2023-12-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 113 residents. The sample included three residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to provide adequate supervision to prevent Resident (R) 1, who was cognitively impaired and at risk for elopement (when a cognitively impaired resident leaves the facility without the knowledge or supervision of staff), from exiting the facility without staff knowledge or supervision on 11/26/23 at 01:23 PM. R1 pushed on a door leading to the stairwell for 15 seconds and was able to open the door. The door alarm sounded but the roam alert system (system which alerts when a linked roam alert bracelet is near) did not alert even though R1 wore a roam alert bracelet. Staff reset the door alarm but did not check the stairwell. R1 then went down a flight of stairs and exited through an outside door in the stairwell. R1 walked along the sidewalk around the building, to the front of the building where he entered the front door at 01:39 PM…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · Fcited before2026-04-22 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions to prevent the potential for food borne bacteria. Finding included:- During the initial tour of the main kitchen on 04/20/26 at 08:00 AM, observation revealed the kitchen did not have foot activated trash cans by the hand-washing station, and four of the trash cans did not have lids. The kitchen refrigerator had two bags of diced onions without a date, and one bag was open to air. In the freezer, one bag of hash browns was left open, and in the dry storage one can of prunes had a dent.On 04/20/26 at 08:20 AM, observation of the rehabilitation on the second floor's refrigerator revealed one box of hamburger patties left open to air, food particles in the cabinet drawers and dust or dirt in the grooves of the cabinet's doors.On 04/20/26 at 08:30 AM, observation of the third rehabilitation kitchen revealed one bag of biscuits in the freezer, which had a brown substance in the bottom of the freezer, also observed dried food particles in the crevices of the cabinet…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-22 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure Resident (R) 143 and his representative were provided with a bed hold policy that included the facility's per diem rate to hold a bed. Findings included:- R143's Electronic Medical Record (EMR) documented R143 admitted the facility on 01/27/26. A Notice of Transfer form in the EMR dated 02/02/26 documented R143 was sent out to the hospital. The Notice of Transfer form, documented the form was provided to R143 and their representative.R143's EMR lacked evidence the bed hold policy was provided to R143 and his representative. Upon request, the facility was unable to provide evidence the bed hold policy was provided to the resident at the time of transfer. On 04/22/26 at 09:19 AM, Administrative Staff A confirmed the bed hold policy was not provided to R142 because the resident was on skilled services. Administrative Staff A stated that the facility did not provide bed holds for their short stay residents per facility policy. The facility's Bed Holds and Return to Facility policy dated 09/06/18 documented the facility…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-22 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to update the plan of care for activity of daily living (ADL) assistance for Resident (R) 3. Findings included:- R3's Electronic Health Record (EHR) documented the following diagnosis: cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) with hemiparesis/hemiplegia (weakness and paralysis on one side of the body).R3's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition. R3 required assistance with all ADLs.R3's Care Plan dated 10/08/25 recorded she had an impaired ability to care for herself and directed staff she needed help performing ADLs. The care plan lacked intervention to provide nail care.On 04/20/26 at 09:10 AM, observation of R3's right hand revealed a black substance under two of the five fingernails.On 04/23/26…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-22 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to provide activity of daily living (ADL) assistance for Resident (R) 3 when staff failed to ensure she received fingernail hygiene care. Findings included:- R3's Electronic Health Record (EHR) documented the following diagnoses: cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) with hemiparesis/hemiplegia (weakness and paralysis on one side of the body).R3's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition. R3 required assistance with all ADLs.R3's Care Plan dated 10/08/25 recorded she had an impaired ability to care for herself and directed staff she needed help performing ADLsOn 04/20/26 at 09:10 AM, observation of R3's right hand revealed a black substance under two of the five fingernails.04/21/26 at 2:00 PM…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-22 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, and record reviews, the facility failed to ensure staff implemented the interventions to promote wound healing for Resident (R) 11 when staff failed to use the foot cradle and Prevalon boots. Findings included:-R11's Electronic Health Record (EHR) documented diagnoses that included Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), dementia (a progressive mental disorder characterized by failing memory and confusion), anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to the body) and peripheral vascular disease (PVD-slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel).R11's 03/18/26 Quarterly Minimum Data Set (MDS) documented R11 had one Stage 2 (partial-thickness skin loss into but no deeper than the dermis, including intact or ruptured blisters) and one Stage 3 (full-thickness pressure injury extending through the skin into the tissue below). R11's Care Plan documented R11 was at risk for a pressure ulcer or other…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure an environment free from accident hazards for Resident (R)37 who required supplemental oxygen continuously and had the oxygen concentrator (a medical device that filters surrounding air to deliver concentrated oxygen) set-up in his bathroom with approximately 30 feet of oxygen tubing strung throughout his room, and R146 who required staff assistance when ambulating and ambulated throughout his room without staff present. Findings included:- Review of the Electronic Medical Record (EHR) revealed the following: 1. The EMR for R37 documented diagnoses of acute on chronic Systolic (congestive) heart failure (when a patient with pre-existing systolic heart failure experiences a sudden, severe worsening of symptoms), chronic respiratory failure with hypoxia (a long-term condition where the respiratory system cannot adequately oxygenate the blood), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-22 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, and record review, the facility failed to provide Resident (R)148's physician ordered medications due to lack of availability. Findings included:- R148's Electronic Medical Records (EMR) documented diagnoses, which included anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and aftercare following joint replacement surgery. R148's 04/22/26 admission Minimum Data Set (MDS) was not completed. R148's ADL functional/Rehabilitation Potential Care Area Assessment (CAA), dated 04/12/26, documented R148 required assistance with care including toileting. R148's admission Care Plan dated 04/18/26, documented staff were to assess R148 for pain and give pain medications as ordered.R148's admission Care Plan dated 04/18/26, directed staff to give medications as ordered and monitor behavior concerns or anxiety.R148's Physician Orders documented an order for clonazepam (an antianxiety medication) one milligram (mg) at bedtime for anxiety, started on 04/18/26.R148's Physician Orders documented an order for Soma (a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-06-05 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 116 residents. The facility had one main kitchen and two kitchenettes with dining areas. Based on observation, record review, and interview, the facility failed to ensure that staff stored and prepared food items in accordance with the professional standards for food service safety. This deficient practice placed the residents at risk for foodborne illnesses. Findings included: - On 06/03/24 at 07:17 AM, the initial tour of the kitchen revealed the following: Freezer number 12 had opened bags of frozen carrots, hash browns, sweet potato fries, French toast sticks, chicken wings, breaded okra, and curly fries that were not closed, labeled, or dated. Walk-in freezer number two had unlabeled and undated blueberries. Walk-in refrigerator number one had a rolling cart with a tray of macaroni and cheese and a tray of dried rice with butter that was not covered, labeled, or dated. Cooler number seven for leftover food had three containers of mashed potatoes, two containers of gravy, a tub of chicken base, and a container of chili that were not labeled or…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-06-05 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 116 residents. The sample included 24 residents. Based on observation, record review, and interviews, the facility failed to ensure proper infection control standards were followed related to the implementation of procedures to monitor and prevent Legionella disease (Legionella is a bacterium that can cause pneumonia in vulnerable populations) or other opportunistic waterborne pathogens, hand hygiene, placement of urinary dependent drainage bag, and the sanitary storage of respiratory equipment. This deficient practice placed the residents at risk for complications related to infectious diseases. Findings included: - During an observation on 06/03/24 at 10:17 AM, Resident (R)413's nasal cannula was laid directly on the floor next to R413's bed, and a pile of soiled linen was laid directly on the right side of his bed. During an observation on 06/03/24 at 11:17 AM, R89 sat in his recliner in his room. R89's catheter tubing and catheter drainage bag were touching the floor. During an observation on 06/04/24 at 11:42 AM, R89 sat in his recliner in…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-06-05 · tag F0585 — failed to handle grievances — pattern
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 116 residents. The sample includes 24 residents. Based on observation, record review, and interviews, the facility failed to implement a system to allow residents and their representatives to file grievances anonymously. This deficient practice placed the residents at risk for decreased psychosocial well-being and had the potential to affect all residents. Findings Included: - An inspection of the facility revealed a suggestion box, located inside a walkway area that required a door code to access. The facility inspection revealed the facility had no labeled grievance boxes in place. On 06/04/24 at 10:19 AM, the Resident Council (RC) members reported they were not aware of how to file a grievance, or if the facility provided a way to file an anonymous grievance. The RC members reported they turned their complaints into Social Services or would have a member of their family contact Social Services to file a complaint on their behalf. The RC members stated they were not aware of any grievance form drop box. On 06/04/24 at 11:17 AM Administrative…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · D2024-06-05 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 116 residents. The sample included 24 residents with two residents sampled for pressure ulcers (a localized injury to the skin and/or underlying tissue usually over a bony prominence, due to pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to ensure staff followed the intervention in place for pressure-reducing boots for Resident (R) 14 to prevent the possible development of a pressure ulcer. This deficient practice placed R14 at risk for complications associated with skin breakdown. Findings included: - R14's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), atrial fibrillation (rapid, irregular heartbeat), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), depressive disorder (a mood disorder that causes a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 116 residents. The sample included 24 residents with five residents reviewed for falls. Based on observation, record review, and interviews, the facility failed to identify and implement appropriate, resident-centered interventions to prevent falls for cognitively impaired Resident (R) 96. This placed R96 at risk for additional falls and or injuries. Findings included: - R96's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses sequelae of cerebrovascular accident (CVA-stroke- the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), vascular dementia (problems with reasoning, planning, judgment, memory, and other thought processes caused by brain damage), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), chronic kidney disease (kidneys are damaged and can't filter blood the way they should), diabetes…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-05 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 116 residents. The sample included 24 residents with three residents reviewed for bowel and bladder. Based on observations, record review, and interviews, the facility failed to provide the necessary care and services related to incontinence (lack of voluntary control over urination or defecation) care for Resident (R) 33, who had a history of urinary tract infections (UTI- infection of the urinary tract system) and failed to provide the necessary care and services related to indwelling catheters for R415. This deficient practice placed R33 and R415 at risk for UTIs and related complications. Findings included: - R33's Electronic Medical Record (EMR) documented diagnoses of overactive bladder (a bladder control problem that leads to the sudden urge to urinate), need for assistance with personal care, dementia (a progressive mental disorder characterized by failing memory, confusion) without behavioral disturbance, and Parkinson's disease (a slowly progressive neurologic…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-05 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 116 residents. The sample included 24 residents with one resident reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure the oxygen tubing was stored in a sanitary manner to decrease exposure and contamination for Resident (R)413. This deficient practice placed R413 at increased risk for respiratory infection and complications. Findings included: - R413's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of pulmonary fibrosis (lungs become scared and damaged), need for assistance with personal care, and congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid). The admission Minimum Data Set (MDS) dated [DATE] was in progress. R413's Care Area Assessment (CAA) was in progress. R413's Care Plan dated 05/29/24 documented staff would monitor for shortness of breath, assess his lung sounds, and give medications as ordered. R413's EMR under the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-05 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 116 residents. The sample included 24 residents with five residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to ensure that Resident (R) 60 had a documented risk assessment, a consent for the use of the side rails, and failed to ensure the resident and/or responsible party were advised of the risks and/or benefits of the use of the side rails. This placed the R60 at risk for uninformed decisions and impaired safety related to the risks associated with the use of side rails. Findings included: - R60's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), abnormalities of gait, delirium (sudden severe confusion, disorientation, and restlessness), lack of coordination, cognitive-communication deficit, and hypertension (HTN-elevated blood pressure). The Annual Minimum Data Set (MDS) dated [DATE]…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-05 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 116 residents. The sample included 24 residents with five residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to ensure an appropriate indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat a mental disorder characterized by gross impairment in reality testing) for Resident (R) 71 and R92, who had a diagnosis of dementia (a progressive mental disorder characterized by failing memory, confusion). This placed these residents at risk for unnecessary psychotropic (alters perception, mood, consciousness, cognition, or behavior) medications and related complications. Findings included: - R71's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of Alzheimer's disease (progressive mental deterioration…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-05 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 116 residents. The sample included 24 residents with six residents sampled for hospice services. Based on observation, record review, and interview, the facility failed to ensure a consistent method of communication process, including how the communication would be documented between the facility and the hospice provider, to ensure the needs of the resident were addressed and met 24 hours per day for Resident (R) 5. This placed R5 at risk of decline and/or from maintaining the highest practicable physical, mental, and psychosocial well-being. Findings included: - R5's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of cerebral atherosclerosis (a disease that occurs when the arteries in the brain become hard, thick, and narrow due to the buildup of plaque (fatty deposits) inside the artery walls, kidney disease(your kidneys are damaged and cannot filter blood the way they should), dementia (a progressive mental disorder characterized by failing memory, confusion), and diabetes mellitus (DM-when the body cannot use…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-05 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 116 residents. The sample included 24 residents with five residents reviewed for immunizations. Based on record review, and interviews, the facility failed to obtain consent or declinations for Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial infections) pneumococcal (type of bacterial infection) vaccination or administration information for Residents (R) 53 and R71. This placed the residents at increased risk for complications related to pneumonia. Findings included: - Review of R53's clinical record lacked documentation the PCV20 was offered or declined and lacked documentation of a historical administration. A review of R71's clinical record lacked documentation the PCV20 was offered or declined and lacked documentation of a historical administration. Upon request for R53's and R71's declination or administration of PCV20, the facility was unable to provide consent or declination. During an interview on 06/05/24 at 11:37 AM, Administrative Nurse E, the facility infection preventionist, stated that R53 and R71 had a history of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-01-12 · tag F0558 — failed to accommodate residents' needs and preferences — pattern
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 101 residents. The sample included 21 residents with 21 reviewed for reasonable accommodation of needs. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 6's call light remote was within reach while in her room. The facility additionally failed to ensure foot pedals were provided for Resident (R) 14's, R22's, and R19's wheelchairs to prevent their feet from dragging on the floor. This deficient practice placed R6 at risk unmet care needs and R14, R22, and R19 at risk for injuries. Findings Included: - The Medical Diagnosis section within R6's Electronic Medical Records (EMR) included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), dysphagia (swallowing difficulty), abnormal posture, history of pneumonia (inflammation of the lungs), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), and gastro-esophageal reflux disease (backflow of stomach contents to the esophagus). R6's Quarterly Minimum Data Set (MDS) dated…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-12 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 101 residents. The sample included 21 residents with four reviewed for bowel and bladder management. Based on observation, record review, and interviews, the facility failed follow up on identified changes in R61 bowel and bladder incontinence. This deficient practice placed the residents at risk for complications related to incontinence. Findings Included: - The Medical Diagnosis section within R61's Electronic Medical Records (EMR) included diagnoses dementia (progressive mental disorder characterized by failing memory, confusion), type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), muscle weakness, history of falling, need for assistance with personal cares, chronic kidney disease, major depressive disorder (major mood disorder), and abnormal gait and mobility. R61's Quarterly Minimum Data Set (MDS) dated 09/27/22 noted a Brief Interview for Mental Status (BIMS) score of 13 indicating intact cognition. The MDS indicated that she was frequently incontinent of bowel and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-12 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 101 residents. The sample included 21 residents with two reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to provide orders to administer supplemental oxygen to Resident (R)6. The facility additionally failed to store R5 and R6's supplemental oxygen equipment (masks and tubing) in a sanitary manner. This deficient practice placed R6 at risk for complications related to respiratory care and infections. Findings Included: - The Medical Diagnosis section within R6's Electronic Medical Records (EMR) included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), tachycardia (rapid heartbeat greater than 100 beats per minute), dysphagia (swallowing difficulty), abnormal posture, hypertension (high blood pressure), cardiomegaly (enlarged heart with serious complications related to pumping blood and oxygen throughout the body), history of pneumonia (inflammation of the lungs),…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-12 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 101 residents. The sample included 21 residents. Five residents were sampled for medication review. Based on observation, record review and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified that Resident (R) 14's anti-hypertensive (a medication used to treat elevated blood pressure) medication was given outside of physician ordered parameters. This deficient practice placed R14 at risk for unnecessary medication administration and adverse side effects. Findings included: - The electronic medical record (EMR) for R14 documented diagnoses of atrial fibrillation (A-fib-a rapid, irregular heartbeat), heart failure (the heart cannot pump blood as well as it should), hypertension (HTN- elevated blood pressure). The Annual Minimum Data Set (MDS) dated [DATE] documented R14 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderately impaired cognition. R14 required limited to extensive assistance of one to two staff for her…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-12 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 101 residents. The sample included 21 residents. Five residents were sampled for medication review. Based on observation, record review and interview, the facility failed to ensure Resident (R)14's anti-hypertensive (a medication used to treat elevated blood pressure) medication was given within the physician ordered parameters. This deficient practice placed R14 at risk for unnecessary medication administration and adverse side effects. Findings included: - The electronic medical record (EMR) for R14 documented diagnoses of atrial fibrillation (A-fib-a rapid, irregular heartbeat), heart failure (the heart cannot pump blood as well as it should), hypertension (HTN- elevated blood pressure). The Annual Minimum Data Set (MDS) dated [DATE] documented R14 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderately impaired cognition. R14 required limited to extensive assistance of one to two staff for her activities of daily living (ADLs). R14 required…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2026-04-22 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to display accurate and identifiable posted nurse staffing information. Findings included:- On 04/21/2026 at 08:55 AM, observation revealed a daily staffing sheet hanging on the wall near the nursing station on the first floor of the facility.Review of the Daily Nursing Staffing Information sheets from 07/04/25, 12/02/26, 03/05/26, and 04/21/26 revealed the sheets lacked the scheduled hours. The resident census was missing from the daily nursing staffing information sheets on 12/02/26 & 03/05/26.On 04/22/26 at 01:30 PM, Administrative Nurse D reported that the floor nurse assigned to each unit would fill out the posted staffing sheet for that unit and would then post it prior to the upcoming shift. She then stated that the posted staffing sheet required the facility name, date, current census and the staffing sheet listed the actual hours worked for the nurses, Certified Nurse Aides (CNA), and Certified Medication Aides (CMA), but was unsure about the total hours being listed.The facility posting daily nurse…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$27,841 in federal fines across 2 penalties.

  • $14,444 — penalty dated 2025-04-22
  • $13,397 — penalty dated 2023-12-19

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleShareSince
LAKEVIEW VILLAGE, INC.Organization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 01/01/1996
BEE TRIPLETT, JANAIndividualCORPORATE DIRECTORsince 11/01/2017
BIESMA, JILLIndividualCORPORATE DIRECTORsince 12/19/2019
CLAUSEN, ROBERTIndividualCORPORATE DIRECTORsince 12/29/2008
KARLIN, AMYIndividualCORPORATE DIRECTORsince 03/31/2022
KIMBROUGH, JAYIndividualCORPORATE DIRECTORsince 12/19/2018
SHULL, DAVIDIndividualCORPORATE DIRECTORsince 06/01/2023
STUKE, AMANDAIndividualCORPORATE DIRECTORsince 01/01/2013
WARMAN, GEORGEIndividualCORPORATE DIRECTORsince 10/01/2005
WEST, ROBERTIndividualCORPORATE DIRECTORsince 06/01/2016
HERMON, PAMELAIndividualCORPORATE OFFICERsince 01/01/2021
VALASEK, BRANDONIndividualCORPORATE OFFICERsince 08/04/2025
GARCIA, STEPHANIEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2016
TURLEY, RICHARDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2021
CITY OF LENEXAOrganizationADP OF THE SNFsince 05/29/1991
CURANA HEALTH OF MISSOURI-KANSAS LLCOrganizationADP OF THE SNFsince 06/01/2016

CMS files one row per role, so the 18 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted.

3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$44.4M
Net patient revenuemost recent cost report
-17.5%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 18%Medicare 22%Other / private 59%

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$860per resident / day
operating cost
$26,130per month
≈ monthly operating cost
$732per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in KS

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Kansas Medicaid page.

Typical monthly cost in Kansas
$8,669/mo
Nursing home (semi-private)
$9,064/mo
Nursing home (private)
$5,975/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 175242. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-22, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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