Cycle 1
Health 2024-09-12 · Fire 2024-09-12
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
17 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Parsons, KS
Parsons Presbyterian Manor
3-star overall rating with 3-star inspections with $14,433 in total fines with 6 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
3501 Dirr Avenue, Parsons, KS
(620) 421-1450
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
43
Certified beds
Average residents
28
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
1.03
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.51
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
5.00
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.54
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
4.47
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.50
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
1.20
CMS adjusted RN staffing hours
Adjusted total hours
5.84
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
65%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
928
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
62.03
Composite VBP score used to determine payment impact.
Payment multiplier
1.0170
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
2.41
Baseline 42.86% · Performance 53.85% · Measure score 2.41 · Achievement 2.41 · Improvement 0
Adjusted total nurse staffing
10
Baseline 5 hours · Performance 5.85 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.96% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 30 · Observed rate 3.33% · Lower 95% interval 5.99% |
| Discharge to community | 46.92% |
50.57%
3.6 pts worse
|
No Different than the National Rate · Eligible stays 26 · Observed rate 46.15% · Lower 95% interval 34.18% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 14 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 2.9% |
8.2%
5.3 pts worse
|
Numerator 2 · Denominator 69 |
| Staff flu vaccination coverage | 30.56% |
42%
11.4 pts worse
|
Numerator 22 · Denominator 72 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · 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 8 · 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 | 1.4 |
1.8
0.4 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.2 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.0 |
2.2
0.8 pts worse
|
1.8
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 2.5 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 89.7% |
91.8%
2.1 pts worse
|
93.4%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 92.0% · Q2 100.0% · Q3 89.3% · Q4 78.6% · 4Q avg 89.7% |
| 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 | 4.7% |
4.4%
0.3 pts worse
|
3.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 3.8% · Q3 3.6% · Q4 3.6% · 4Q avg 4.7% · 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 | 0.0% |
5.0%
5 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.8% |
23.2%
1.4 pts better
|
19.6%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 23.8% · 4Q avg 21.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.5% |
19.8%
7.3 pts better
|
16.7%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.5% · 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 · 4Q avg 23.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.7% |
18.8%
6.9 pts worse
|
14.9%
10.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 25.0% · 4Q avg 25.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.9% |
1.8%
0.1 pts worse
|
1.0%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.4% · Q4 4.7% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
3.1%
2.1 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.7% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.7% |
23.2%
2.5 pts better
|
19.8%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.0% · Q2 24.1% · Q3 19.6% · Q4 8.1% · 4Q avg 20.7% |
| Percentage of long-stay residents with pressure ulcers | 14.3% |
4.6%
9.7 pts worse
|
5.1%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 14.7% · Q3 11.6% · Q4 12.2% · 4Q avg 14.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 62.9% |
75.6%
12.7 pts worse
|
81.7%
18.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 85.0% · 4Q avg 62.9% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 9.1% |
2.2%
6.9 pts worse
|
1.6%
7.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 9.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-12-20 · Fire 2022-12-20
9 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2021-06-21 · Fire 2021-06-21
5 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-12
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-11-15
F · Potential for more than minimal harm
2024-09-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-08
F · Potential for more than minimal harm
2024-09-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-08
F · Potential for more than minimal harm
2024-09-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-08
F · Potential for more than minimal harm
2024-09-12
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 2024-11-08
F · Potential for more than minimal harm
2024-09-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-08
E · Potential for more than minimal harm
2024-09-12
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 2024-11-08
E · Potential for more than minimal harm
2024-09-12
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 2024-11-08
E · Potential for more than minimal harm
2024-09-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-08
E · Potential for more than minimal harm
2024-09-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-08
E · Potential for more than minimal harm
2024-09-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-11-08
E · Potential for more than minimal harm
2024-09-12
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-11-08
E · Potential for more than minimal harm
2024-09-12
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-11-08
E · Potential for more than minimal harm
2024-09-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-09-12
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-09-12
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-09-12
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-11-08
F · Potential for more than minimal harm
2022-12-20
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 2023-03-21
F · Potential for more than minimal harm
2022-12-20
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-03-21
F · Potential for more than minimal harm
2022-12-20
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 2023-03-21
F · Potential for more than minimal harm
2022-12-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-03-21
F · Potential for more than minimal harm
2022-12-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-21
F · Potential for more than minimal harm
2022-12-20
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-03-21
F · Potential for more than minimal harm
2022-12-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-21
F · Potential for more than minimal harm
2022-12-20
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-03-21
E · Potential for more than minimal harm
2022-12-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-03-21
F · Potential for more than minimal harm
2021-06-21
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-09-03
F · Potential for more than minimal harm
2021-06-21
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 2021-09-03
F · Potential for more than minimal harm
2021-06-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-09-03
F · Potential for more than minimal harm
2021-06-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-09-03
F · Potential for more than minimal harm
2021-06-21
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2021-09-03
F · Potential for more than minimal harm
2021-06-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-09-03
F · Potential for more than minimal harm
2021-06-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-09-03
E · Potential for more than minimal harm
2021-06-21
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 2021-09-03
E · Potential for more than minimal harm
2021-06-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-09-03
E · Potential for more than minimal harm
2021-06-21
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-09-03
D · Potential for more than minimal harm
2021-06-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-09-03
Inspection history
Recent health citations
J · Immediate jeopardy
2024-10-29
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-09-12
F · Potential for more than minimal harm
2024-09-12
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-09-26
F · Potential for more than minimal harm
2024-09-12
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 2024-09-26
D · Potential for more than minimal harm
2024-09-12
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-07-11
D · Potential for more than minimal harm
2024-09-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-09-12
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-09-12
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 2024-09-26
G · Actual harm
2022-12-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-01-06
E · Potential for more than minimal harm
2022-12-20
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-01-06
D · Potential for more than minimal harm
2022-12-20
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-01-06
D · Potential for more than minimal harm
2022-12-20
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 2023-01-06
D · Potential for more than minimal harm
2022-12-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-01-06
D · Potential for more than minimal harm
2022-12-20
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 2023-01-06
D · Potential for more than minimal harm
2022-12-20
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 2023-01-06
D · Potential for more than minimal harm
2022-12-20
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 2023-01-06
G · Actual harm
2021-06-21
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2021-07-14
E · Potential for more than minimal harm
2021-06-21
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 2021-07-14
E · Potential for more than minimal harm
2021-06-21
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 2021-07-14
D · Potential for more than minimal harm
2021-06-21
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-07-14
D · Potential for more than minimal harm
2021-06-21
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 2021-07-14
Penalties and ownership
What sits behind the stars
$14,433
2024-09-12
Fine
Fine · fine $14,433
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
Pegues, Maegen
W-2 Managing Employee · Individual
Presbyterian Manors Of Mid-America Inc
Operational/Managerial Control · Organization
Shogren, Bruce
Corporate Officer · Individual
Taylor, William
Corporate Officer · Individual
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