Below 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 Salina Presbyterian Manor during CMS and state inspections, most recent first.
Failure to supervise a high-fall-risk resident in the bathroom led to a serious fall injury. A CNA assisted the resident to the toilet after he returned from an appointment, then left him alone after notifying an LPN. Another CNA later found him on the bathroom floor with a head hematoma and urine on the floor; the resident was on Eliquis and aspirin, had hemiplegia/hemiparesis, aphasia, TIA history, and needed substantial ADL assistance. Hospital imaging showed an acute subarachnoid bleed, and the resident later died.
A resident with PVD, osteomyelitis, and recent toe amputations had ordered wound vac therapy for a right foot surgical wound. An LPN placed Aquacel AG under the wound vac despite the TAR, and the wound care clinic later found the dressing had clogged the vac, the wound had worsened with more necrosis and pain, and the resident was sent to the ED for further evaluation. The nurse said there were conflicting orders and she did not verify the correct one.
Failure to prevent a right heel pressure injury occurred when a resident with dementia, a recent hip fracture, very limited mobility, incontinence, and a Braden score showing mild risk did not have documented pressure injury prevention measures in place before the wound developed. The chart lacked evidence of heel offloading, repositioning, or other preventive interventions despite identified risk for friction and shear. Nursing later found a sore with eschar and an open blister on the heel, and the wound progressed to a painful DTI with increasing eschar.
Two Certified Medication Aides administered medications to residents after their certifications had expired, due to a failure by Human Resources and nursing administration to properly track and communicate licensure expiration dates. This resulted in unlicensed staff providing care and placed all residents at risk of not receiving care from properly credentialed personnel.
Two CMAs administered medications to residents after their licenses had expired due to a failure in the facility's administrative oversight and tracking of licensure expiration dates. Human Resources and nursing administration did not identify the expired licenses in time, resulting in unlicensed staff providing care.
A CNA in a LTC facility was reported for abusive behavior towards three residents, including shoving, slapping, and neglecting care. The residents, who had various medical conditions requiring assistance, reported feeling unsafe and mistreated. The facility's response was delayed, and the incidents were not documented in the residents' medical records, highlighting a failure to protect residents from abuse.
Two residents suffered burns from hot liquids due to inadequate supervision and failure to assess beverage temperatures. One resident, with a history of hemiplegia and arthritis, spilled coffee on their thigh, while another resident was burned by soup and coffee when a student CNA accidentally tilted a bedside table. The facility did not follow procedures for serving hot beverages, and care plans did not address the residents' needs for assistance with hot liquids.
Failure to Supervise Resident in Bathroom After Return From Appointment
Penalty
Summary
The facility failed to provide adequate supervision to prevent a fall with serious injury for a resident who was at high risk for falls, had hemiplegia and hemiparesis following a cerebral infarction, atrial fibrillation, aphasia, transient ischemic attacks, and moderately impaired cognitive function. The resident required moderate to substantial assistance with all ADLs except eating, had a documented history of falls, and was receiving Eliquis and aspirin. The resident’s care documentation also identified impaired balance, generalized weakness, decreased safety awareness, poor communication/comprehension, and non-compliance with using the call light. After returning from an appointment, a CNA assisted the resident into the bathroom, sat him on the toilet, and then left him alone in the bathroom after notifying an LPN that he was there. Shortly afterward, another CNA entered the room and found the resident on the bathroom floor. The resident had a hematoma to the right side of his head, urine was on the floor in front of the toilet, and his pants were urine-soaked. Staff assisted him from the floor, notified the physician, and arranged transfer to the hospital by EMS. Hospital imaging showed an acute subarachnoid bleed along the right side of the head. Facility documentation and witness statements described that the resident had been left alone in the bathroom after returning from the appointment and that staff later found him on the floor. The resident was alert and oriented when assessed after the fall, but he was later informed to have a head bleed at the hospital and subsequently died there.
Improper wound vac dressing placement led to wound deterioration
Penalty
Summary
The facility failed to ensure the resident received wound care in accordance with the ordered treatment plan for the right foot surgical wound after amputation of the third, fourth, and fifth toes. The resident had peripheral vascular disease, osteomyelitis of the right foot, and surgical aftercare for toe amputations. The resident’s record showed intact cognition, substantial assistance needs for several activities of daily living, and a care plan directing staff to provide wound care per treatment orders and monitor the wound for improvement or deterioration. The resident’s wound treatment orders changed several times in April, including wound vac therapy and later dressing changes. On 04/27/26, the wound vac dressing was changed and the wound vac resumed at 125 mmHg continuous pressure per provider order. However, the wound care clinic later documented that Aquacel AG had been placed underneath the wound vac. The clinic noted that the wound had deteriorated and increased in size since the prior appointment, with increased fascial necrosis and significantly increased pain. The clinic also documented that the facility needed education. The wound care clinic completed partial debridement, obtained a bone and wound culture, covered the wound with Dakin’s-soaked gauze, and sent the resident to the emergency department for further evaluation and possible admission. Subsequent documentation showed the resident was confused and shaky, and hospital testing showed osteomyelitis in the right foot. The facility later documented that the wound vac had been clogged by Aquacel AG placed in the wound bed and that the wound had deteriorated. The nurse involved stated there were two different orders and that she did not double-check the correctness of the 24-hour shift sheet, while administrative nursing staff stated nurses were expected to follow the TAR and clarify discrepancies.
Failure to Prevent Right Heel Pressure Injury
Penalty
Summary
The facility failed to ensure a resident with dementia, heart failure, atrial fibrillation, a recent right hip fracture, generalized weakness, impaired balance, very limited mobility, and incontinence received necessary pressure injury prevention care. The resident’s admission assessments documented that he required maximum staff assistance with ADLs, had a Braden score indicating mild risk with friction and shear concerns, and was unable to make frequent or significant independent position changes. Although the pressure ulcer/injury CAA identified risk related to ADL/mobility impairment and incontinence and stated a licensed nurse would assess the skin weekly and put proper interventions in place, the care plan initially lacked any focus, goals, or interventions related to skin assessment or pressure ulcer prevention. The record showed no evidence that preventative measures were implemented before the wound developed. Admission skin assessment documented no redness on the heels, but the EMR lacked evidence of heel offloading, repositioning, or other pressure injury prevention interventions despite the resident’s limited mobility and risk for friction and shear. A later skin check documented no new skin issues, and subsequent Braden assessments continued to show very limited mobility and probable inadequate nutrition, with friction and shearing noted as a potential problem. The chart still lacked evidence of preventive measures being used to avoid pressure injuries. On 11/24/25, nursing staff identified a sore on the resident’s right heel with eschar and an open blister. Two days later, the resident was documented as having a new in-house deep tissue injury to the right heel, painful and burning, with a wound bed containing 60% eschar. The care plan then added repositioning and heel offloading with Prevalon boots, but the record also noted the resident often removed the boots while in bed. The wound persisted with increasing eschar over time, and the discharge summary documented an ulcerated area on the right heel.
Expired Licensure for Medication Aides Led to Unqualified Staff Administering Medications
Penalty
Summary
The facility failed to ensure that nursing staff, specifically two Certified Medication Aides (CMAs), maintained current licensure as required by regulations. According to the Kansas Nurse Aide Registry and facility work schedules, both CMAs worked and administered medications to residents after their certifications had expired. The facility's records showed that one CMA worked six days and the other worked two days with expired licenses before the issue was identified. Human Resources staff and the Administrative Nurse were responsible for monitoring licensure expiration dates but did not detect the lapses, resulting in unlicensed staff providing care. Interviews with Human Resources and the Administrative Nurse confirmed that the oversight occurred because the expiration dates for the two CMAs were not properly tracked or communicated. The facility had a policy in place to ensure nursing services were provided by appropriately licensed staff, but this policy was not effectively implemented in these instances. As a result, all residents in the facility were placed at risk of not receiving care from properly credentialed staff.
Failure to Monitor Nursing Staff Licensure Resulting in Unlicensed Medication Administration
Penalty
Summary
The facility failed to ensure adequate administrative oversight by not monitoring and verifying that all nursing staff maintained active licenses as required. Specifically, two Certified Medication Aides (CMAs) worked in the facility and administered medications to residents after their licenses had expired. The Kansas Nurse Aide Registry confirmed that both CMAs' licenses had expired, yet the facility's working schedule showed that one CMA worked six days and the other worked two days post-expiration. Both individuals continued to provide care to residents during this period without valid certification. Human Resources staff was responsible for tracking licensure expiration dates and notifying staff in advance, but in these instances, the expiration dates for the two CMAs were overlooked. The lapse was acknowledged by both Human Resources and the Administrative Nurse, who stated that the oversight occurred because the expiration dates for these staff members "fell through the cracks." This failure to monitor licensure status resulted in unlicensed staff providing medication administration to residents.
Failure to Protect Residents from Abuse by CNA
Penalty
Summary
The facility failed to protect three residents, identified as R1, R2, and R3, from abuse by a Certified Nurse Aide (CNA) M. On the morning of December 17, 2024, R1 reported to a Licensed Nurse (LN) G that CNA M had shoved her into the wall and slapped her buttocks during a change. R1's medical records indicated she had anxiety, psychosis, and obsessive-compulsive disorder, with moderately impaired cognition, requiring substantial assistance for daily activities. Despite these needs, R1 was left uncovered and upset after the incident, as observed by another CNA, N. R2, who had chronic pain, COPD, and artificial knee joints, reported that CNA M did not listen to her instructions during a transfer, causing her pain and tremors. R2's records showed she required assistance with activities of daily living and had depression related to her recent move to the facility. R3, with acute kidney failure and diabetes, reported erratic behavior from CNA M, who refused to assist him to the bathroom, leaving him to manage on his own. R3's records indicated he required substantial assistance and was planning a short-term stay. The facility's incident report and subsequent interviews confirmed the residents' accounts of mistreatment by CNA M. Despite the absence of physical marks on R1, the psychological impact was evident, as R1 expressed fear and distress. The facility's policy on abuse prevention and reporting was not effectively implemented, as the incidents were not documented in the residents' medical records, and the initial response to the reported abuse was delayed. The failure to protect these residents from abuse and neglect placed them at risk for further harm.
Failure to Prevent Hot Liquid Burns in Residents
Penalty
Summary
The facility failed to identify the risk for burns and provide adequate supervision to prevent accidental hot liquid burns for two residents. The first resident, who had a history of hemiplegia, hemiparesis, calcific tendonitis, and rheumatoid arthritis, required staff assistance with eating and drinking. During lunch, the resident attempted to drink coffee without assistance, resulting in a spill that caused a second-degree burn on the right thigh. The resident's care plan was not updated to reflect the need for a lid on hot beverages until after the incident, and the coffee temperature was not checked before serving. The second resident, diagnosed with peripheral vascular disease, hypertension, and depression, experienced a similar incident when a student CNA accidentally tilted the bedside table, causing hot tomato soup and coffee to spill on the resident's left thigh. The resident suffered burns that were initially red and non-blistered but later developed into raised welts. The student CNA had not assessed the temperature of the hot liquids before serving, and the bedside table was unstable, contributing to the accident. Both incidents highlight the facility's failure to provide adequate supervision and assess the temperature of hot liquids before serving, resulting in burns and pain for the residents. The facility's procedures for serving hot beverages were not followed, and the residents' care plans did not adequately address their needs for assistance with hot liquids, leading to these preventable accidents.
Removal Plan
- Assess R1's safety with hot liquids and update his care plan to ensure he always receives a lid on hot beverages.
- Dietary staff assess the temperature of the coffee carafes to ensure temperatures are in the appropriate range.
- Remove microwaves from the dining rooms and staff must take all food and beverages to the dietary staff for reheating so temperatures can be assessed and ensured in the appropriate range.
- Switch out R2's tray table and mark for increased staff awareness regarding the tilt function.
- Staff receive education on the new processes and accident prevention.
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 72 citations issued within 25 miles in the last 12 months — including the 1 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) |
|---|---|---|---|---|
| Holiday Resort Of Salina | 0.9 mi | ★★★★★ | 18 | 0 |
| Kenwood View Healthcare And Rehabilitation Center | 1.7 mi | ★★★★★ | 0 | 0 |
| Smoky Hill Rehabilitation Center | 1.9 mi | ★★★★★ | 5 | 1 |
| Legacy At Salina | 2.2 mi | ★★★★★ | 27 | 0 |
| Pinnacle Park Nursing & Rehab Center | 4.4 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Salina Presbyterian Manor.
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.