Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 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.
A resident with CVA, hemiplegia, and ADL dependence was given morning meds in a bowl at the bedside without a physician order or documented interdisciplinary self-administration assessment. An LPN left multiple medications in the room, and later the resident reported she could not reach them when her electric wheelchair lost battery power; staff were not present, and an admin nurse stated the meds should not have been left there.
A resident with dementia, vascular dementia, mood disorder, and major depressive disorder received risperidone with changing indications documented in the EMR, including mood disorder, adjunct to depression, agitation, and psychosis with delusions. The chart lacked documentation of multiple unsuccessful nonpharmacological interventions and a clear risk-benefit rationale for continued antipsychotic use, and the care plan was not revised to reflect new interventions. Nursing leadership stated no nonpharmacological approaches had been tried, while pharmacy/provider notes questioned the non-FDA-labeled indication and requested GDR review.
A CNA provided nail care to a resident with DM and daily insulin use, despite care plan directions for foot monitoring and podiatry involvement. The CNA cut the resident’s left great toe, causing bleeding and a skin injury, and the record lacked documentation of a wound assessment or physician notification. Staff interviews confirmed CNAs were not to provide nail care to diabetic residents.
Failure to Hold Metoprolol Per Ordered Parameters: A resident with HTN, Afib, and DM2 had a physician order for metoprolol with hold parameters for SBP and HR. The TAR showed the med was administered on multiple occasions when the resident’s HR was below 60 bpm, and an LN verified the medication should have been held when HR was out of range.
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.
Bedside Medications Left Without Self-Administration Assessment
Penalty
Summary
The facility failed to ensure a resident had a physician's order and an assessment for the ability to safely self-administer medications left at the bedside. The resident had diagnoses including major depressive disorder, cerebral infarction, hemiplegia, and a need for assistance with personal care. The resident's quarterly MDS documented intact cognition, functional range of motion impairment on one side of the upper and lower extremities, and dependence on staff for dressing, personal and toileting hygiene, transfers, and bed mobility. The care plan documented the resident needed assistance with activities of daily living related to hemiplegia and directed staff to transfer the resident using a sit-to-stand lift and two staff members. During medication administration, an LPN prepared the resident's morning medications and placed them in a small wooden bowl on the overbed table after the resident had been transferred to a recliner. The LPN reported the resident preferred to use a bowl because the resident could place the medications into her mouth. On a later observation, the resident was sitting in an electric wheelchair that had lost battery function and reported she could not reach the bowl of medications on the overbed table; the bowl contained several medications of different sizes and shapes, and staff were not present in the room. An administrative nurse stated the LPN should not have left the resident's medications in the room. The facility policy stated a resident may only self-administer medications after the interdisciplinary team determines which medications may be safely self-administered and the assessment is recorded in the medical record.
Inadequate justification for continued antipsychotic use
Penalty
Summary
The facility failed to ensure Resident 7 had an appropriate indication, or a documented physician rationale that included multiple unsuccessful attempts at nonpharmacological symptom management and a risk-versus-benefit review, for continued use of risperidone, an antipsychotic medication. Resident 7 had diagnoses including cerebral infarction, dementia with agitation, vascular dementia, mood disorder, and major depressive disorder, and the MDS documented moderately impaired cognition with a BIMS score of 12. The resident received an antipsychotic during the look-back period, and the last gradual dose reduction attempt was documented on 08/25/25, with the physician later documenting that a GDR was clinically contraindicated on 01/19/26. The resident’s psychotropic drug use CAA dated 03/03/26 identified psychotropic use related to risperidone for mood disorder and adjunct to depression. The care plan for psychotropic medications, initiated on 01/04/24, included monitoring, quarterly review for dosage reduction, discussion with the physician and family about ongoing need, review of behaviors and interventions, and education regarding risks and side effects, but it had not been revised with new interventions or any non-pharmacological approaches tried. The EMR showed multiple risperidone orders over time for mood disorder, agitation, adjunct to depression, and psychosis with delusions, with several orders discontinued and replaced. The record also showed pharmacy/provider notes stating the risperidone order did not have an FDA-labeled indication and requesting a risk-benefit assessment and GDR review. The physician responded that the medication was being used for mood disorder and later for psychosis, and documented that the resident had been assessed and that GDR was contraindicated because the medication had been effective at alleviating behavioral symptoms. During interviews, Administrative Nurse E and Administrative Nurse D stated the facility had not tried non-pharmacological interventions for Resident 7, and the facility’s psychotropic medication policy stated non-pharmacological approaches must be attempted unless contraindicated. The policy, however, lacked information on an appropriate indication for psychotropic medication use.
Improper Foot Care Caused Toe Injury in a Diabetic Resident
Penalty
Summary
The facility failed to provide appropriate foot care when a CNA cut the toenails of a resident with type 2 diabetes mellitus and caused a cut to the left great toe. The resident’s EMR documented diabetes and daily insulin use, and her MDS documented intact cognition and dependence on staff for toileting, lower-body dressing, shoes, mobility, and transfers. Her care plan directed staff to inspect her body and feet for breaks in the skin, avoid over-the-counter remedies for corns and calluses, refer her to a podiatrist, and ensure nails were cut straight across and filed, with daily inspection of her feet for open areas, sores, pressure areas, blisters, edema, or redness. On 03/04/2026, the resident reported that a CNA had cut her toenails, and the left great toe was noted to be bloody on the left side of the nail with a small piece of skin cut off. The area was cleansed and a bandage was applied, but the EMR lacked documentation of a wound assessment or physician notification. During interviews, the wound care nurse stated she was unaware a CNA had cut the resident’s skin and that CNAs were not to provide any type of foot care to a diabetic resident. A CNA stated she was not to provide nail care to diabetic residents, and an administrative nurse stated CNAs should not have provided nail care to the resident and the physician should have been informed of the injury.
Failure to Hold Metoprolol Per Ordered Parameters
Penalty
Summary
The facility failed to hold metoprolol for Resident 13 when the resident’s heart rate was below the physician-ordered parameter of 60 bpm. Resident 13 had diagnoses of hypertension, atrial fibrillation, and type 2 diabetes mellitus, and the care plan directed staff to give medications as ordered and monitor for side effects. The physician’s order, dated 08/28/25, directed metoprolol 37.5 mg by mouth twice daily for hypertension and to hold the medication if systolic blood pressure was less than 100 mmHg and heart rate was less than 60 bpm. The Treatment Administration Record showed metoprolol was administered on multiple days in April and May 2026 when the resident’s heart rate was below the ordered parameters, including heart rates of 57, 59, 58, 55, 54, and 57 bpm. During interview, the LN stated that if the heart rate was below 60 bpm, staff would hold the medication and document it in the progress notes, and verified that there were days the medication was given when it should have been held. The Administrative Nurse stated the order should have been clarified because it was not clear whether the medication should be held when both systolic blood pressure and heart rate were out of parameters, and also verified that staff were to follow the physician’s orders and hold medication when out of parameters.
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 30 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 | ★★★★★ | 2 | 0 |
| Kenwood View Healthcare And Rehabilitation Center | 3.4 mi | ★★★★★ | 0 | 0 |
| Smoky Hill Rehabilitation Center | 4.2 mi | ★★★★★ | 4 | 1 |
| Salina Presbyterian Manor | 4.4 mi | ★★★★★ | 5 | 3 |
| Holiday Resort Of Salina | 5.2 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Pinnacle Park Nursing & Rehab Center.
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 August 2026) and official state health department websites.