Cycle 1
Health 2024-06-05 · Fire 2024-06-05
12 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Lenexa, KS
Lakeview Village
3-star overall rating with 2-star inspections with $35,619 in total fines with 12 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
13840 W 91st Terrace, Lenexa, KS
(913) 888-1900
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
158
Certified beds
Average residents
114
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1993-03-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.01
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.91
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
3.74
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
5.66
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.92
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
5.26
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.72
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.26
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
1.26
CMS adjusted RN staffing hours
Adjusted total hours
7.00
CMS adjusted total nurse staffing hours
Case-mix index
1.11
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
897
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
62.37
Composite VBP score used to determine payment impact.
Payment multiplier
1.0173
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.35% · Performance 23.71% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
10
Baseline 4.85% · Performance 4.57% · Measure score 10 · Achievement 10 · Improvement 9
Total nurse turnover
4.95
Baseline 36.36% · Performance 43.45% · Measure score 4.95 · Achievement 4.95 · Improvement 0
Adjusted total nurse staffing
10
Baseline 5.70 hours · Performance 6.26 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.71% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 538 · Observed rate 10.41% · Lower 95% interval 9.28% |
| Discharge to community | 51.54% |
50.57%
1 pts better
|
No Different than the National Rate · Eligible stays 519 · Observed rate 50.1% · Lower 95% interval 48.12% |
| Medicare spending per beneficiary | 0.74 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 97.79% |
95.27%
2.5 pts better
|
Numerator 310 · Denominator 317 |
| Falls with major injury | 0.63% |
0.77%
0.1 pts better
|
Numerator 2 · Denominator 317 |
| Discharge self-care score | 82.63% |
53.69%
28.9 pts better
|
Numerator 214 · Denominator 259 |
| Discharge mobility score | 80.69% |
50.94%
29.8 pts better
|
Numerator 209 · Denominator 259 |
| Pressure ulcers or injuries, new or worsened | 0.95% |
2.29%
1.3 pts better
|
Numerator 3 · Denominator 317 · Adjusted rate 1.3% |
| Healthcare-associated infections requiring hospitalization | 4.57% |
7.12%
2.5 pts better
|
Better than the National Rate · Eligible stays 316 · Observed rate 2.22% · Lower 95% interval 2.92% |
| Staff COVID-19 vaccination coverage | 15.25% |
8.2%
7.1 pts better
|
Numerator 95 · Denominator 623 |
| Staff flu vaccination coverage | 36.86% |
42%
5.1 pts worse
|
Numerator 268 · Denominator 727 |
| Discharge function score | 89.19% |
56.45%
32.7 pts better
|
Numerator 231 · Denominator 259 |
| Transfer of health information to provider | 98.55% |
95.95%
2.6 pts better
|
Numerator 204 · Denominator 207 |
| Transfer of health information to patient | 97.26% |
96.28%
1 pts better
|
Numerator 71 · Denominator 73 |
| Resident COVID-19 vaccinations up to date | 63.91% |
25.2%
38.7 pts better
|
Numerator 108 · Denominator 169 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.8
0.3 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.6 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
2.2
0.9 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.3 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
91.8%
7.3 pts better
|
93.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.0% · Q3 98.8% · Q4 98.8% · 4Q avg 99.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.5%
4.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.9% |
4.4%
0.5 pts worse
|
3.3%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 6.2% · Q3 7.5% · Q4 3.6% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.3% |
5.6%
1.3 pts better
|
11.4%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 3.8% · Q3 8.7% · Q4 4.1% · 4Q avg 4.3% |
| Percentage of long-stay residents who lose too much weight | 5.0% |
5.0%
About the same
|
5.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 3.0% · Q3 8.1% · Q4 3.3% · 4Q avg 5.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 31.1% |
23.2%
7.9 pts worse
|
19.6%
11.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.4% · Q2 32.9% · Q3 31.7% · Q4 32.8% · 4Q avg 31.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.9% |
19.8%
15.9 pts better
|
16.7%
12.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 5.5% · Q3 1.8% · Q4 3.6% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 27.1% |
18.4%
8.7 pts worse
|
16.3%
10.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.8% · Q2 27.2% · Q3 36.3% · Q4 21.7% · 4Q avg 27.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.8% |
18.8%
6 pts worse
|
14.9%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 26.8% · Q3 33.9% · Q4 27.4% · 4Q avg 24.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.8%
1.8 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.5% |
3.1%
1.6 pts better
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 1.1% · Q3 1.3% · Q4 1.2% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.9% |
23.2%
2.7 pts worse
|
19.8%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.1% · Q2 29.5% · Q3 28.9% · Q4 25.4% · 4Q avg 25.9% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
4.6%
About the same
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 4.2% · Q3 6.9% · Q4 5.5% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.4% |
75.6%
21.8 pts better
|
81.7%
15.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.7% · Q2 97.9% · Q3 97.7% · Q4 94.8% · 4Q avg 97.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.2% |
11.7%
4.5 pts better
|
12.0%
4.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.2% · Observed 6.2% · Expected 9.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
2.2%
2 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.0% · Q3 0.0% · Q4 0.4% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.3% |
73.5%
23.8 pts better
|
79.7%
17.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.4% |
23.0%
6.4 pts worse
|
23.9%
5.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.4% · Observed 20.5% · Expected 16.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-01-12 · Fire 2023-01-12
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2021-07-12 · Fire 2021-07-12
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
15 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-06-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-12
F · Potential for more than minimal harm
2024-06-05
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-08-12
F · Potential for more than minimal harm
2024-06-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-08-13
F · Potential for more than minimal harm
2024-06-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-12
F · Potential for more than minimal harm
2024-06-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-08-12
E · Potential for more than minimal harm
2024-06-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-12
F · Potential for more than minimal harm
2023-01-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-03-07
F · Potential for more than minimal harm
2023-01-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-07
F · Potential for more than minimal harm
2023-01-12
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-03-07
F · Potential for more than minimal harm
2023-01-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-07
F · Potential for more than minimal harm
2023-01-12
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-03-07
E · Potential for more than minimal harm
2023-01-12
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-03-07
E · Potential for more than minimal harm
2023-01-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-03-07
E · Potential for more than minimal harm
2023-01-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-03-07
E · Potential for more than minimal harm
2023-01-12
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-03-07
E · Potential for more than minimal harm
2023-01-12
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-03-07
F · Potential for more than minimal harm
2021-07-12
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2021-09-02
F · Potential for more than minimal harm
2021-07-12
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-09-02
F · Potential for more than minimal harm
2021-07-12
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2021-09-02
F · Potential for more than minimal harm
2021-07-12
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2021-09-02
F · Potential for more than minimal harm
2021-07-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-09-02
F · Potential for more than minimal harm
2021-07-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-09-02
F · Potential for more than minimal harm
2021-07-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-09-02
F · Potential for more than minimal harm
2021-07-12
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-09-02
F · Potential for more than minimal harm
2021-07-12
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2021-09-02
F · Potential for more than minimal harm
2021-07-12
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2021-09-02
F · Potential for more than minimal harm
2021-07-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-09-02
F · Potential for more than minimal harm
2021-07-12
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2021-09-02
F · Potential for more than minimal harm
2021-07-12
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-09-02
E · Potential for more than minimal harm
2021-07-12
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-09-02
D · Potential for more than minimal harm
2021-07-12
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-09-02
Inspection history
Recent health citations
J · Immediate jeopardy
2025-04-22
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-15
F · Potential for more than minimal harm
2024-06-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-07-05
F · Potential for more than minimal harm
2024-06-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-05
E · Potential for more than minimal harm
2024-06-05
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-06-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-06-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-06-05
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-06-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-06-05
F700 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-06-05
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-06-05
F849 · Administration Deficiencies
Health
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.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-06-05
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-07-05
J · Immediate jeopardy
2023-12-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-05
E · Potential for more than minimal harm
2023-01-12
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-02-12
D · Potential for more than minimal harm
2023-01-12
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-02-12
D · Potential for more than minimal harm
2023-01-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-02-12
D · Potential for more than minimal harm
2023-01-12
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-02-12
D · Potential for more than minimal harm
2023-01-12
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-02-12
Penalties and ownership
What sits behind the stars
$22,222
2025-04-22
Fine
Fine · fine $22,222
Fine
$13,397
2023-12-19
Fine
Fine · fine $13,397
Fine
Ownership
Lakeview Village, Inc.
5% Or Greater Direct Ownership Interest · Organization
Bee Triplett, Jana
Corporate Director · Individual
Biesma, Jill
Corporate Director · Individual
Clausen, Robert
Corporate Director · Individual
Garcia, Stephanie
Operational/Managerial Control · Individual
Hermon, Pamela
Corporate Officer · Individual
Karlin, Amy
Corporate Director · Individual
Kimbrough, Jay
Corporate Director · Individual
Shull, David
Corporate Director · Individual
Stuke, Amanda
Corporate Director · Individual
Turley, Richard
Operational/Managerial Control · Individual
Valasek, Brandon
Corporate Officer · Individual
Warman, George
Corporate Director · Individual
West, Robert
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Westchester Village Of Lenexa
Lenexa, KS
3-star overall rating with 4-star inspections with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Delmar Gardens Of Lenexa
Lenexa, KS
4-star overall rating with 5-star inspections with 7 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#3
Shawnee Gardens Healthcare & Rehab Center
Shawnee, KS
1-star overall rating with 1-star inspections with abuse icon flag with $94,968 in total fines with 24 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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