Cycle 1
Health 2024-10-14 · Fire 2024-10-14
8 health deficiencies
Top issue: Resident Rights (6 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Lawrence, KS
Lawrence Memorial Hospital SNF
4-star overall rating with 3-star inspections with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
325 Maine Street, Lawrence, KS
(785) 749-6470
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
14
Certified beds
Average residents
15
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1985-10-08
CMS approved date
Coverage
Medicare
Participation flags
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
3.11
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.81
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
3.46
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
7.38
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
3.91
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
6.50
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
2.18
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
3.20
CMS adjusted RN staffing hours
Adjusted total hours
7.59
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
1
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
100
Composite VBP score used to determine payment impact.
Payment multiplier
1.0278
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 16.14% · Performance 16.54% · Measure score 10 · Achievement 10 · Improvement 0
Healthcare-associated infections
10
Baseline 4.03% · Performance 4.55% · Measure score 10 · Achievement 10 · Improvement 0
Total nurse turnover
10
Baseline 30.95% · Performance 18.92% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.1% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 436 · Observed rate 9.4% · Lower 95% interval 8.96% |
| Discharge to community | 75.7% |
50.57%
25.1 pts better
|
Better than the National Rate · Eligible stays 385 · Observed rate 80.52% · Lower 95% interval 72.39% |
| Medicare spending per beneficiary | 0.65 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 99.53% |
95.27%
4.3 pts better
|
Numerator 211 · Denominator 212 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 212 |
| Discharge self-care score | 30.21% |
53.69%
23.5 pts worse
|
Numerator 58 · Denominator 192 |
| Discharge mobility score | 48.96% |
50.94%
2 pts worse
|
Numerator 94 · Denominator 192 |
| Pressure ulcers or injuries, new or worsened | 0.94% |
2.29%
1.4 pts better
|
Numerator 2 · Denominator 212 · Adjusted rate 1.39% |
| Healthcare-associated infections requiring hospitalization | 4.55% |
7.12%
2.6 pts better
|
Better than the National Rate · Eligible stays 223 · Observed rate 1.35% · Lower 95% interval 2.51% |
| Staff COVID-19 vaccination coverage | 35.29% |
8.2%
27.1 pts better
|
Numerator 6 · Denominator 17 |
| Staff flu vaccination coverage | 96.65% |
42%
54.7 pts better
|
Numerator 2597 · Denominator 2687 |
| Discharge function score | 52.6% |
56.45%
3.9 pts worse
|
Numerator 101 · Denominator 192 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 37 · Denominator 37 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 175 · Denominator 175 |
| Resident COVID-19 vaccinations up to date | 51.4% |
25.2%
26.2 pts better
|
Numerator 55 · Denominator 107 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
75.6%
24.2 pts better
|
81.7%
18.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 99.4% · 4Q avg 99.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.8% |
11.7%
1.9 pts better
|
12.0%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.8% · Observed 7.9% · Expected 9.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
2.2%
1.3 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.0% · Q4 2.5% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.5% |
73.5%
23 pts better
|
79.7%
16.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.6% |
23.0%
1.4 pts better
|
23.9%
2.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.6% · Observed 13.8% · Expected 15.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-21 · Fire 2023-06-21
1 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2021-12-22 · Fire 2021-12-22
0 health deficiencies
No concentrated health issue counts in this cycle.
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-10
F · Potential for more than minimal harm
2024-10-14
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-12-10
F · Potential for more than minimal harm
2024-10-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-12-10
F · Potential for more than minimal harm
2024-10-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-12-10
F · Potential for more than minimal harm
2024-10-14
K924 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that anesthesia apparatus are tested after any adjustment, modification or repair.
Corrected 2024-12-10
F · Potential for more than minimal harm
2023-06-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-10
F · Potential for more than minimal harm
2023-06-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-07-10
F · Potential for more than minimal harm
2023-06-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-10
F · Potential for more than minimal harm
2021-12-22
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-01-15
F · Potential for more than minimal harm
2021-12-22
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2022-01-15
F · Potential for more than minimal harm
2021-12-22
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2022-01-15
F · Potential for more than minimal harm
2021-12-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-01-15
F · Potential for more than minimal harm
2021-12-22
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-01-15
D · Potential for more than minimal harm
2021-12-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-01-15
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-10-14
F575 · Resident Rights Deficiencies
Health
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Corrected 2024-11-15
F · Potential for more than minimal harm
2024-10-14
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 2024-11-15
F · Potential for more than minimal harm
2024-10-14
F620 · Resident Rights Deficiencies
Health
Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
Corrected 2024-11-15
F · Potential for more than minimal harm
2024-10-14
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-14
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-14
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-14
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-11-15
C · Minimal harm
2024-10-14
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2024-11-15
D · Potential for more than minimal harm
2023-06-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-28
Penalties and ownership
What sits behind the stars
Ownership
Chestnut, Robert
Operational/Managerial Control · Individual
D'amico, Sheryle
Operational/Managerial Control · Individual
Hilmes, Kelly
Operational/Managerial Control · Individual
Johnson, Russell
Operational/Managerial Control · Individual
Quick, Shari
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Lawrence Presbyterian Manor
Lawrence, KS
5-star overall rating with 4-star inspections with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Pioneer Ridge Retirement Community
Lawrence, KS
1-star overall rating with 1-star inspections with $14,901 in total fines with 23 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Medicalodges Eudora
Eudora, KS
1-star overall rating with 1-star inspections with abuse icon flag with $14,901 in total fines with 23 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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