Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Pinnacle Park Nursing & Rehab Center during CMS and state inspections, most recent first.
The facility did not complete the required yearly performance evaluations for five CNAs employed for over 12 months, as per their policy. This oversight was confirmed through a staffing list review and interviews, highlighting a risk of inadequate care for residents.
The facility failed to follow infection control standards, risking residents' health. Observations showed improper handling of soiled linens, inadequate hand hygiene, and unsanitary storage of oxygen tubing. Laundry procedures were not followed, with wet clothes left overnight and lack of PPE. Staff interviews revealed a lack of awareness and training on infection control protocols.
A resident with a history of falls and significant medical conditions required a Hoyer lift for transfers, but this was not updated in her care plan. Despite being a high fall risk and needing two staff for safe transfers, the care plan lacked this critical information, which was accessible to all direct care staff. The facility's policy mandated care plan revisions to reflect comprehensive care needs, but this was not adhered to, placing the resident at risk for impaired care.
A resident with a history of falls and medical conditions experienced multiple preventable falls due to inadequate supervision and failure to follow care-planned interventions. Despite being at high risk for falls and requiring substantial assistance, the resident was left standing for extended periods or attempted to stand without adequate support, leading to falls. The facility's policy on accidents and supervision was not effectively implemented, resulting in a deficiency in care practices.
A facility failed to provide individualized toileting interventions for a resident with frequent bladder and occasional bowel incontinence. Despite the resident's ability to communicate needs and being a good candidate for a toileting program, the care plan lacked specific interventions. Staff were uncertain about the resident's need for a toileting program, and the facility's incontinence policy was not followed, placing the resident at risk for complications.
Failure to Conduct Yearly CNA Performance Evaluations
Penalty
Summary
The facility failed to conduct the required yearly performance evaluations for five Certified Nurse Aides (CNAs) who had been employed for more than 12 months. This deficiency was identified during a review of the facility's staffing list and confirmed through interviews. The CNAs in question were hired on various dates ranging from August 2020 to May 2023, yet none had documented yearly performance evaluations available upon request. The facility's Evaluation Process policy, dated December 2019, mandates annual formal written evaluations of employee work performance. The absence of these evaluations placed residents at risk for inadequate care, as stated in the report.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to sanitary infection control standards, which placed residents at risk for infectious diseases. Observations revealed that an electric razor with brown shavings was left on an Enhanced Barrier Precautions (EBP) cart outside a resident's room without being contained. A Certified Nursing Aide (CNA) moved a Hoyer lift from one resident's room to another without sanitizing it and neglected to perform hand hygiene between resident interactions. Additionally, a resident's oxygen cannula was improperly stored, wrapped around a wheelchair instead of being placed in a sanitary container. Further deficiencies were noted in the handling of soiled linens and laundry. A CNA placed soiled linens directly on the floor without sanitizing the area afterward. Commercial washers were found with wet clothing left overnight, and dryers had lint in the traps. The laundry area lacked personal protective equipment (PPE), and staff were unaware of proper procedures for handling red-bagged laundry, which indicates transmission-based precautions. Housekeeping staff were not informed that laundry should not sit in washers overnight, and there was confusion about the monitoring of water temperatures and chemical use in laundry processes. Interviews with staff highlighted a lack of awareness and training regarding infection control protocols. A CNA admitted to not knowing the requirement to clean equipment between residents and acknowledged forgetting to perform hand hygiene. The administrative nurse confirmed that shared equipment should be cleaned after each use and that hand hygiene is essential when moving between residents. The facility's policies on hand hygiene, cleaning, and disinfection were not followed, contributing to the risk of infection transmission among residents.
Failure to Update Care Plan with Hoyer Lift Requirement
Penalty
Summary
The facility failed to revise the care plan of a resident, identified as R5, to include her Hoyer lift transfer requirements. R5 had a medical history that included heart failure, cerebrovascular disease, major depression, cognitive-communication disorder, abnormalities of gait, muscle weakness, and unsteadiness of her feet. Her Minimum Data Set (MDS) indicated she was dependent on staff for various activities of daily living (ADLs) and was at risk for falls, having experienced multiple falls since her last assessment. Despite these needs, her care plan did not reflect the requirement for a Hoyer lift for transfers, which was necessary due to her recent decline in physical abilities. Observations and interviews revealed that R5 was a high fall risk and required two staff members and a Hoyer lift for safe transfers. However, this critical information was not updated in her care plan, which all direct care staff could access. The facility's policy required care plans to be revised to reflect comprehensive care needs, but this was not done for R5, placing her at risk for impaired care due to uncommunicated care needs. Staff members, including a CNA and an administrative nurse, acknowledged the oversight and the necessity for the care plan to include the Hoyer lift requirement.
Failure to Ensure Safe Care Practices Resulting in Multiple Falls
Penalty
Summary
The facility failed to ensure safe care practices during staff-assisted care, resulting in multiple preventable falls for a resident, R5. R5 had a medical history that included heart failure, cerebrovascular disease, major depression, cognitive-communication disorder, abnormalities of gait, muscle weakness, and unsteadiness of her feet. Her Minimum Data Set (MDS) indicated she was at risk for falls and required substantial assistance with activities of daily living (ADLs). Despite these known risks, R5 experienced several falls during staff-assisted care, highlighting a deficiency in the facility's supervision and care practices. R5's care plan included interventions to reduce fall risks, such as ensuring her call light was within reach and maintaining a clutter-free environment. However, multiple incidents occurred where these interventions were not effectively implemented. For instance, R5 fell in the shower room when her chair was not within reach, and she had to be assisted to the ground. In another incident, she fell while holding onto a bathroom railing during care, and the staff member was unable to prevent her from falling. These incidents indicate a lack of adequate supervision and failure to follow care-planned interventions. Interviews with staff revealed that R5 required two staff members and a Hoyer lift for transfers due to her weakness and recent decline. Despite this, there were instances where she was left standing for extended periods or attempted to stand without adequate support, leading to falls. The facility's policy on accidents and supervision stated that residents would be comprehensively assessed for safety and falls, and sufficient staff and supervision would be provided. However, the repeated falls experienced by R5 demonstrate a failure to adhere to this policy, placing her at risk for further falls and injuries.
Failure to Implement Individualized Toileting Interventions
Penalty
Summary
The facility failed to implement individualized toileting interventions for a resident, identified as R17, who was frequently incontinent of bladder and occasionally incontinent of bowel. Despite R17's intact cognition and ability to communicate needs, the care plan lacked specific interventions to address his incontinence. The resident's medical records indicated he was a good candidate for a toileting program, yet no such program was in place. Observations and interviews revealed that staff were uncertain about R17's need for a toileting program, and the care plan did not reflect individualized interventions to maintain or improve his bowel and bladder function. R17's medical history included legal blindness, muscle weakness, and unsteadiness, which required assistance with activities of daily living. The facility's incontinence policy stated that residents should receive appropriate treatment to prevent infections and improve incontinence, but this was not adhered to in R17's case. The lack of a tailored toileting program and the absence of specific interventions in the care plan placed R17 at risk for complications related to incontinence.
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 59 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) |
|---|---|---|---|---|
| Legacy At Salina | 3.2 mi | ★★★★★ | 27 | 0 |
| Kenwood View Healthcare And Rehabilitation Center | 3.4 mi | ★★★★★ | 0 | 0 |
| Smoky Hill Rehabilitation Center | 4.2 mi | ★★★★★ | 5 | 1 |
| Salina Presbyterian Manor | 4.4 mi | ★★★★★ | 7 | 3 |
| Holiday Resort Of Salina | 5.2 mi | ★★★★★ | 18 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 July 2026) and official state health department websites.