Cycle 1
Health 2024-08-14 · Fire 2024-08-14
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Clay Center, KS
Clay Center Presbyterian Manor
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
924 8th Street, Clay Center, KS
(785) 632-5646
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
30
Certified beds
Average residents
29
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Presbyterian Manors Of Mid-America
Operator or chain grouping
Approved since
1994-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
13 facilities
Chain averages 4 overall / 4 health / 4 staffing / 3 quality stars
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
0.75
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.50
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
3.15
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.40
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.25
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.91
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.42
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.90
CMS adjusted RN staffing hours
Adjusted total hours
5.31
CMS adjusted total nurse staffing hours
Case-mix index
1.13
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
30%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,225
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
58.69
Composite VBP score used to determine payment impact.
Payment multiplier
1.0139
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
3.05
Baseline 7.25% · Performance 6.92% · Measure score 3.05 · Achievement 3.05 · Improvement 0.95
Total nurse turnover
5.57
Baseline 35.48% · Performance 40.91% · Measure score 5.57 · Achievement 5.57 · Improvement 0
Adjusted total nurse staffing
8.98
Performance 5.63 hours · Measure score 8.98 · Achievement 8.98 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.68% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 39 · Observed rate 7.69% · Lower 95% interval 6.58% |
| Discharge to community | 28.06% |
50.57%
22.5 pts worse
|
Worse than the National Rate · Eligible stays 27 · Observed rate 11.11% · Lower 95% interval 19.13% |
| Medicare spending per beneficiary | 1.14 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 95% |
95.27%
0.3 pts worse
|
Numerator 19 · Denominator 20 |
| Falls with major injury | 5% |
0.77%
4.2 pts worse
|
Numerator 1 · Denominator 20 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 20 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.92% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 26 · Observed rate 3.85% · Lower 95% interval 3.57% |
| Staff COVID-19 vaccination coverage | 20.99% |
8.2%
12.8 pts better
|
Numerator 17 · Denominator 81 |
| Staff flu vaccination coverage | 34.62% |
42%
7.4 pts worse
|
Numerator 27 · Denominator 78 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
1.8
0.5 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 1.4 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.1 |
2.2
0.9 pts worse
|
1.8
1.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 2.3 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
91.8%
7.2 pts better
|
93.4%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 96.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.0% |
| 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 | 7.6% |
4.4%
3.2 pts worse
|
3.3%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 16.0% · Q3 0.0% · Q4 0.0% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.0% |
5.6%
3.4 pts worse
|
11.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 8.7% · Q3 7.7% · Q4 8.0% · 4Q avg 9.0% |
| Percentage of long-stay residents who lose too much weight | 4.8% |
5.0%
0.2 pts better
|
5.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.0% · Q3 7.4% · Q4 7.7% · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.6% |
23.2%
15.6 pts better
|
19.6%
12 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 4.0% · Q3 7.4% · Q4 7.7% · 4Q avg 7.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.2% |
19.8%
11.6 pts better
|
16.7%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 8.7% · Q3 7.7% · Q4 8.0% · 4Q avg 8.2% · 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 | 20.5% |
18.4%
2.1 pts worse
|
16.3%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.2% · Q2 30.4% · Q3 11.8% · Q4 15.7% · 4Q avg 20.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.0% |
18.8%
7.2 pts worse
|
14.9%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 20.0% · Q3 22.2% · Q4 34.6% · 4Q avg 26.0% · 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 | 6.7% |
3.1%
3.6 pts worse
|
1.7%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 4.0% · Q3 7.4% · Q4 11.5% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.5% |
23.2%
5.7 pts better
|
19.8%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 32.7% · Q3 12.2% · Q4 19.5% · 4Q avg 17.5% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
4.6%
4.6 pts better
|
5.1%
5.1 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 short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
75.6%
24.4 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-07 · Fire 2023-03-07
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2021-09-02 · Fire 2021-09-02
3 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
6 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-17
F · Potential for more than minimal harm
2023-03-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-08
F · Potential for more than minimal harm
2023-03-07
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-05-08
F · Potential for more than minimal harm
2021-09-02
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2021-11-11
F · Potential for more than minimal harm
2021-09-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-11-11
F · Potential for more than minimal harm
2021-09-02
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2021-11-11
F · Potential for more than minimal harm
2021-09-02
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2021-11-11
F · Potential for more than minimal harm
2021-09-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-11-11
F · Potential for more than minimal harm
2021-09-02
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2021-11-11
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-08-14
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-09-12
D · Potential for more than minimal harm
2024-08-14
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-09-12
D · Potential for more than minimal harm
2024-08-14
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 2024-09-12
D · Potential for more than minimal harm
2024-08-14
F741 · Quality of Life and Care Deficiencies
Health
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Corrected 2024-09-12
D · Potential for more than minimal harm
2024-08-14
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-09-12
D · Potential for more than minimal harm
2024-08-14
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-09-12
E · Potential for more than minimal harm
2023-03-07
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 2023-04-09
D · Potential for more than minimal harm
2023-03-07
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-04-09
D · Potential for more than minimal harm
2023-03-07
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-04-09
D · Potential for more than minimal harm
2023-03-07
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2023-04-09
D · Potential for more than minimal harm
2023-03-07
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 2023-04-09
F · Potential for more than minimal harm
2021-09-02
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2021-10-02
F · Potential for more than minimal harm
2021-09-02
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 2021-10-02
D · Potential for more than minimal harm
2021-09-02
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2021-10-02
Penalties and ownership
What sits behind the stars
Ownership
Presbyterian Manors Inc
5% Or Greater Direct Ownership Interest · Organization
Bonney, Robert
Corporate Director · Individual
Brennecke, Gary
Corporate Director · Individual
Cook, James
Corporate Director · Individual
Gilbert, Christian
W-2 Managing Employee · Individual
Goodwin, John
Corporate Director · Individual
Harris, Daniel
Corporate Director · Individual
Hind, Sherry
Corporate Officer · Individual
Mckell, Elizabeth
Corporate Director · Individual
Miller, Joan
Corporate Officer · Individual
Morrison, Aaron
Corporate Director · Individual
Nelson, Eleanor
Corporate Director · Individual
Owens, Melanie
Corporate Officer · Individual
Presbyterian Manors Of Mid-America Inc
Operational/Managerial Control · Organization
Shogren, Bruce
Corporate Officer · Individual
Taylor, William
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Wakefield Care And Rehab
Wakefield, KS
4-star overall rating with 4-star inspections with $15,593 in total fines with 3 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
Leonardville Nursing Home
Leonardville, KS
4-star overall rating with 5-star inspections with $7,446 in total fines with 4 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
Linn Community Nursing Home
Linn, KS
2-star overall rating with 2-star inspections with $10,036 in total fines with 11 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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