Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Clay Center Presbyterian Manor during CMS and state inspections, most recent first.
Unsanitary meal service and hand hygiene failures: A CNA repeatedly touched her hair and scrub pants during meal service, then delivered plates of food and a cup of thickened liquid to residents without washing her hands or using hand gel. She also handled a clothing protector for a resident and assisted a resident with eating while continuing to skip hand hygiene. An Administrative Nurse verified staff should not touch hair or scrubs while assisting residents or delivering food, and the facility policy required safe serving practices and clean hands during dining service.
A resident with anxiety and HTN had PRN lorazepam and PRN Xanax orders that lacked stop dates and did not include a documented physician rationale or specified duration for extended use. The care plan did not reflect the PRN use of either medication, and the RN verified the orders were active without the required documentation.
Monthly DRR Missed Missing Stop Dates for PRN Antianxiety Medications: A resident with anxiety and HTN received PRN lorazepam and PRN Xanax orders that lacked stop dates, and the EMR lacked a documented duration and prescriber rationale for extended use. The care plan did not reflect the PRN antianxiety use, and the consultant pharmacist’s monthly reviews did not identify the missing stop dates or the lack of rationale for continued PRN use.
Improper Storage of Oxygen Tubing and Cannula: Staff failed to store two residents' oxygen tubing and nasal cannula in a sanitary manner. One resident's unbagged oxygen equipment was observed on the back of a wheelchair in the hall, and another resident's uncovered oxygen tubing was observed on a wheelchair back with the tubing touching the chair. An LN and an administrative nurse verified the observations and stated the equipment should be stored in a plastic bag when not in use.
The facility failed to submit accurate staffing information through PBJ, as required by CMS, for six dates in FY Quarter 3 2023. Although licensed nurse coverage was present 24/7 according to timeclock data, incorrect data was submitted due to new staff being unaware of the error. This failure placed residents at risk for inadequate staffing.
A resident with dementia and anxiety experienced skin tears and bruises during combative outbursts, but the facility failed to update the care plan with interventions to prevent these injuries. Despite multiple incidents documented in nurse's notes, the care plan lacked specific strategies to manage the resident's behavior, placing them at risk for further injury.
A resident with dementia and a history of falls was not properly positioned on the bed by staff, leading to her rolling out of bed. Despite being assessed as high risk for falls, staff failed to follow the care plan and facility policy on safe transfers, resulting in a preventable accident.
A resident with dementia and anxiety exhibited combative behaviors during care, resulting in bruises and skin tears. Despite a care plan directing staff to ensure her safety and reapproach her later, staff did not consistently follow these guidelines. Multiple staff members attempted to manage her care simultaneously, overwhelming the resident and leading to injuries. The facility's behavioral health services policy emphasized the need for qualified staff, but the failure to adhere to the care plan resulted in the resident sustaining injuries.
A facility failed to monitor and provide necessary interventions for a resident's bowel management, placing them at risk for fecal impaction. Despite a care plan and physician orders for constipation prevention, staff did not document interventions during a six-day period without bowel movement. Observations and interviews confirmed the facility's bowel protocol was not followed, as staff failed to act after three days without a bowel movement.
A facility failed to label a Novolog flex pen with an open or discard date, as required by policy, placing a resident at risk of receiving expired insulin. A nurse confirmed the oversight and discarded the pen. The facility's policy mandates labeling to ensure medication effectiveness.
Unsanitary Meal Service and Hand Hygiene Failures
Penalty
Summary
The facility failed to serve food in a sanitary manner for the 29 residents who received food from the facility kitchen. During meal service, a CNA repeatedly touched her ponytail and scrub pants with both hands and did not wash her hands or use hand gel before continuing to deliver plates of food to residents. She also handled a small glass of thickened liquid by the top of the cup and touched the lip surface with her hand before delivering it to a resident, and she grabbed a rolling stool to assist a resident with eating a few bites of pureed food. The same CNA continued throughout the meal service without washing her hands or using hand gel, including after touching her hair and clothing and while delivering a clothing protector to another CNA for placement on a resident before lunch. An Administrative Nurse later verified that staff should not touch their hair or scrubs while assisting residents with meals or while delivering plates of food. The facility's Serving Basic policy stated staff would ensure safe serving practices to prevent contamination and would use clean hands and utensils during dining service.
PRN Antianxiety Orders Lacked Required Stop Dates and Rationale
Penalty
Summary
The facility failed to ensure that Resident 3’s ongoing PRN antianxiety medications had a 14-day stop date or a documented specified duration with a physician rationale for extended use. Resident 3 had diagnoses of anxiety and hypertension, and the MDS documented intact cognition, assistance needs for bed mobility and transfers, and receipt of an antianxiety medication during the observation period. Her care plan addressed psychotropic medication use and noted scheduled Xanax, but it did not document PRN Xanax use or PRN lorazepam use for anxiety, even though both medications were ordered PRN. Resident 3’s physician orders directed lorazepam 1.0 ml every 8 hours as needed for anxiety and Xanax 0.25 mg every 6 hours as needed for anxiety, and both orders lacked stop dates. The EHR also lacked evidence of a specified duration or physician rationale for the continued PRN use of either medication. On observation, the resident received scheduled Xanax in the morning, and later the Administrative Nurse verified that the PRN lorazepam and PRN Xanax orders were active without the required 14-day stop date or documented rationale for extended use.
Monthly DRR Missed Missing Stop Dates for PRN Antianxiety Medications
Penalty
Summary
The facility failed to ensure a licensed pharmacist completed a monthly drug regimen review that identified irregularities related to Resident 3’s PRN antianxiety medications. Resident 3 had diagnoses of anxiety and hypertension, intact cognition on the Significant Change MDS, and required staff assistance with bed mobility, transfers, and ADL care. Her care plan documented psychotropic medication use and monthly pharmacy consultation, but it did not reflect the PRN use of lorazepam or Xanax. The physician’s orders for lorazepam 1.0 ml every 8 hours PRN for anxiety and Xanax 0.25 mg every 6 hours PRN for anxiety both lacked stop dates. The resident’s EMR also lacked documentation of a specified duration and physician rationale for the extended use of the PRN lorazepam and PRN Xanax. The consultant pharmacist completed monthly reviews on 05/05/2026, 06/02/2026, and 07/02/2026, but those reviews did not identify the missing stop dates or the lack of rationale for continued PRN use. On 07/07/2026, Administrative Nurse D verified that the facility had failed to obtain the required 14-day stop date or documented rationale for continued use, and also verified that the consultant pharmacist’s monthly reviews did not include a recommendation regarding the missing stop date or rationale.
Improper Storage of Oxygen Tubing and Cannula
Penalty
Summary
The facility failed to ensure a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when staff did not store residents' oxygen tubing and nasal cannula in a sanitary manner. On 07/07/2026 at 03:02 PM, R21's unbagged oxygen tubing and nasal cannula were observed coiled and placed on the back of her wheelchair in the hall by her room, and LN G verified the observation and stated staff were to place R21's oxygen tubing and nasal cannula in a plastic bag when not in use. On 07/08/2026 at 09:35 AM, R3's uncovered oxygen tubing was observed coiled on the top of the resident's wheelchair back with the cannula and tubing touching the wheelchair, and Administrative Nurse D verified the observation and stated she would expect staff to store the residents' oxygen tubing and nasal cannula in a plastic bag when not in use. The facility's Oxygen Therapy Policy, revised 02/03/2025, stated that when the oxygen device is not in use, it should be stored in a plastic or other bag to keep the tubing and device off the floor and the bag should be labeled with the resident name, date, time, and staff initial.
Inaccurate PBJ Data Submission
Penalty
Summary
The facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) as required by the Centers for Medicare & Medicaid Services (CMS). The PBJ report for Fiscal Year Quarter 3 2023 indicated that the facility did not have licensed nurse coverage 24 hours a day, seven days a week on six specific dates. However, a review of the facility's licensed nurse timeclock data for those dates revealed that a licensed nurse was indeed on duty 24 hours a day, seven days a week. On the day of the survey, a registered nurse was observed on duty, and Administrative Staff A confirmed that the facility had submitted incorrect data to CMS. The staff member explained that the facility had new staff who were unaware that the information submitted was incorrect. The facility's PBJ Reporting Procedure Policy, which was undated, stated that PBJ hours must be reported to CMS at least quarterly, although it is highly recommended to report them monthly. The failure to submit accurate PBJ data placed the residents at risk for unidentified and ongoing inadequate staffing.
Failure to Update Care Plan for Combative Resident
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as R19, who experienced skin tears and bruises during combative outbursts. R19, diagnosed with dementia, anxiety, and pain, exhibited moderately impaired decision-making skills and was dependent on staff for various activities of daily living. The resident's care plan, dated 07/26/24, included instructions for skin inspections but lacked specific interventions to prevent skin tears and bruises related to the resident's resistance or combativeness. Multiple nurse's notes documented incidents where R19 became combative during care, resulting in bruises and skin tears, yet the care plan was not updated to address these issues. Observations and interviews revealed that the facility's care plan policy required person-centered plans to be reviewed and revised when significant changes occurred. Despite this policy, the care plan for R19 was not updated to include strategies for managing the resident's combative behavior and preventing further skin injuries. This oversight placed R19 at risk for additional skin injuries and pain due to uncommunicated care needs, as confirmed by an administrative nurse who acknowledged the care plan should have provided direction to staff on preventing skin tears and bruises.
Failure to Prevent Resident Accident Due to Improper Positioning
Penalty
Summary
The facility failed to ensure a resident remained free from preventable accidents when staff did not properly position the resident on the bed before placing her legs in bed, resulting in the resident rolling out of bed. The resident, who had diagnoses including dementia, a history of falls, and abnormalities of gait and mobility, was assessed as high risk for falls. The care plan directed staff to ensure the bed was in a position that was easiest for the resident to access or exit, and to maintain a safe environment. However, during an incident, a CNA attempted to place the resident's legs into bed without ensuring proper positioning, causing the resident to slip off the bed and end up between the bed and a recliner. Observations and interviews revealed that staff were unaware of the incident, and there was a lack of communication regarding the resident's fall risk and transfer needs. The facility's policy on lifting and transferring residents emphasized the importance of proper body mechanics and resident safety, but this was not adhered to in the incident involving the resident. The failure to follow these protocols placed the resident at risk for injury related to preventable accidents.
Failure to Follow Behavioral Health Care Plan for Resident
Penalty
Summary
The facility failed to provide appropriate behavioral health care for a resident, identified as R19, who exhibited combative behaviors during care. R19, diagnosed with dementia, anxiety, and pain, had a care plan that directed staff to ensure her safety, leave her alone, and reapproach her later if she became agitated or combative. However, the care plan lacked specific instructions on preventing skin tears and bruises related to her resistance or combativeness. Despite the care plan's directives, staff did not consistently follow these guidelines, leading to multiple instances where R19 sustained bruises and skin tears during care. Observations and nurse's notes documented several incidents where R19 became combative, resulting in injuries. For instance, on multiple occasions, R19 was noted to have bruises on her arms and hands, and skin tears on her forearms, often due to hitting walls or during physical interactions with staff. The notes indicated that R19 was combative during personal care, hitting, kicking, and screaming, which led to injuries such as bruises and skin tears. Staff interventions during these episodes were not aligned with the care plan, as they involved multiple staff members attempting to manage R19's care simultaneously, which was overwhelming for her. Interviews with staff revealed a lack of adherence to the care plan. A licensed nurse and a certified nurse aide acknowledged R19's aggressive behaviors and the need to reapproach her later, yet staff often attempted to expedite care by having multiple caregivers present, contrary to the care plan's guidance. An administrative nurse confirmed that having three staff members in the room could be overwhelming for R19 and stated that education would be provided to staff on how to approach her. The facility's behavioral health services policy emphasized the need for qualified staff to provide mental and behavioral health services, but the failure to follow the care plan during R19's combative episodes resulted in her sustaining injuries and placed her at risk for impaired quality of life.
Failure to Monitor and Intervene in Bowel Management
Penalty
Summary
The facility failed to adequately monitor and provide necessary interventions for bowel management for Resident 19, who was at risk for fecal impaction and physical decline. Resident 19 had a history of dementia, anxiety, diabetes mellitus, pain, and constipation, and was dependent on staff for personal hygiene, toileting, and dressing. The care plan for Resident 19 directed staff to follow the facility's bowel protocol and administer medications for constipation prevention as ordered. However, the Medication Administration Record for July 2024 lacked documentation that staff provided the physician-ordered interventions during a period when Resident 19 did not have a bowel movement for six consecutive days. Observations and interviews revealed that staff did not follow the facility's bowel protocol, which required an evaluation and physician notification if a resident did not have a bowel movement in three days. Despite the facility's Bowel Elimination policy, which outlined guidelines for monitoring bowel function to prevent complications, staff failed to act when Resident 19 showed signs of constipation. Administrative Nurse D confirmed that interventions were not provided, acknowledging that staff should have followed the protocol after three days without a bowel movement.
Failure to Label and Store Insulin Properly
Penalty
Summary
The facility failed to properly label and store biologicals as required, specifically concerning a Novolog flex pen used by a resident. During an observation, it was found that the Novolog flex pen did not have an open date or discard date, which is necessary to ensure the insulin remains effective and is not expired. A Licensed Nurse confirmed the absence of the labeling and discarded the pen. The facility's policy requires that the date opened be recorded on multidose vials, but this was not adhered to in this instance. This oversight placed the resident at risk of receiving an expired or ineffective dose of insulin.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Clay Center
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Advena Living Of Clay Center | 0.9 mi | — | 0 | 0 |
| Wakefield Care And Rehab | 12.6 mi | ★★★★★ | 0 | 0 |
| Leonardville Nursing Home | 13.8 mi | ★★★★★ | 0 | 0 |
| Linn Community Nursing Home | 20.9 mi | ★★★★★ | 7 | 0 |
| Park Villa | 21.1 mi | ★★★★★ | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.