Cycle 1
Health 2025-05-28 · Fire 2025-05-28
10 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Wichita, KS
Wichita Presbyterian Manor
4-star overall rating with 4-star inspections with 10 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
4700 W 13th Street North, Wichita, KS
(316) 942-7456
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
47
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
0.78
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.83
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
2.89
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
1.61
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
4.03
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.61
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.86
CMS adjusted RN staffing hours
Adjusted total hours
4.94
CMS adjusted total nurse staffing hours
Case-mix index
1.25
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
1,972
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
52.54
Composite VBP score used to determine payment impact.
Payment multiplier
1.0071
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.44
Baseline 18.67% · Performance 17.52% · Measure score 8.44 · Achievement 8.44 · Improvement 6.52
Healthcare-associated infections
5.50
Baseline 4.42% · Performance 6.19% · Measure score 5.50 · Achievement 5.50 · Improvement 0
Total nurse turnover
1.91
Baseline 66.67% · Performance 56.60% · Measure score 1.91 · Achievement 1.73 · Improvement 1.91
Adjusted total nurse staffing
5.16
Baseline 4.88 hours · Performance 4.55 hours · Measure score 5.16 · Achievement 5.16 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.81% |
10.72%
1.9 pts better
|
No Different than the National Rate · Eligible stays 199 · Observed rate 5.53% · Lower 95% interval 6.1% |
| Discharge to community | 58.95% |
50.57%
8.4 pts better
|
Better than the National Rate · Eligible stays 193 · Observed rate 58.03% · Lower 95% interval 53.42% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 99.24% |
95.27%
4 pts better
|
Numerator 130 · Denominator 131 |
| Falls with major injury | 0.76% |
0.77%
About the same
|
Numerator 1 · Denominator 131 |
| Discharge self-care score | 68.1% |
53.69%
14.4 pts better
|
Numerator 79 · Denominator 116 |
| Discharge mobility score | 22.41% |
50.94%
28.5 pts worse
|
Numerator 26 · Denominator 116 |
| Pressure ulcers or injuries, new or worsened | 1.53% |
2.29%
0.8 pts better
|
Numerator 2 · Denominator 131 · Adjusted rate 2.2% |
| Healthcare-associated infections requiring hospitalization | 6.19% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 117 · Observed rate 4.27% · Lower 95% interval 3.69% |
| Staff COVID-19 vaccination coverage | 0.58% |
8.2%
7.6 pts worse
|
Numerator 1 · Denominator 171 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 158 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 58 · Denominator 116 |
| Transfer of health information to provider | 97.62% |
95.95%
1.7 pts better
|
Numerator 41 · Denominator 42 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 65 · Denominator 65 |
| Resident COVID-19 vaccinations up to date | 46.38% |
25.2%
21.2 pts better
|
Numerator 32 · Denominator 69 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
1.8
1.1 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.7 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
2.2
1.5 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.7 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.0% |
91.8%
5.2 pts better
|
93.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.8% · Q2 97.2% · Q3 97.0% · Q4 97.1% · 4Q avg 97.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 85.7% |
95.5%
9.8 pts worse
|
95.5%
9.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 85.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.9% |
4.4%
1.5 pts worse
|
3.3%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 2.8% · Q3 9.1% · Q4 8.6% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.5% |
5.6%
3.1 pts better
|
11.4%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.0% · Q3 0.0% · Q4 3.0% · 4Q avg 2.5% |
| Percentage of long-stay residents who lose too much weight | 9.1% |
5.0%
4.1 pts worse
|
5.4%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 3.2% · Q3 3.7% · Q4 21.4% · 4Q avg 9.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.9% |
23.2%
7.7 pts worse
|
19.6%
11.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.2% · Q2 32.3% · Q3 33.3% · Q4 28.6% · 4Q avg 30.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.4% |
19.8%
13.4 pts better
|
16.7%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 4.8% · Q4 4.8% · 4Q avg 6.4% · 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 | 33.3% |
18.4%
14.9 pts worse
|
16.3%
17 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 33.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 32.7% |
18.8%
13.9 pts worse
|
14.9%
17.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 31.0% · Q3 34.6% · Q4 32.0% · 4Q avg 32.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.4% |
1.8%
2.6 pts worse
|
1.0%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 5.8% · Q3 6.2% · Q4 0.0% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.5% |
3.1%
1.6 pts better
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 2.8% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 37.6% |
23.2%
14.4 pts worse
|
19.8%
17.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.3% · Q2 41.0% · Q3 46.0% · Q4 27.3% · 4Q avg 37.6% |
| Percentage of long-stay residents with pressure ulcers | 0.5% |
4.6%
4.1 pts better
|
5.1%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.1% |
75.6%
19.5 pts better
|
81.7%
13.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 87.7% · Q2 96.7% · Q3 97.7% · Q4 100.0% · 4Q avg 95.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.9% |
11.7%
4.8 pts better
|
12.0%
5.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.9% · Observed 6.2% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
2.2%
0.8 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.4% · Q3 1.5% · Q4 1.6% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 51.1% |
73.5%
22.4 pts worse
|
79.7%
28.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 51.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.0% |
23.0%
5 pts better
|
23.9%
5.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.0% · Observed 14.2% · Expected 18.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-14 · Fire 2023-09-14
4 health deficiencies
Top issue: Infection Control (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2021-12-06 · Fire 2021-12-06
4 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-28
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-08-13
F · Potential for more than minimal harm
2025-05-28
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 2025-08-13
F · Potential for more than minimal harm
2025-05-28
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 2025-08-13
F · Potential for more than minimal harm
2025-05-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-13
F · Potential for more than minimal harm
2025-05-28
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-08-13
F · Potential for more than minimal harm
2025-05-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-08-13
F · Potential for more than minimal harm
2025-05-28
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-08-13
F · Potential for more than minimal harm
2024-04-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-05-03
F · Potential for more than minimal harm
2024-04-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-03
F · Potential for more than minimal harm
2024-04-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-03
F · Potential for more than minimal harm
2023-09-14
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-10-31
F · Potential for more than minimal harm
2023-09-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-31
F · Potential for more than minimal harm
2023-09-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-31
F · Potential for more than minimal harm
2021-12-06
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2022-02-18
F · Potential for more than minimal harm
2021-12-06
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-02-18
F · Potential for more than minimal harm
2021-12-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-02-18
F · Potential for more than minimal harm
2021-12-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-02-18
F · Potential for more than minimal harm
2021-12-06
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-02-18
F · Potential for more than minimal harm
2021-12-06
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-02-18
F · Potential for more than minimal harm
2021-12-06
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-02-18
F · Potential for more than minimal harm
2021-12-06
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-02-18
E · Potential for more than minimal harm
2021-12-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-02-18
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-28
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 2025-07-09
E · Potential for more than minimal harm
2025-05-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-09
E · Potential for more than minimal harm
2025-05-28
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2025-07-09
D · Potential for more than minimal harm
2025-05-28
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-07-09
D · Potential for more than minimal harm
2025-05-28
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-07-09
D · Potential for more than minimal harm
2025-05-28
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-07-09
D · Potential for more than minimal harm
2025-05-28
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 2025-07-09
D · Potential for more than minimal harm
2025-05-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-09
D · Potential for more than minimal harm
2025-05-28
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 2025-07-09
D · Potential for more than minimal harm
2025-05-28
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-07-09
F · Potential for more than minimal harm
2023-09-14
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 2023-10-13
D · Potential for more than minimal harm
2023-09-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-10-13
D · Potential for more than minimal harm
2023-09-14
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-10-13
D · Potential for more than minimal harm
2023-09-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-13
J · Immediate jeopardy
2021-12-06
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 2021-11-24
F · Potential for more than minimal harm
2021-12-06
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 2021-12-24
D · Potential for more than minimal harm
2021-12-06
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 2021-12-24
D · Potential for more than minimal harm
2021-12-06
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 2021-12-24
Penalties and ownership
What sits behind the stars
Ownership
Presbyterian Manors Inc
5% Or Greater Direct Ownership Interest · Organization
Brennecke, Gary
Corporate Director · Individual
Cook, James
Corporate Director · Individual
Cumberland, Richard
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
Ott, Ray
Corporate Director · Individual
Owens, Melanie
Corporate Officer · Individual
Presbyterian Manors Of Mid-America Inc
Operational/Managerial Control · Organization
Radatz, Bradley
W-2 Managing Employee · Individual
Shogren, Bruce
Corporate Officer · Individual
Taylor, William
Corporate Officer · Individual
Wedel, Randy
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Lakepoint Wichita, LLC
Wichita, KS
2-star overall rating with 2-star inspections with $18,342 in total fines with 12 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#2
Sandpiper Healthcare & Rehabilitation Center
Wichita, KS
4-star overall rating with 3-star inspections with $16,801 in total fines with 9 recent health deficiencies with 20 fire-safety deficiencies in the latest cycle
#3
Meridian Rehabilitation And Health Care Center
Wichita, KS
2-star overall rating with 1-star inspections with abuse icon flag with $84,501 in total fines with 20 recent health deficiencies with 21 fire-safety deficiencies in the latest cycle
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