Legacy at Salina

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide a safe, functional environment for residents, staff, and the public when the facility failed to ensure the sidewalks were as free from trip hazards as possible and/or failed to flag or post alert for the trip hazards while awaiting repair.

Inspectors wroteThe facility had a census of 39 residents, with three residents sampled for falls. Based on observation, interview, and record review, the facility failed to ensure staff implemented fall prevention interventions to prevent a fall for Resident (R) 1. On 10/16/25, a Certified Nurse Aide (CNA) rolled R1 to her side in bed, and R1 fell out of bed onto the floor. On 10/17/25, after emergency transport for evaluation of R1's complaints of pain, an X-ray revealed R1 had a right femoral neck (top of the thigh bone) fracture (broken bone), which required surgical repair.

Inspectors wroteThe facility had a census of 41 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to employ a full-time certified dietary manager for the 41 residents who reside in the facility and received meals from the facility kitchen. This placed the residents at risk for inadequate nutrition.

Inspectors wroteThe facility had a census of 41 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to measure and record daily refrigerator and freezer temperatures for the evening shift. This placed the residents at risk for food-borne illnesses.

Inspectors wroteThe facility had a census of 41 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to post signage for six of seven residents regarding the use of enhanced barrier precautions (EBP- infection control interventions designed to reduce transmission of resistant organisms, which employ targeted gown and glove use during high contact cares) to ensure staff were aware. This deficient practice placed all residents of the facility at risk for the spread of infections. The facility also failed to ensure staff changed gloves properly during incontinence care for Resident (R) 44, placing the resident at risk for infection.

Inspectors wroteThe facility had a census of 41 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observations, interviews, and record review, the facility failed to ensure an appropriate indication, or a documented physician rationale which included the unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of Resident (R) 4's antipsychotic (a medication used to treat any major mental disorder characterized by a gross impairment testing) medication. This placed R4 at risk for unintended effects related to psychotropic (alters mood or thought) drug medications.

Inspectors wroteThe facility had a census of 41 residents. The sample included 12 residents, with one reviewed for abuse. Based on observation, record review, and interview, the facility failed to report to the state agency the allegation of abuse and neglect when R4 slapped another resident. This placed the residents at risk for ongoing abuse and/or mistreatment.

Inspectors wroteThe facility had a census of 41 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to promote an environment free of hazards for Resident (R) 7, who smoked cigarettes but was not assessed timely for safe smoking practices by the facility, and kept his smoking materials in his nightstand beside his bed. This placed the resident at risk for avoidable injuries and fire-related hazards.

Inspectors wroteThe facility had a census of 41 residents. The sample consisted of 12 residents, with two reviewed for urinary catheters (tubes inserted into the bladder to drain urine into a collection bag). Based on observations, record review, and interview, the facility failed to obtain an order for the urinary catheter for one resident, Resident (R) 44, and failed to monitor urinary catheter output for R44 and R35. This placed the residents at risk for catheter-related complications.

Inspectors wroteThe facility had a census of 41 residents. Based on observation, interview, and record review, the facility failed to label and date one insulin pen (a hormone that lowers the level of glucose in the blood) after opening for use. This deficient practice placed residents at risk for ineffective or outdated medication.

Inspectors wroteThe facility had a census of 41 residents. The sample included 12 residents, with one reviewed for Hospice (specialized care that mainly aims to provide comfort and dignity to the patients, by providing physical comfort and emotional, social, and spiritual support for people nearing the end of life) services. Based on observation, record review, and interview, the facility failed to ensure collaboration between the hospice provider and the facility for one resident, Resident (R) 44, who was admitted to hospice on 08/28/25. This placed the resident at risk of inadequate end-of-life care.

Inspectors wroteThe facility had a census of 41 residents. Based on record review and interview, the facility failed to submit complete and accurate staffing information through the Payroll Based Journal (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing.

Inspectors wroteThe facility had a census of 40 residents. The sample included 3 residents. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 1, R2, and R3 remained free of neglect and abuse. Based on the reasonable person concept, this deficient practice resulted in feelings of belittlement for R1, R2, and R3 and placed all three residents at risk of neglect and the potential for a negative psychosocial impact.

Inspectors wroteThe facility had a census of 40 residents. The sample included 3 residents. Based on observation, record review, and interview, the facility failed to ensure staff immediately reported an allegation of potential abuse and neglect to the administrator. Resident (R)1 reported an allegation of potential abuse and neglect to Licensed Nurse G, after Certified Nurse Aide M did not provide assistance to R1 for urinary care and R1 had a soaked brief. LN G did not report the incident to administrative staff. This failure placed R1 at risk for continued neglect. Findings Included: [...]

Inspectors wroteThe facility identified a census of 42 residents with three residents reviewed for falls. Based on record review, observation, and interview, the facility failed to provide a safe environment for Resident (R) 1 during a transfer. On 07/04/24, Certified Nurse's Aide (CNA) M transferred R1 by herself with the sit-to-stand lift. R1's ankle buckled and R1 fell out of the lift sling and sustained a broken left thumb. This deficient practice also placed R1 at risk for falls, injury, and pain.

Inspectors wroteThe facility had a census of 41 residents. Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the 41 residents who received their meals from the facility's kitchens. This placed the residents at risk for foodborne illness.

Inspectors wroteThe facility had a census of 41 residents. The sample included 14 residents. Based on observation, record review, and interview the facility failed to provide a safe, clean comfortable, and homelike environment in the dining room. This placed the residents at risk of an unsafe and uncomfortable environment.

Inspectors wroteThe facility had a census of 41 residents. The sample included 14 residents. Based on observation, interview, and record review, the facility failed to provide a safe environment free of chemical hazards for five cognitively impaired independently mobile residents and failed to ensure a safe environment for Resident (R) 33. The deficient practice placed the affected residents at risk for preventable accidents, falls, and related injuries.

Inspectors wroteThe facility had a census of 41 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to store drugs and biologicals for two medication storage carts placing the residents at risk for missing medications and unsafe access to medications.

Inspectors wroteThe facility had a census of 41 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to provide proper infection control practices related to point of care testing for COVID-19 (a highly contagious respiratory virus) and also failed to sanitize a resident's walker after it was used by another resident who had not been feeling well. This placed the residents at risk for infectious disease.

Inspectors wroteThe facility had a census of 41 residents. The sample included 14 residents. Based on observation, record review, and interview the facility failed to provide adequate lighting in the main dining room. This put the residents at risk of not being able to see and enjoy their meals.

Inspectors wroteThe facility had a census of 41 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 30 had a physician's order and was assessed for the ability to safely self-administer medications left at the bedside. This placed R30 at risk for improper use of medication and related side effects.

Inspectors wroteThe facility had a census of 41 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to honor Resident (R) 4's preference to receive three showers per week. This placed R4 at risk for decreased self-determination and impaired psychosocial well-being.

Inspectors wroteThe facility had a census of 41 residents. The sample included 14 residents, with three reviewed for Medicare Liability Notices. Based on record review and interview, the facility failed to provide the resident (or their representative) a fully completed Advanced Beneficiary Notice (ABN) for skilled services for Resident (R) 17, R31, and R36 which included the estimated cost of services. This placed the resident at risk for uninformed care decisions.

Inspectors wroteThe facility had a census of 41 residents. The sample included 14 residents, with six reviewed for bathing. Based on observation, record review, and interview, the facility failed to provide consistent bathing services as care planned for one sampled resident, Resident (R) 4. This placed the resident at risk for poor hygiene.

Inspectors wroteThe facility had a census of 41 residents. The sample included 14 residents, with two reviewed for respiratory care. Based on observation, record review, and interview, the facility failed to provide adequate respiratory care and services for Residents (R) 38, and R31 when staff failed to store their oxygen tubing and cannula in a sanitary manner when not in use. This placed the residents at risk for an infection.

Inspectors wroteThe facility had a census of 41 residents. The sample included 14 residents with two reviewed for behaviors. Based on observation, record review, and interview, the facility failed to complete a trauma-informed care assessment for one sampled resident, Resident (R) 1, who had behaviors and past traumatic events in her life. This placed the resident at risk for unmet behavioral health needs.

Inspectors wroteThe facility had a census of 41 residents. Based on observation, record review, and interview the facility kitchen staff failed to provide food prepared by methods that conserve nutritive value, flavor, and appearance when dietary staff failed to follow a recipe while preparing one resident's pureed diet. This placed the resident at risk for impaired nutrition.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 13 residents with two reviewed for activities of daily living (ADLs). Based on observation, record review, and interviews, the facility failed to provide assistance during R14's meals. The facility further failed to identify the unplanned weight loss and implement interventions to prevent further loss. R14 weighed 157.2 pounds on 11/02/21 and 140.8 pounds on 05/06/22 which indicated a significant unplanned weight loss of 10.43 percent (%) in six months. Findings Included: [...]

Inspectors wroteThe facility identified a census of 37 residents with one kitchen and one dining room. Based on observation, record review, and interviews, the facility failed to ensure sanitary food storage. This deficient practice placed the residents at risk for food-borne illness. Findings Include: - On 05/23/22 at 07:08AM an initial walk-through of the kitchen's food storage area was completed. The walkthrough revealed that the floors in the storage areas were sticky in front of the dry food storage area. Upon inspection of the kitchen's walk-in freezer unit, open but undated bags of fries, chicken strips, potato tots, hash browns, peas, and chicken bites were observed. The freezer unit blower vent had visible dust and lint buildup covering the vents blowing towards the food stored in the unit. Inspection of the kitchen's walk-in refrigerator unit revealed an open but undated bag of tortillas. [...]

Inspectors wroteThe facility identified a census of 37 residents. The sample included 13 residents. Based on observation, record review, and interviews, the facility failed to develop an individualized person-centered care plan related to bladder incontinence for Resident (R) 10, R16, and R30 and failed in the development of person-centered care plan related to monitoring of antihypertensive medication for R31. This deficient practice placed the residents at risk of not achieving and/or maintaining their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteThe facility had a census of 37 residents. The sample included 13 residents. Based on record review and interview the facility failed to provide scheduled weekend activities. This placed the residents at risk for boredom and impaired psychosocial well-being.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 13 residents, with five residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported the failure to monitor antihypertensive medication (class of medication used to treat hypertension [high blood pressure]), failure to follow physician ordered parameters for monitoring of antihypertensive medication, the lack of behavior monitoring on psychotropic (medications which alter mood or thoughts) medications and the lack of a stop date for an as needed antidepressant. These deficient practices placed Resident(R) 10, R31, R16, R33 and R14 at increased risk for side effects of unnecessary medications or complications.

Inspectors wroteThe facility had a census of 37 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections when staff failed to wear a mask inside the facility, left uncovered clean laundry in a cart in the hall, and hung Resident (R) 187's personal clothing on the hand rail outside her room. The facility further failed to ensure visitors to isolation room wore proper personal protective equipment (PPE). The facility further failed to ensure staff followed infection control principles during COVID (highly contagious, potentially fatal respiratory infection) test. This placed the 37 residents at risk for infection.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 13 residents with one resident reviewed for dignity. Based on observation, record review, and interviews, the facility failed to ensure R10's right to be treated with respect, dignity, related to bladder incontinence when the facility staff referred to residents as heavy wetters and placed cloth incontinent pads in R10's wheelchair. This deficient practice placed the residents at risk for negative psychosocial outcomes and decreased autonomy and dignity.

Inspectors wroteThe facility had a census of 37 residents. The sample included 13 residents. Based on record review and interview, the facility failed to develop a discharge summary for one of the residents reviewed for discharge that included a recapitulation (a concise summary of the resident's stay and course of treatment in the facility) of the resident's stay and post discharge pan for Resident (R) 38. This placed the resident at risk for receiving inadequate care.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 13 residents with two reviewed for activities of daily living (ADL's). Based on observation, record review, and interviews, the facility failed to provide consistent assistance and supervision with eating for Resident (R)14. This deficient practice placed the resident at risk for weight loss. Findings Included: - The electronic medical record (EMR) indicated the following diagnosis for R14: [...]

Inspectors wroteThe facility had a census of 38 residents. The sample included one resident reviewed for quality of care. Based on observation, record review, and interview, the facility failed to monitor Resident (R) 14's bowel movements and treat when indicated per physician orders which placed R14 at risk for digestive problems, impaired comfort, and bowel blockage.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 13 residents, with two residents reviewed for falls. Based on observation, record review, and interviews, the facility failed ensure fall interventions were implemented as care planned for Resident (R)16, which placed her at risk of major injury from falls

Inspectors wrote- R10's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), hypertension (elevated blood pressure), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), overactive bladder (a frequent and sudden urge to urinate that may be difficult to control), and stress incontinence (is the unintentional loss of urine). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented that R10 required extensive assistance of two staff members for activities of daily living (ADL's). The MDS documented R10 was not on a toileting plan. [...]

Inspectors wroteThe facility identified a census of 37 residents. The sample included 13 residents with five residents reviewed for respiratory care. Based on observations, record reviews, and interviews, the facility failed ensure consistent respiratory care for Residents (R)13 and R32. This deficient practice placed the residents at risk for complications due to respiratory therapy. Findings Included: -The electronic medical record (EMR) indicated the following diagnosis for R13: [...]

Inspectors wroteThe facility identified a census of 37 residents. The sample included 13 residents with one reviewed for dialysis services (process of filtering and purifying blood using machines) . Based on observation, record review, and interviews, the facility failed to provide consistent care and services including communication between the facility and dialysis center for Resident (R)30. This deficient practice placed R30 at risk for complications related to dialysis services.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 13 residents, with five residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to monitor for Resident (R) 10's antihypertensive medication (class of medication used to treat hypertension [high blood pressure]) and failed to follow physician ordered parameters for monitoring of antihypertensive medication for R31 and R16. These deficient practices had the risk for side effects of unnecessary medications or complications.

Inspectors wroteThe facility reported a census of 37. The sample included 13 residents with five residents reviewed for unnecessary medications. Based on observations, interviews, and record reviews, the facility failed to implement behavioral monitoring associated with antidepressant medications (class of medications used to treat mood disorders and relieve symptoms of intense sadness, hopelessness and suicidal thoughts) and the facility failed to implement a discontinuation date (stop date) for as needed psychotropic ( medications which alter thoughts or mood) medication for Residents (R) 14, R31 and R33. This deficient practice placed the residents at risk for ineffective treatment and unnecessary side effects from psychotropic medications. Fingings lncluded: -The electronic medical records (EMR) indicated the following diagnoses for R14: [...]

Inspectors wroteThe facility had a census of 37 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure the daily staff nursing schedule was posted for two of three days of the onsite survey. This placed the residents at risk for not knowing how many staff would be providing them care.