Cycle 1
Health 2024-04-15 · Fire 2024-04-15
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Emporia, KS
Emporia Presbyterian Manor
3-star overall rating with 3-star inspections with $30,244 in total fines with 4 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
2300 Industrial Road, Emporia, KS
(620) 343-2613
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
53
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
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.66
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.59
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
3.25
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.50
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
3.96
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.37
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.76
CMS adjusted RN staffing hours
Adjusted total hours
5.15
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,196
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
45.54
Composite VBP score used to determine payment impact.
Payment multiplier
0.9988
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
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
1.99
Baseline 56.86% · Performance 55.56% · Measure score 1.99 · Achievement 1.99 · Improvement 0
Adjusted total nurse staffing
7.12
Baseline 4.73 hours · Performance 5.10 hours · Measure score 7.12 · Achievement 7.12 · Improvement 3.05
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.93% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 32 · Observed rate 9.38% · Lower 95% interval 6.68% |
| Discharge to community | 42.47% |
50.57%
8.1 pts worse
|
No Different than the National Rate · Eligible stays 25 · Observed rate 36% · Lower 95% interval 28.87% |
| Medicare spending per beneficiary | 0.79 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 96.77% |
95.27%
1.5 pts better
|
Numerator 30 · Denominator 31 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 31 |
| Discharge self-care score | 40.91% |
53.69%
12.8 pts worse
|
Numerator 9 · Denominator 22 |
| Discharge mobility score | 54.55% |
50.94%
3.6 pts better
|
Numerator 12 · Denominator 22 |
| Pressure ulcers or injuries, new or worsened | 6.45% |
2.29%
4.2 pts worse
|
Numerator 2 · Denominator 31 · Adjusted rate 7.07% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 5% |
8.2%
3.2 pts worse
|
Numerator 6 · Denominator 120 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 68.18% |
56.45%
11.7 pts better
|
Numerator 15 · Denominator 22 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · 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 | 1.5 |
1.8
0.3 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.2 · Expected 1.6 · 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 2.7 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 84.8% |
91.8%
7 pts worse
|
93.4%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 77.8% · Q2 72.2% · Q3 93.9% · Q4 96.0% · 4Q avg 84.8% |
| 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 | 3.5% |
4.4%
0.9 pts better
|
3.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 1.9% · Q3 2.0% · Q4 6.0% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
5.6%
5.6 pts better
|
11.4%
11.4 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 who lose too much weight | 12.0% |
5.0%
7 pts worse
|
5.4%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 11.6% · Q3 5.0% · Q4 10.5% · 4Q avg 12.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.0% |
23.2%
7.2 pts better
|
19.6%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 16.3% · Q3 14.3% · Q4 15.4% · 4Q avg 16.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.5% |
19.8%
6.3 pts better
|
16.7%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 17.6% · Q3 12.1% · Q4 8.6% · 4Q avg 13.5% · 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 | 23.3% |
18.4%
4.9 pts worse
|
16.3%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 30.5% · Q3 25.2% · Q4 14.6% · 4Q avg 23.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.5% |
18.8%
7.7 pts worse
|
14.9%
11.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.2% · Q2 26.8% · Q3 25.0% · Q4 19.4% · 4Q avg 26.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
1.8%
0.9 pts better
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 2.2% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.6% |
3.1%
1.5 pts worse
|
1.7%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 5.6% · Q3 2.1% · Q4 8.0% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 35.9% |
23.2%
12.7 pts worse
|
19.8%
16.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.5% · Q2 42.2% · Q3 36.0% · Q4 27.8% · 4Q avg 35.9% |
| Percentage of long-stay residents with pressure ulcers | 7.8% |
4.6%
3.2 pts worse
|
5.1%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 6.8% · Q3 14.1% · Q4 3.6% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 73.8% |
75.6%
1.8 pts worse
|
81.7%
7.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 48.1% · Q3 77.4% · Q4 92.6% · 4Q avg 73.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.2%
2.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 65.0% |
73.5%
8.5 pts worse
|
79.7%
14.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 65.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-11-22 · Fire 2022-11-22
16 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2021-05-10 · Fire 2021-05-10
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
L · Immediate jeopardy
2024-04-15
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-05-15
F · Potential for more than minimal harm
2024-04-15
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2024-06-03
F · Potential for more than minimal harm
2024-04-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-03
F · Potential for more than minimal harm
2024-04-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-06-03
E · Potential for more than minimal harm
2024-04-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-03
E · Potential for more than minimal harm
2024-04-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-05-30
D · Potential for more than minimal harm
2024-04-15
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-06-03
F · Potential for more than minimal harm
2022-11-22
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-02-16
F · Potential for more than minimal harm
2022-11-22
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2023-02-16
E · Potential for more than minimal harm
2022-11-22
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-02-16
F · Potential for more than minimal harm
2021-05-10
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2021-07-22
F · Potential for more than minimal harm
2021-05-10
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2021-06-23
F · Potential for more than minimal harm
2021-05-10
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 2021-07-22
F · Potential for more than minimal harm
2021-05-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-07-22
F · Potential for more than minimal harm
2021-05-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-06-23
F · Potential for more than minimal harm
2021-05-10
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-07-22
F · Potential for more than minimal harm
2021-05-10
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-07-22
F · Potential for more than minimal harm
2021-05-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-06-23
F · Potential for more than minimal harm
2021-05-10
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-07-22
E · Potential for more than minimal harm
2021-05-10
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-07-22
E · Potential for more than minimal harm
2021-05-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-07-22
E · Potential for more than minimal harm
2021-05-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-07-22
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-08-20
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-09-06
D · Potential for more than minimal harm
2024-08-20
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 2024-09-06
F · Potential for more than minimal harm
2024-04-15
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-05-02
E · Potential for more than minimal harm
2024-04-15
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-05-02
D · Potential for more than minimal harm
2024-04-15
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-05-02
D · Potential for more than minimal harm
2024-04-15
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-05-02
J · Immediate jeopardy
2023-08-29
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 2023-08-25
J · Immediate jeopardy
2022-11-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-12-16
F · Potential for more than minimal harm
2022-11-22
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2022-12-16
F · Potential for more than minimal harm
2022-11-22
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 2022-12-16
E · Potential for more than minimal harm
2022-11-22
F572 · Resident Rights Deficiencies
Health
Give residents a notice of rights, rules, services and charges.
Corrected 2022-12-16
E · Potential for more than minimal harm
2022-11-22
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 2022-12-16
E · Potential for more than minimal harm
2022-11-22
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-12-16
E · Potential for more than minimal harm
2022-11-22
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 2022-12-16
D · Potential for more than minimal harm
2022-11-22
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-12-16
D · Potential for more than minimal harm
2022-11-22
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 2022-12-16
D · Potential for more than minimal harm
2022-11-22
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2022-12-16
D · Potential for more than minimal harm
2022-11-22
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-12-16
D · Potential for more than minimal harm
2022-11-22
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-12-16
D · Potential for more than minimal harm
2022-11-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-16
C · Minimal harm
2022-11-22
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2022-12-16
F · Potential for more than minimal harm
2021-05-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-06-09
D · Potential for more than minimal harm
2021-05-10
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 2021-06-09
D · Potential for more than minimal harm
2021-05-10
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 2021-06-09
D · Potential for more than minimal harm
2021-05-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-06-09
D · Potential for more than minimal harm
2021-05-10
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 2021-06-09
D · Potential for more than minimal harm
2021-05-10
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-06-09
Penalties and ownership
What sits behind the stars
$14,651
2024-05-15
Fine
Fine · fine $14,651
Fine
$0
2024-05-15
Payment Denial
Payment Denial · denial start 2024-06-01 · 2 days
2 day denial
$15,593
2023-08-29
Fine
Fine · fine $15,593
Fine
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
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
Shogren, Bruce
W-2 Managing Employee · Individual
Siepelmeier, Susan
Corporate Director · Individual
Siepelmeier, Susan
W-2 Managing Employee · Individual
Taylor, William
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Flint Hills Care And Rehabilitation Center
Emporia, KS
4-star overall rating with 3-star inspections with $49,432 in total fines with 10 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Chase County Care And Rehab
Cottonwood Falls, KS
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#3
Diversicare Of Council Grove
Council Grove, KS
1-star overall rating with 2-star inspections with 16 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
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