Lawrence, KS

Lawrence Presbyterian Manor

5-star overall rating with 4-star inspections with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle

1429 Kasold Dr, Lawrence, KS

(785) 841-4262

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

4 / 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

40

Certified beds

Average residents

37

Average occupied residents

Ownership

For-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

1.31

Registered nurse staffing · state 0.72 · national 0.68

LPN hours / resident day

0.18

Licensed practical nurse staffing · state 0.67 · national 0.87

Aide hours / resident day

4.50

Nurse aide staffing · state 2.69 · national 2.35

Total nurse hours

5.99

All reported nurse hours · state 4.07 · national 3.89

Licensed hours

1.49

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

5.29

Weekend nurse staffing · state 3.58 · national 3.43

Weekend RN hours

0.81

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

1.48

CMS adjusted RN staffing hours

Adjusted total hours

6.75

CMS adjusted total nurse staffing hours

Case-mix index

1.21

Higher values indicate more complex resident acuity

RN turnover

31%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

49%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

1,091

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

59.98

Composite VBP score used to determine payment impact.

Payment multiplier

1.0152

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

4.07

Performance 19.54% · Measure score 4.07 · Achievement 4.07 · This facility did not have sufficient data to calculate a baseline period measure result.

Healthcare-associated infections

4.38

Performance 6.53% · Measure score 4.38 · Achievement 4.38 · This facility did not have sufficient data to calculate a baseline period measure result.

Total nurse turnover

5.54

Baseline 51.06% · Performance 41.03% · Measure score 5.54 · Achievement 5.54 · Improvement 3.33

Adjusted total nurse staffing

10

Baseline 4.77 hours · Performance 6.50 hours · Measure score 10 · Achievement 10 · Improvement 9

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.18%	10.72% 0.5 pts worse	No Different than the National Rate · Eligible stays 64 · Observed rate 9.38% · Lower 95% interval 7.31%
Discharge to community	34.18%	50.57% 16.4 pts worse	Worse than the National Rate · Eligible stays 57 · Observed rate 28.07% · Lower 95% interval 25.66%
Medicare spending per beneficiary	0.81	1.02 0.2 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 41 · Denominator 41
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 41
Discharge self-care score	43.75%	53.69% 9.9 pts worse	Numerator 14 · Denominator 32
Discharge mobility score	43.75%	50.94% 7.2 pts worse	Numerator 14 · Denominator 32
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 41 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	6.53%	7.12% 0.6 pts better	No Different than the National Rate · Eligible stays 37 · Observed rate 2.7% · Lower 95% interval 3.8%
Staff COVID-19 vaccination coverage	11.27%	8.2% 3.1 pts better	Numerator 16 · Denominator 142
Staff flu vaccination coverage	Not Available	42%	Numerator Not Available · Denominator Not Available · No data were submitted for this measure.
Discharge function score	50%	56.45% 6.5 pts worse	Numerator 16 · Denominator 32
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 11 · 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	0.8	1.8 1 pts better	1.9 1.1 pts better	Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.6 · Expected 1.4 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.8	2.2 0.4 pts better	1.8 About the same	Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.5 · Expected 1.4 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	98.6%	91.8% 6.8 pts better	93.4% 5.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 94.6% · Q3 100.0% · Q4 100.0% · 4Q avg 98.6%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	97.5%	95.5% 2 pts better	95.5% 2 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 97.5%
Percentage of long-stay residents experiencing one or more falls with major injury	6.3%	4.4% 1.9 pts worse	3.3% 3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 5.4% · Q3 5.9% · Q4 8.3% · 4Q avg 6.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	2.3%	5.6% 3.3 pts better	11.4% 9.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 0.0% · Q3 0.0% · Q4 5.6% · 4Q avg 2.3%
Percentage of long-stay residents who lose too much weight	3.6%	5.0% 1.4 pts better	5.4% 1.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 0.0% · Q3 0.0% · Q4 12.5% · 4Q avg 3.6%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	12.6%	23.2% 10.6 pts better	19.6% 7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 9.7% · Q3 15.4% · Q4 8.3% · 4Q avg 12.6%
Percentage of long-stay residents who received an antipsychotic medication	5.7%	19.8% 14.1 pts better	16.7% 11 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q3 4.8% · Q4 5.0% · 4Q avg 5.7% · 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	18.8%	18.4% 0.4 pts worse	16.3% 2.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q3 22.6% · 4Q avg 18.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	12.3%	18.8% 6.5 pts better	14.9% 2.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 3.7% · Q3 15.4% · Q4 12.5% · 4Q avg 12.3% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.6%	1.8% 1.2 pts better	1.0% 0.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	7.8%	3.1% 4.7 pts worse	1.7% 6.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 8.3% · Q3 2.9% · Q4 13.9% · 4Q avg 7.8% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	30.9%	23.2% 7.7 pts worse	19.8% 11.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 35.6% · Q3 27.0% · Q4 32.1% · 4Q avg 30.9%
Percentage of long-stay residents with pressure ulcers	2.4%	4.6% 2.2 pts better	5.1% 2.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 3.4% · Q3 2.6% · Q4 0.0% · 4Q avg 2.4% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	78.1%	75.6% 2.5 pts better	81.7% 3.6 pts worse	Short Stay · 2024Q4-2025Q3 · 4Q avg 78.1%
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

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-05-08 · Fire 2024-05-08

7 health deficiencies

Top issue: Nursing and Physician Services (2 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 2 Health 2022-11-02 · Fire 2022-11-02

2 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)

5 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 3 Health 2021-06-17 · Fire 2021-06-17

0 health deficiencies

No concentrated health issue counts in this cycle.

9 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-05-08

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-07-01

F · Potential for more than minimal harm 2024-05-08

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-07-01

F · Potential for more than minimal harm 2024-05-08

K347 · Smoke Deficiencies

Fire Safety

Properly provide smoke detection systems in areas open to corridors.

Corrected 2024-07-01

F · Potential for more than minimal harm 2024-05-08

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-07-01

E · Potential for more than minimal harm 2024-05-08

K354 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Corrected 2024-07-17

F · Potential for more than minimal harm 2022-11-02

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-01-20

E · Potential for more than minimal harm 2022-11-02

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2023-01-20

E · Potential for more than minimal harm 2022-11-02

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 2023-01-20

E · Potential for more than minimal harm 2022-11-02

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2023-01-20

E · Potential for more than minimal harm 2022-11-02

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-01-20

F · Potential for more than minimal harm 2021-06-17

K311 · Smoke Deficiencies

Fire Safety

Have an enclosure around a vertical opening shaft.

Corrected 2021-08-18

F · Potential for more than minimal harm 2021-06-17

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2021-08-18

F · Potential for more than minimal harm 2021-06-17

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2021-08-18

F · Potential for more than minimal harm 2021-06-17

K531 · Services Deficiencies

Fire Safety

Have elevators that firefighters can control in the event of a fire.

Corrected 2021-08-18

F · Potential for more than minimal harm 2021-06-17

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2021-08-18

F · Potential for more than minimal harm 2021-06-17

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2021-08-18

E · Potential for more than minimal harm 2021-06-17

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 2021-08-18

E · Potential for more than minimal harm 2021-06-17

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2021-08-18

E · Potential for more than minimal harm 2021-06-17

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2021-08-18

Inspection history

Recent health citations

F · Potential for more than minimal harm 2024-05-08

F730 · Nursing and Physician Services Deficiencies

Health

Observe each nurse aide's job performance and give regular training.

Corrected 2024-06-13

D · Potential for more than minimal harm 2024-05-08

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-06-13

D · Potential for more than minimal harm 2024-05-08

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-06-13

D · Potential for more than minimal harm 2024-05-08

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 2024-06-13

D · Potential for more than minimal harm 2024-05-08

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 2024-06-13

D · Potential for more than minimal harm 2024-05-08

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2024-06-13

C · Minimal harm 2024-05-08

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2024-06-13

D · Potential for more than minimal harm 2022-11-02

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2022-12-01

D · Potential for more than minimal harm 2022-11-02

F726 · Nursing and Physician Services Deficiencies

Health

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Corrected 2022-12-01

Penalties and ownership

What sits behind the stars

Ownership

Presbyterian Manors Inc

5% Or Greater Direct Ownership Interest · Organization

100% 13 facilities 1989-03-30

Bonney, Robert