Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Legacy At Salina during CMS and state inspections, most recent first.
A resident with intact cognition, osteoarthritis, and a prior femur fracture was dependent on staff for bed mobility and had a care plan for two-person assistance with bed mobility, dressing, and transfers. While a CNA was dressing the resident alone and rolled her onto her side in bed, the resident slid out of bed onto the floor. The resident later had worsening pain and ROM deficits, and an X-ray showed a partially impacted right femoral neck fracture requiring surgical repair.
Lack of Certified Dietary Manager: A dietary staff member was overseeing meal prep and helping deliver trays, but she was not yet certified and was still waiting to take the test. The facility did not have a full-time certified dietary manager for the residents receiving meals from the kitchen, despite policy stating that a food and nutrition services manager would oversee food production, storage, and delivery and work closely with the dietician.
Missing Evening Refrigerator and Freezer Temperature Logs: The facility failed to document daily refrigerator and freezer temperatures for the evening shift. During a kitchen tour, surveyors found missing temperature logs for multiple refrigerators and a freezer on several days, and Dietary BB confirmed the lack of documentation. The facility policy required temps to be checked and recorded daily upon opening and at closing.
Missing EBP signage was found in multiple resident rooms, and an RN verified the signage should have been posted. The facility also observed a CNA providing incontinence and catheter care to a resident with urinary retention, cancer, HTN, and DM2 while failing to remove soiled gloves before continuing care and adjusting clothing. The resident was dependent for toileting hygiene, dressing, and transfers and had a catheter.
A resident with dementia, Alzheimer’s disease, and anxiety received Seroquel for irritability and anger/physical aggression, but the record lacked a documented physician rationale showing unsuccessful nonpharmacological attempts or a risk-versus-benefit review for continued antipsychotic use. The resident was observed receiving the medication, and an admin nurse confirmed the antipsychotic was being given despite the diagnosis being identified as inaccurate.
Failure to Report Resident-to-Resident Abuse: A resident with dementia, Alzheimer's disease, anxiety, severely impaired cognition, and a history of physical aggression slapped another resident after the other resident wandered into the room. Nursing notes documented the other resident left holding her face, and the interdisciplinary team later discussed the incident, but the facility had no evidence the allegation and investigation were reported to the state agency as required by policy.
Failure to Assess Safe Smoking Practices and Secure Smoking Materials: A resident with CVA-related deficits, hemiplegia, hemiparesis, unsteady gait, and weakness smoked cigarettes with staff assistance, but the facility lacked a recent smoking safety assessment. Staff observed that he kept cigarettes in a nightstand beside his bed, including items in a locked box and additional unsecured cigarette packs, despite the smoking care plan and tobacco policy requiring periodic assessment and secured tobacco materials.
Failure to obtain a Foley catheter order and document catheter output for two residents. One resident with urinary retention, metastatic cancer, HTN, and DM had a Foley catheter noted in the MDS and care plan, but the EMR lacked a catheter order and intake/output documentation. A CNA provided catheter care and said she told the nurse the urine amount instead of documenting it. Another resident with neurogenic bladder and a hx of bladder cancer had a urinary catheter, but the chart lacked urinary output documentation for 30 days; a CNA emptied the leg bag and said there was no place to document the output.
A Novolog insulin pen in the north med cart was found unlabeled and undated after opening. An LPN confirmed it should have been labeled and dated when opened, and the DON verified staff were to label and date insulin pens when opened. The facility policy directed staff to record the expiration date and time after opening.
A resident on hospice with urinary retention, metastatic cancer, HTN, and DM2 had a care plan that said hospice would provide medications, equipment, and supplies, but it did not specify what would be provided or when hospice staff would be in the building. During care, CNAs used a mechanical lift, provided catheter and personal care, and one CNA continued care while wearing soiled gloves. An LPN stated hospice visited a couple of times a week and staff could call if needed.
Incomplete PBJ Staffing Submission: The facility failed to submit complete and accurate PBJ direct care staffing data, and the CMS PBJ report for FY 2024 Q4 showed excessively low weekend staffing. Administrative Staff A verified the facility completed the quarterly data, sent it to corporate, and then to Prime View for final submission, but was unsure why it was submitted incorrectly. The facility stated staffing was adequate during the quarter, while the PBJ policy required staffing data to be reported electronically to CMS using payroll and other verifiable records.
Three residents with significant medical needs, including urinary catheters and dependence on staff for toileting, were denied necessary incontinent care by a CNA who refused to assist or change them as required. The incidents were not immediately reported to administration as per facility policy, and the staff member was not promptly suspended or segregated from residents during the investigation, resulting in feelings of fear and belittlement among the affected residents.
A resident with a urinary catheter and dependent on staff for toileting reported to a licensed nurse that a CNA refused to provide incontinence care, resulting in the resident remaining in a soaked brief. The licensed nurse did not immediately report the allegation to administration as required by policy, delaying protective actions and investigation.
A resident with diabetes, dementia, and atrial fibrillation, requiring extensive assistance for transfers, fell and broke a thumb when a CNA attempted a solo transfer using a sit-to-stand lift, contrary to the care plan and facility policy requiring two staff members.
Failure to Follow Two-Staff Bed Mobility and Dressing Care Plan
Penalty
Summary
The facility failed to ensure fall prevention interventions were followed for a resident who was dependent on staff for most activities of daily living, including bed mobility, and whose care plan directed two staff assistance with bed mobility, dressing, and transfers. The resident had diagnoses including osteoarthritis and a prior closed fracture of the right distal femur. Her quarterly MDS documented intact cognition with a BIMS score of 15, and her fall risk assessment identified her as alert and oriented with a low fall risk score. During dressing care in bed, a CNA was the only staff member in the room and rolled the resident onto her side to adjust her clothing while the resident held the positioning rail. The resident rolled out of bed onto the floor. Staff observed the resident crying and anxious, and she was assisted back to bed using a total mechanical lift with three staff assistance. Initial nursing assessments documented no obvious abnormalities, but the resident complained of pain, and later notes documented ongoing pain, tearfulness, and ROM deficits. The resident’s condition worsened after the fall, and an X-ray obtained after emergency transport showed a partially impacted right femoral neck fracture, requiring hospital admission for surgical repair. Staff interviews confirmed the CNA knew the resident required two staff for transfers but did not know two staff were also required for dressing, and the administrative nurse verified the CNA had not followed the care plan. The facility investigation documented that the resident had been on an air mattress at the time of the fall and that the fall occurred while the CNA was attempting to provide care without the required second staff member.
Lack of Certified Dietary Manager
Penalty
Summary
The facility failed to employ a full-time certified dietary manager for the 41 residents who received meals from the facility kitchen. During observation of the noon meal, dietary staff BB was seen overseeing meal preparation and assisting with delivering meal trays to residents. On interview, BB stated she was not certified, had completed the course, and was waiting to take the test, while the Administrative Nurse stated BB had taken the course but there was a waiting period before she could take the test. The facility’s Dietician policy stated that a food and nutrition services manager would oversee the production, storage, and delivery of food and work closely with the dietician. This deficiency was identified based on observation, record review, and interview.
Missing Evening Refrigerator and Freezer Temperature Logs
Penalty
Summary
The facility failed to measure and record daily refrigerator and freezer temperatures for the evening shift. During the initial kitchen tour on 09/08/25 at 08:00 AM, the daily temperature logs for the large silver refrigerator and freezer were missing documentation for the evening shift on 09/01/25, 09/03/25, and 09/06/25. The small silver stand-alone refrigerator lacked evening shift temperature documentation on 09/01/25 and 09/03/25, and the tan refrigerator lacked evening shift temperature documentation on 09/01/25 and 09/03/25. At 08:45 AM, Dietary BB verified the lack of documentation and stated the temperatures were to be taken as directed. The facility policy dated 10/14 stated that refrigerator and freezer temperatures would be checked and recorded daily upon opening and at closing in the evening, with monthly tracking sheets posted to record time, temperature, initials, and actions taken.
Missing EBP Signage and Improper Glove Use During Resident Care
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program when it did not post enhanced barrier precautions (EBP) signage for six of seven residents identified for EBP. On 09/09/25 at 09:15 AM, observation in six of seven facility-identified resident rooms where EBP protocol was to be followed found no EBP signage in the room or on the doorway. On 09/08/25 at 11:10 AM, Administrative Nurse D verified the lack of signage and stated there should be signage. The facility policy dated 03/25/24 stated signs would be posted indicating the resident required EBP and that personal protective equipment was available. The facility also failed to ensure proper glove changes during incontinence care for R44. R44’s EMR documented urinary retention, malignant neoplasm of the upper lobe right bronchus or lung, secondary malignant neoplasm of the brain, hypertension, and type 2 DM. The admission MDS documented intact cognition, dependence on staff for toileting hygiene, dressing, and transfers, and that R44 had a catheter. During observation on 09/09/25 at 02:00 PM, CNA M and CNA P assisted R44 with bed transfer and catheter care. After CNA M removed one pair of gloves and donned a clean pair, she continued personal care while R44 began to have a BM, but CNA M did not remove her soiled gloves before putting on a clean brief and adjusting R44’s clothing. CNA M stated she should have removed the soiled gloves before putting on the clean brief and clothing, and LN G and Administrative Nurse D stated staff should have followed facility protocol.
Unnecessary Antipsychotic Use Without Documented Rationale
Penalty
Summary
The facility failed to ensure an appropriate indication and documented physician rationale for R4’s continued use of Seroquel, an antipsychotic medication. R4’s EMR listed diagnoses of dementia, Alzheimer’s disease, and anxiety, and the Quarterly MDS recorded severely impaired cognition and use of an antipsychotic during the observation period. The Psychotropic Drug Use CAA also recorded antipsychotic use, and the care plan identified the medication as being for irritability and anger/physical aggression. The physician’s order dated 08/01/25 directed Seroquel 25 mg three times daily for irritability and anger. The record did not contain a documented physician rationale that included unsuccessful attempts at nonpharmacological symptom management or a risk-versus-benefit statement for continued Seroquel use. On 09/09/25, observation showed R4 standing in her room and changing clothes when the morning medications, including Seroquel 25 mg, were administered. An Administrative Nurse confirmed the resident was receiving Seroquel for irritability and anger and stated the pharmacist had identified the inaccurate diagnosis for the medication, with the facility working with the physician to obtain appropriate diagnoses for residents on antipsychotics. The facility policy stated residents should not receive medications that were not clinically indicated and that antipsychotics should be used only when necessary for specific conditions and with documentation of symptoms and effectiveness.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse and neglect to the state agency after one resident slapped another resident. The resident involved in the incident had diagnoses of dementia, Alzheimer's disease, and anxiety, and the record showed severely impaired cognition, limited assistance needs with most ADLs, antipsychotic medication use, and a wander guard/elopement alarm used daily. The resident's care plan documented a history of irritability, anger, and physical aggression, including hitting, kicking, biting, spitting, screaming, and profanity, and directed staff to use calming and redirection interventions when agitation occurred. On 04/20/25, nursing notes documented that another resident wandered into the room, loud yelling was heard, and the other resident walked out holding her face. The note stated the other resident agreed she had been hit in the face by the resident and was removed from the room, with all parties safe at that time. The following day, the interdisciplinary team met and documented that the intervention was adequate, and later nursing notes stated the resident kept to herself with no reports or observations of resident contact. Review of the electronic record showed no evidence that the investigation, including witness statements, was reported to the state. When asked for the investigation that was sent to the state, the facility could not provide it. Administrative staff later verified that the facility had not reported the incident to the State agency. The facility policy stated allegations of abuse, neglect, mistreatment, injuries of unknown origin, and misappropriation must be reported immediately to the Administrator and reported to the appropriate state entity within two hours when applicable, and that resident-to-resident physical contact such as hitting or slapping that results in physical harm, pain, or mental anguish is considered resident-to-resident abuse.
Failure to Assess Safe Smoking Practices and Secure Smoking Materials
Penalty
Summary
The facility failed to maintain an environment free of accident hazards for a resident who smoked cigarettes but was not timely assessed for safe smoking practices. The resident had diagnoses including cerebral infarction, hemiplegia, hemiparesis, unsteady gait, and weakness. His MDS documented a BIMS score of 15, use of a wheelchair, dependence on staff for toilet hygiene and personal hygiene, and substantial to maximal assistance needed for bathing, sit-to-stand transfers, and chair-to-bed transfers. The fall CAA documented that he was at risk for falls, used a wheelchair for mobility, had unsteady balance, and had a grab bar on the upper portion of his bed to aid bed mobility. The resident’s smoking care plan stated he preferred to smoke, did not want cessation, and that the facility would complete smoking assessments quarterly and as needed while following the smoking policy to ensure safety. However, the clinical record lacked evidence of a recent assessment for safe smoking practices, including safe storage of smoking materials. Staff observations and interviews showed the resident smoked with staff assistance and kept cigarettes in a nightstand beside his bed, including cigarettes in a locked box with a key on a necklace and two additional packages of cigarettes that were not locked up. Administrative staff verified the resident was not supposed to keep smoking materials in his room and that the last smoking assessment had not been completed as required.
Failure to Obtain Catheter Order and Document Urinary Output
Penalty
Summary
The facility failed to obtain an order for a Foley catheter for one resident and failed to monitor urinary catheter output for two residents. One resident had diagnoses including urinary retention, metastatic cancer, hypertension, and type 2 DM, and the admission MDS documented intact cognition, dependence for toileting hygiene, dressing, and transfers, and the presence of a catheter. The urinary catheter CAA documented an indwelling Foley catheter for bladder elimination, catheter care every shift, and input and output monitoring per facility protocol, and the care plan directed staff to assess the catheter, change it as needed, encourage fluids, monitor and document intake and output, notify the physician of infection signs, and provide catheter care per policy. The resident’s EMR lacked documentation of an order for the Foley catheter and lacked documentation that staff monitored intake and output. During observation, the resident had a catheter with a small amount of amber urine in the drainage bag. A CNA provided catheter care and personal care, but did not document the catheter output and stated she had told the nurse the amount. A nurse later verified there was no order for the catheter, and another nurse stated staff did not document catheter output and relied on CNAs to tell them if the resident had no output. A second resident had diagnoses of neurogenic bladder and a history of bladder cancer, and the annual MDS documented severely impaired cognition, moderate assistance with toileting, and a urinary catheter. The care plan directed staff to monitor and document intake and urinary output per facility policy, but the medical record lacked documentation of urinary output for the past 30 days. During observation, a CNA emptied approximately 100 ml from the urinary leg bag, disinfected the port, and stated there was no place to document the output, so she did not. An administrative nurse verified the lack of urinary output documentation and stated staff should document output when a resident has a catheter.
Unlabeled and Undated Insulin Pen
Penalty
Summary
One Novolog insulin pen stored in the north medication cart was found unlabeled and undated during observation. The facility had a census of 41 residents at the time of the survey. On 09/08/25 at 08:12 AM, the insulin pen was observed without a label or date after opening, and Licensed Nurse G confirmed it should have been labeled and dated when opened. On 09/10/25 at 01:25 PM, Administrative Nurse D also verified that staff were to label and date insulin pens when opened. The facility’s Insulin Administration policy, dated September 2014, directed staff to record the expiration date and time on the insulin vial after opening.
Hospice Care Plan Lacked Coordination Details
Penalty
Summary
The facility failed to ensure collaboration between the hospice provider and the facility for one resident who was admitted to hospice on 08/28/25. The resident’s EMR documented urinary retention, malignant neoplasm of the upper lobe/right bronchus or lung, secondary malignant neoplasm of the brain, hypertension, and type 2 DM. The admission MDS documented intact cognition, dependence on staff for toileting hygiene, dressing, and transfers, set-up assistance for eating and oral hygiene, and the need for pain medication while on hospice services. The resident’s care plan, dated 08/28/25, directed staff to administer medications as ordered, assess respiratory and cardiac status as needed, encourage family and friends to visit, and use pressure reduction equipment and procedures as indicated. It also stated that hospice would provide medications, equipment, and supplies due to the terminal diagnosis and that staff were to refer to facility social services and/or hospice social services and the pastor as needed. However, the care plan did not document what supplies or medications hospice would provide or when hospice staff would be in the building. During observation, the resident had a catheter with a small amount of amber urine, and two CNAs used a full-body mechanical lift to transfer the resident to bed and provided catheter and personal care. One CNA removed gloves and later continued care while wearing soiled gloves, and the resident began to have a BM during care. A nurse stated hospice came a couple of times a week and staff could call if needed, and an administrative nurse stated the care plan should be specific to the resident’s needs and what the facility and hospice would provide.
Incomplete PBJ Staffing Submission
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information through the Payroll Based Journal (PBJ) as required. The facility had a census of 41 residents, and the CMS PBJ report for FY 2024 Quarter 4 showed excessively low weekend staffing. During interview on 09/09/24 at 03:30 PM, Administrative Staff A verified that the facility completed the quarterly PBJ data and sent it to corporate, which then sent the information to Prime View, the data collection program used for final submission to PBJ. Administrative Staff A stated the facility had adequate staffing during 2024 Quarter 4 but was unsure how the information was incorrectly submitted. The facility policy, Reporting Direct Care Staffing Information (PBJ), dated August 2022, stated that direct care staffing information is reported electronically to CMS through the PBJ system and is based on payroll records, invoices, tied-back contracts, or other verifiable information. The policy also stated that direct care staffing information is submitted by designated personnel with PBJ training and is reported no less frequently than quarterly.
Failure to Protect Residents from Neglect and Inadequate Incontinent Care
Penalty
Summary
The facility failed to protect three residents from neglect and potential abuse by not providing necessary incontinent care and failing to follow internal reporting and response protocols. One resident, who had diagnoses including anxiety disorder, neuromuscular bladder dysfunction, and urinary retention, was dependent on staff for toileting and had a urinary catheter. This resident reported that a CNA refused to change her when requested, stating she was not wet due to the catheter, despite evidence of leakage. The resident expressed fear of the CNA, and the incident was not immediately reported to administration as required by facility policy. Another resident with chronic kidney disease, anxiety disorder, muscle weakness, and a urinary catheter also required substantial staff assistance with toileting. This resident was denied assistance by the same CNA, who told her she did not need to go to the bathroom again after already being assisted twice. The care plan for this resident required staff to provide perineal care for every incontinent episode and to monitor intake and output, but these instructions were not followed. A third resident, diagnosed with cerebral palsy, muscle weakness, and neuromuscular bladder dysfunction, was dependent on staff for most activities of daily living and required two staff for toileting. The CNA in question did not check or change this resident’s brief for an entire eight-hour shift, despite the resident’s request. In all three cases, the facility’s policy required immediate reporting and suspension or segregation of staff accused of abuse or neglect, but this was not done when the allegations were first reported to a nurse. The failure to provide necessary care and to follow abuse prevention and reporting protocols resulted in feelings of belittlement, fear, and placed the residents at risk for neglect and psychosocial harm.
Failure to Immediately Report and Respond to Allegation of Neglect
Penalty
Summary
A resident with diagnoses including anxiety disorder, neuromuscular bladder dysfunction, and urinary retention, who was dependent on staff for toileting and had a urinary catheter, reported to a licensed nurse that a certified nurse aide refused to provide necessary urinary care. The resident stated that when she requested to be changed due to being wet, the aide told her she did not need to be changed because she had a catheter and then left the room. The resident's brief was later found to be soaked, and she expressed fear of the aide involved. The resident had intact cognition and was able to clearly communicate her needs and the incident. The licensed nurse who received the allegation did not immediately report the incident to administrative staff as required by facility policy. Instead, the issue was only brought to the attention of administration when the nurse asked the administrative nurse to speak with the resident upon arrival for work. Facility policy required immediate reporting and separation of the accused staff member from residents upon receiving an allegation of abuse or neglect. The failure to promptly report the allegation and implement protective measures resulted in a delay in addressing the situation and in suspending the staff member involved.
Failure to Provide Safe Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to provide a safe environment for a resident during a transfer, resulting in a fall and injury. The resident, who had diagnoses of diabetes mellitus, dementia, and atrial fibrillation, required extensive assistance for transfers and was identified as a high fall risk. The resident's care plan specified the need for two staff members to assist with transfers using a sit-to-stand lift. However, on the day of the incident, a Certified Nurse's Aide (CNA) attempted to transfer the resident alone using the lift, which led to the resident's ankle buckling and the resident falling out of the lift sling. The resident sustained a broken left thumb as a result of the fall. The resident's medical records indicated that the resident had intact cognition but required a manual wheelchair and extensive assistance for various activities of daily living. The resident's care plan and assessments highlighted the need for two staff members during transfers due to the resident's unsteady balance and high fall risk. Despite these documented requirements, the CNA proceeded with the transfer alone, contrary to the facility's policy and the resident's care plan. The incident was witnessed, and the resident was found on the floor with no immediate head injury but complained of knee pain. Subsequent medical evaluation revealed a fracture in the resident's left hand, necessitating a splint and changes to the resident's transfer protocol. The facility's policy required at least two nursing assistants for safe transfers using mechanical lifts, which was not adhered to in this case, leading to the resident's fall and injury.
Removal Plan
- CNA M was retrained on proper mechanical lift protocol and placed on a performance improvement plan.
- An in-service was completed for all employees regarding when using any mechanical lift two staff members must be present per facility policy.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 32 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Salina
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kenwood View Healthcare And Rehabilitation Center | 0.5 mi | ★★★★★ | 0 | 0 |
| Smoky Hill Rehabilitation Center | 1 mi | ★★★★★ | 5 | 1 |
| Salina Presbyterian Manor | 2.2 mi | ★★★★★ | 7 | 3 |
| Holiday Resort Of Salina | 2.6 mi | ★★★★★ | 18 | 0 |
| Pinnacle Park Nursing & Rehab Center | 3.2 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Legacy At Salina.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.