Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lawrence Presbyterian Manor during CMS and state inspections, most recent first.
Food was not stored, handled, or served according to policy. A refrigerator contained an unlabeled, undated container of fish filets, and during meal service staff touched residents and resident items, handled food with soiled gloves, passed plates without hand hygiene, and entered the kitchenette with hair not fully covered and no beard cover.
Staff failed to follow EBP for two residents during high-contact care by not wearing gowns and not changing gloves during peri-care and transfers, even though both residents had MDRO-related EBP orders/signage. Staff also transported residents’ laundry down the hall on an uncovered cart. One resident had severe cognitive impairment, incontinence, and dependence for ADLs, while the other resident also required EBP for MDRO in the urine.
Failure to monitor antibiotic use and apply antibiotic stewardship was identified when a resident with a history of UTI, MDRO in the urine, dementia, incontinence, and impaired mobility was receiving daily prophylactic cephalexin. Staff provided peri-care and a lift transfer under EBP without changing gloves during the procedure and without wearing gowns, and one CNA did not know why EBP was required. Admin staff reported prophylactic antibiotics were not tracked, trended, or reviewed by the pharmacist and were not included in QAPI reporting, despite facility policies calling for an antibiotic stewardship program with surveillance and monitoring.
Resident Council concerns about dining service and call light response times were repeatedly documented and not resolved. Minutes showed ongoing reports of cold or late meals, unavailable menu items, tough or overcooked food, and residents waiting 30 to 49 minutes for call lights to be answered. Staff interviews confirmed the complaints were discussed with management, but no QAPI plan had been implemented to address the ongoing dining issues.
A resident with Alzheimer’s disease, depression, and impaired cognition who required staff assistance with ADLs was observed with greasy hair, several days of facial hair growth, and a shirt with dried food stains from a prior meal. Documentation showed the resident needed help with bathing, personal hygiene, and dressing and preferred daily shaving, yet bathing occurred only intermittently and the resident reported not remembering the last bath. Staff interviews confirmed expectations to offer showers, provide bed baths if refused, and change clothing and perform hygiene when residents appeared unclean, but these practices were not carried out for this resident, resulting in a failure to provide needed grooming, shaving, and clean clothing.
Improper portioning of ground meat diets was observed for two residents during a noon meal. Dietary staff used a teaspoon to serve only three teaspoons of ground country fried chicken and collard greens to each resident, even though the CDM verified that each resident should have received 3 oz of each item and the facility policy listed standard portions of meat and vegetables.
The facility failed to complete the required yearly performance evaluations for two CNAs, placing residents at risk for inadequate care. Administrative Nurse D acknowledged the oversight and stated that the evaluations had not been completed despite starting the process in August 2023.
A facility failed to ensure a resident's low air loss mattress was set correctly for their weight, increasing the risk of pressure ulcers. The resident, with multiple diagnoses and dependent on staff for all ADLs, had a mattress set at 210 pounds instead of their actual weight of 140.50 pounds. Staff were unclear about the correct settings and believed hospice was responsible for adjustments.
A facility failed to store a resident's CPAP mask in a sanitary manner, increasing the risk of respiratory infection. The resident, with diagnoses of asthma and obstructive sleep apnea, was observed with her CPAP mask laying unbagged on her bedside table. Staff had differing understandings of proper storage, and the facility lacked a clear policy on respiratory equipment care.
The facility failed to ensure nonpharmacological interventions were attempted and documented before administering an antipsychotic medication to a resident with dementia and other conditions. The resident's care plan included monitoring for side effects of Seroquel, but there was no evidence that nonpharmacological approaches were tried first, contrary to the facility's policy.
The facility failed to ensure a communication process was implemented between the facility and the hospice provider, leading to a risk for missed or delayed services and impaired care for a resident with Alzheimer's, dementia, and other conditions. The hospice communication binder lacked essential documentation, and staff were uncertain about its contents and use.
The facility failed to obtain signed consent or declination for the pneumococcal vaccination Prevnar 20 (PCV20) for three residents. The clinical records lacked evidence of receiving Prevnar 20 or having a signed declination, despite the residents having received other pneumococcal vaccinations. Staff acknowledged the oversight and mentioned that they had recently received new guidance regarding Prevnar 20 but had not yet updated their procedures.
The facility failed to retain the daily posted nursing staffing data for the required 18 months. A review found that the data for December 2023 was missing. The nursing staff scheduler was responsible for this task, but the previous staff member did not retain the forms as required by the facility's policy.
Food Storage and Meal Service Hygiene Failures
Penalty
Summary
The facility failed to store, distribute, and serve food in accordance with professional standards in the kitchen, kitchenette, and one of two dining rooms. In the kitchen, a silver one-door refrigerator contained an unlabeled, undated container with two fish filets. Dietary staff verified the finding and stated food items should be labeled and dated before being placed in the refrigerator, and the fish filets were discarded. The facility’s Storing: Food and Equipment Policy required food items to be labeled with product name, use-by date, date prepared or opened, time prepared and team member initials where applicable, and date frozen or thawed if applicable. During meal service, multiple staff members handled food and resident items without following hand hygiene and food handling practices described in the facility’s Personal Hygiene Policy. A LN touched a resident’s hair, did not wash her hands, and then passed dinner plates and touched the inside top surface of three residents’ plates. In the kitchenette, a CNA entered in front of the open steam table with hair hanging out of the hairnet and without a beard cover, and a dietary staff member handled food with soiled gloves, touching the steam table, hot box door, microwave door, hamburger bun, hamburger patty, lettuce, onions, and chicken strips before discarding the gloves. Another CNA entered the kitchenette with hair hanging out of the hairnet and without a beard cover, then retrieved coffee for a resident. A CNA also touched the inside top surface of three residents’ plates, removed necklaces from a resident, did not wash her hands, and passed trays again without washing her hands.
Failure to Follow EBP During Resident Care and Transport Laundry Covered
Penalty
Summary
The facility failed to provide a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when staff did not follow Enhanced Barrier Precautions (EBP) during personal care for two residents and when laundry was transported uncovered down the hall. The report states that staff failed to use gowns and did not change gloves as required during high-contact care activities for residents who were on EBP, and that resident laundry was moved on an uncovered cart in the hallway. One resident had diagnoses including dementia, history of TIA and cerebral infarction, PVD, palliative care, and anxiety disorder. The resident’s MDS documented severe cognitive impairment, behavioral symptoms directed toward others, dependence on staff for bed mobility, transfers, and activities of daily living, and incontinence of urine and bowel. The resident’s CAA and care plan documented dependence for toileting and hygiene, a history of UTI, oral preventative antibiotic use, and EBP for all care due to MDRO in the urine. During observed care, two CNAs provided peri-hygiene, changed the brief, and transferred the resident to a Broda chair without wearing gowns and without changing gloves during the procedure. A second resident also had an EBP sign posted outside the room. During observed care, two CNAs provided turning and perineal care without a gown, despite the resident being on EBP. Staff interviews confirmed that the resident required EBP due to MDRO in the urine and that staff should wear gowns and gloves for personal care, with glove changes after perineal care and placement of clean incontinent products. In addition, laundry staff were observed pushing residents’ clothing down the hall on an uncovered cart, and the housekeeping supervisor stated laundry should be covered when delivered to residents.
Failure to Monitor Antibiotic Use and Apply Antibiotic Stewardship
Penalty
Summary
The facility failed to utilize an antibiotic stewardship program that included tracking, monitoring, and attempts to decrease the use of unnecessary antibiotics. The sample included 12 residents out of a census of 37, and the deficiency involved a resident whose Quarterly MDS documented receipt of an antibiotic. The resident’s CAA documented a history of UTI, dependence on staff for ADLs and toileting hygiene, use of an oral preventative antibiotic, and the need for Enhanced Barrier Precautions due to MDRO in the urine. The care plan documented functional bladder and bowel incontinence, dementia, impaired mobility, a history of UTI, and long-term antibiotics used as a preventative for UTI. A physician order directed cephalexin 250 mg by mouth daily for UTI prevention. During observation, the resident’s room had an EBP sign and a tote with gloves and gowns, but two CNAs entered the room, retrieved gloves from the bathroom, and provided peri-hygiene care and a mechanical lift transfer without changing gloves during the procedure and without wearing gowns. One CNA stated she was not sure why the resident had EBP, but thought it had something to do with the resident’s bottom area. A nurse later verified that EBP was required due to MDRO in the urine. Administrative staff reported that prophylactic antibiotics were not tracked, trended, or reviewed by the pharmacist and therefore had not been included in reporting to the QAPI plan or meetings. The facility’s infection control and antibiotic stewardship policies stated that the community used an antibiotic stewardship program with protocols and surveillance to monitor antibiotic use.
Resident Council Concerns Not Resolved
Penalty
Summary
The facility failed to resolve recurring concerns raised by the Resident Council regarding dining service and call light response times. Resident Council minutes from 01/2025 through 02/2026 repeatedly documented complaints that meals were served late, food was cold or lukewarm, menu items were unavailable or different from what was ordered, and some meats were tough or overcooked. The minutes also documented ongoing concerns that residents had difficulty getting staff attention in the dining room and that call lights were taking 30 to 49 minutes to be answered. During interviews, Social Service X stated she assisted with Resident Council meetings and note-taking, and that the dietary supervisor attended most monthly meetings because of the dining complaints. Administrative Nurse D stated the concerns were brought to department directors and that call light response times were reviewed, with an expectation of three to five minutes for response. Administrative Staff A stated that a QAPI plan had not been implemented to address the ongoing dining service complaints. The facility's Resident Council policy stated the Executive Director shall act upon the Council's recommendations concerning policy and operational decisions affecting resident care and life in the community.
Failure to Assist Resident With Grooming, Shaving, and Clean Clothing
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate assistance with activities of daily living (ADLs), specifically grooming, shaving, and maintaining clean clothing for Resident 25. The resident’s EMR documented Alzheimer’s disease, major depressive disorder, hypertension, lack of coordination, and a need for assistance with personal care. A recent MDS showed moderately impaired cognition with a BIMS score of 12 and documented that the resident required setup or cleanup assistance with eating, supervision or touch assistance with oral hygiene, partial/moderate assistance with toileting, and substantial/maximal assistance for bathing. The Care Area Assessment indicated the resident triggered for further review of functional abilities due to cognitive status and increased ADL assistance needs, and the care plan documented dependence on staff for bathing, moderate assistance for personal hygiene and dressing, and a preference to be shaved daily. Despite these identified needs and care plan directives, observations showed the resident sitting in a recliner with greasy hair, three-to-four days of facial hair growth, and a blue shirt with two large food stains that the resident reported were from the previous evening’s supper and had not been changed. The resident stated he liked his face shaved every day and could not remember his last bath. Bathing records showed only sporadic baths and one documented refusal, and staff interviews confirmed that while residents were asked about baths and refusals were reported to nurses, CNAs were expected to change clothing and provide hygiene when residents appeared unclean. Administrative staff stated the expectation that residents receive at least one shower weekly and that CNAs wash and change residents’ clothes and shave them as desired, but the observed condition of the resident and the resident’s statements demonstrated that these expectations were not met, resulting in a failure to ensure assistance with grooming, shaving, and clean clothing in accordance with the resident’s needs and preferences.
Improper Portioning of Ground Meat Diets
Penalty
Summary
The facility failed to measure food portions for two residents who received ground meat diets, R33 and R28. During the noon meal observation, Dietary Staff CC removed ground country fried chicken from the hot box and used a plastic teaspoon to place three teaspoons of the ground meat on each resident’s plate. CC also removed collard greens from the same hot box and placed three teaspoons on each plate before serving the meals to the residents. The Certified Dietary Manager later verified that each resident should have received three ounces of each food item and stated staff should measure the proper portion before serving. The facility’s Adjusted Portions Policy stated the standard portion of meat should be three to four ounces and the standard portion of vegetables should be half a cup.
Failure to Complete Yearly Performance Evaluations for CNAs
Penalty
Summary
The facility failed to ensure that two of the five Certified Nurse Aides (CNAs) reviewed had the required yearly performance evaluations completed. CNA N, hired on 01/10/14, and CNA M, hired on 05/26/22, did not have their yearly performance evaluations available upon request. Administrative Nurse D acknowledged that he started updating the nursing staff's yearly performance reviews in August 2023 but had not completed the evaluations for CNA M and CNA N. The facility's Staff Competency policy, last reviewed on 10/11/21, mandates that all clinical employees must complete a competency test at their annual review. The lack of completed performance evaluations placed the residents at risk for inadequate care.
Failure to Ensure Correct Mattress Setting for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that a resident's low air loss mattress was set at the appropriate setting for the resident's weight, who was prone to pressure-related injury. The resident had multiple diagnoses, including dementia, Parkinson's disease, and hypertension, and was dependent on staff for all activities of daily living. The resident's care plan documented the need for a low air loss mattress and regular checks for redness and application of barrier cream. However, the care plan did not specify the correct setting for the mattress, and the mattress was observed to be set at 210 pounds, significantly higher than the resident's actual weight of 140.50 pounds. Licensed nurses and administrative staff were unsure about the correct settings and believed that the hospice was responsible for adjusting the mattress settings. The facility's Skin Integrity policy required nursing staff to evaluate skin integrity, implement preventative measures, and treat skin breakdown. Despite this policy, the facility did not ensure that the low air loss mattress was set correctly, placing the resident at increased risk for the development of pressure ulcers. Interviews with staff revealed a lack of clarity and responsibility regarding the adjustment of mattress settings, indicating a gap in the facility's procedures and communication regarding pressure ulcer prevention and care.
Improper Storage of CPAP Mask
Penalty
Summary
The facility failed to ensure that a resident's CPAP mask was stored in a sanitary manner, which increased the risk of respiratory infection. The resident, who had diagnoses of asthma, pulmonary nodule, and obstructive sleep apnea, was observed on multiple occasions with her CPAP mask laying directly on her bedside table unbagged. Despite having intact cognition and requiring extensive assistance with activities of daily living, the resident's CPAP mask was not stored properly when not in use. This was confirmed through observations on two separate days and interviews with staff members who acknowledged the mask should be bagged or stored in a container with a cleaning solution. The facility did not have a policy related to the care of respiratory equipment, and staff members had differing understandings of how the CPAP mask should be stored. A Certified Nurse Aide believed the mask should be stored in a plastic bag, while a Licensed Nurse stated the resident's daughter was responsible for cleaning and replacing the mask. An Administrative Nurse indicated that the nursing staff should clean the mask and store it in a container. The lack of a clear policy and consistent practice led to the deficient practice of improper storage of the CPAP mask, placing the resident at an increased risk of developing a respiratory infection.
Failure to Attempt Nonpharmacological Interventions Before Administering Antipsychotic Medication
Penalty
Summary
The facility failed to ensure nonpharmacological interventions were attempted and documented prior to the administration of an antipsychotic medication for Resident 2, who had a diagnosis of dementia, Parkinson's disease with Lewy bodies, neurocognitive disorder, psychotic disorder, and hypertension. The resident's electronic medical record lacked documentation or evidence of nonpharmacological symptom management interventions that were implemented and failed before starting Seroquel. The care plan for Resident 2 included monitoring for potential side effects of Seroquel, but there was no evidence that nonpharmacological approaches were tried first. Licensed Nurse G stated that antipsychotic medications were acceptable for residents with a dementia diagnosis and that nonpharmacological interventions would be tried first if possible. Administrative Nurse D also acknowledged that a nonpharmacological approach would be best but noted that residents often came into the facility already on antipsychotic medications. The facility's policy on psychotropic medication use emphasized that such medications should not be used unless necessary to treat medical symptoms and that gradual dose reductions and behavioral interventions should be attempted unless clinically contraindicated. Despite this policy, the facility did not document attempts at nonpharmacological interventions for Resident 2 before administering Seroquel.
Failure to Implement Communication Process with Hospice Provider
Penalty
Summary
The facility failed to ensure a communication process was implemented between the facility and the hospice provider, which included how the communication would be documented. This deficiency was identified during a review of a resident's (R32) care. R32 had diagnoses of Alzheimer's disease, dementia, hearing loss, anxiety, and dysphagia, and was dependent on two staff assistants for all activities of daily living. The resident's care plan documented that the facility would coordinate care and services with the hospice provider, including weekly nurse visits and hospice aide visits for various care needs. However, the hospice communication binder lacked the plan of care for R32 and the physician-signed terminal diagnosis for admission to hospice, with the last documentation of hospice care dated 05/02/24. Interviews with staff revealed uncertainty about the contents and use of the hospice binders, and the facility was unable to provide a policy related to hospice services. The deficiency created a risk for missed or delayed services and impaired care for R32. The facility's failure to implement a clear communication process and document the necessary information in the hospice binder led to this issue. Staff interviews indicated that hospice information was kept in binders, but there was confusion about what to look for and where to find specific care plans. The administrative nurse confirmed that the facility collaborated with hospice through care plans, but R32's care plan had been scanned into the medical records instead of being placed in the hospice binder. The lack of a documented communication process between the facility and the hospice provider contributed to the deficiency.
Failure to Obtain Consent or Declination for Prevnar 20 Vaccination
Penalty
Summary
The facility failed to obtain signed consent or declination for the pneumococcal vaccination Prevnar 20 (PCV20) for three residents. Specifically, the clinical records of these residents lacked evidence of receiving Prevnar 20 or having a signed declination for the vaccination. This deficiency was identified during a review of the clinical records and interviews with the facility staff. The residents involved had previously received other pneumococcal vaccinations (Prevnar 13 and Pneumovax 23) but not the Prevnar 20, which is now recommended as per the latest guidance. The facility staff, including licensed nurses and administrative nurses, acknowledged the oversight and mentioned that they had recently received new guidance regarding the importance of Prevnar 20. However, the facility's existing policy on immunizations, last revised in January 2022, did not reflect this new guidance. The staff stated that they had started working on updating their procedures to include Prevnar 20 but had not yet completed the process. This lapse in updating and implementing the new immunization guidance led to the failure in obtaining the necessary consents or declinations for the affected residents.
Failure to Retain Daily Nursing Staffing Data
Penalty
Summary
The facility failed to retain the daily posted nursing staffing data for the required 18 months. The facility identified a census of 35 residents. Upon review, it was found that the daily posted nursing staffing data for December 2023 (31 days) was missing. An interview with Administrative Nurse D revealed that the nursing staff scheduler was responsible for ensuring the retention of these records. However, the previous staff member who was responsible for maintaining the posted nursing staff hours had not retained the forms as required. The facility's policy, last reviewed on 10/11/21, stated that the Daily Nurse Staffing Form should be maintained for a minimum of 18 months and filed in the business office. The failure to retain these records was a violation of this policy.
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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 Lawrence
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pioneer Ridge Retirement Community | 1.6 mi | ★★★★★ | 26 | 0 |
| Lawrence Memorial Hospital Snf | 2.2 mi | ★★★★★ | 0 | 0 |
| Medicalodges Eudora | 9.8 mi | ★★★★★ | 1 | 1 |
| Baldwin Healthcare & Rehab Center, Llc | 13.6 mi | ★★★★★ | 11 | 0 |
| Tonganoxie Terrace | 14.6 mi | ★★★★★ | 31 | 0 |
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