Salina Presbyterian Manor

Inspectors wroteBased on interviews and record review, the facility failed to provide adequate supervision to prevent a fall with serious injury for Resident (R) 1, who was at high risk for falls, received an anticoagulant (a class of medications used to prevent the blood from clotting), and required assistance with activities of daily living. On [DATE], Certified Nurse Aide (CNA) M assisted R1 into the bathroom in his room, sat R1 on the toilet, then left R1 alone in the bathroom. CNA M alerted Licensed Nurse (LN) G that R1 was in the bathroom. At 10:55 AM, CNA N entered R1's room and found R1 on the floor of the bathroom. R1 had hematoma (a collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) on the right side of his head. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure Resident (R) 3 received quality treatment and care in accordance with professional standards of practice. On 04/27/26, Licensed Nurse (LN) G failed to follow wound vac (a vacuum-assisted wound treatment that applies gentle suction to a wound to help it heal) treatment orders for the treatment of R3's third, fourth and fifth right toe amputations (surgical removal of a body part), which caused R3's surgical wound to worsen and require intravenous (IV-administered directly into the bloodstream via a vein) antibiotic administration.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure Resident (R) 2 received the necessary care, consistent with professional standards of practice, to prevent a pressure injury from developing when staff failed to identify and implement preventative measures such as heel offloading or repositioning to address R2's risk for pressure risk related to friction and shear and very limited ability to reposition. This failure resulted in an unstageable pressure injury unstageable (depth of the wound is unknown due to the wound bed being covered by a thick layer of other tissue and pus).

Inspectors wroteThe facility identified a census of 53 residents. Based on record review and interview, the facility failed to ensure nursing staff possessed current licensure as required. This deficient practice placed all the residents in the facility at risk for not attaining or maintaining the highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteThe facility identified a census of 53 residents. Based on record review and interview, the facility failed to ensure adequate administrative oversight when the facility failed to monitor and ensure all nursing staff practicing in the facility maintained active licenses as required to provide the residents residing in the facility with the care they needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being. This deficient practice placed the residents residing in the facility at risk for a lack of quality nursing care.

Inspectors wroteThe facility had a census of 56 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food under sanitary conditions for the 56 residents in the facility, who receive their food from the kitchen. This deficient practice placed the residents at risk for foodborne illness.

Inspectors wrote- R30's Electronic Medical Record (EMR) documented diagnoses of diabetes mellitus (DM - when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), bacteremia (presence of bacteria in the blood), and acute pyelonephritis (infection of the kidneys). R30's EMR documented she was discharged to a hospital on [DATE] to 03/17/25 and again on 04/30/25 to 05/07/25. Upon request, the facility lacked documentation the Long-Term Care Ombudsman (LTCO) had been notified of the discharges from the facility. On 06/25/25 at 02:30 PM, Social Services Staff X verified she had not notified the LTCO of the March 2025 and April 2025 discharges to a hospital. She stated she only notified the ombudsman of the monthly admissions and discharges to home or another facility. [...]

Inspectors wroteThe facility had a census of 56 residents. The sample included 14 residents. Based on observation, interview, and record review, the facility failed to label Resident (R)158 and R37s' insulin (a hormone that lowers the level of glucose in the blood) flex pens when initially opened for use and when expired. This deficient practice placed the affected residents at risk for ineffective medications.

Inspectors wroteThe facility had a census of 56 residents. The sample included 15 residents. Based on observation, interview, and record review, the facility failed to ensure staff used Enhanced Barrier Precautions (EBP) when providing care with close contact to residents with an open wound or an indwelling device. This deficient practice placed all residents at risk for infection.

Inspectors wroteThe facility had a census of 56 residents. The sample included 14 residents, with one reviewed for dignity. Based on observation, record review, and interview, the facility failed to provide dignity and quality of life for Resident (R) 159, by having an uncovered urinary collection leg bag visible to guests and other residents. This placed the residents at risk for embarrassment and an undignified living environment.

Inspectors wroteThe facility had a census of 56 residents. The sample included 15 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to monitor physician-ordered blood pressures for one resident, Resident (R) 19, which placed the resident at risk for adverse effects related to medication and physical decline.

Inspectors wroteThe facility identified a census of 56 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 1, R2, and R3 remained free from abuse. On 12/17/24 at 05:00 AM, Licensed Nurse (LN) G and Certified Nurse Aide (CNA) N received a report from R1 that CNA M had shoved her hard into the wall when turning to change her and slapped her buttocks. During the night shift, LN G removed CNA M from another hall, due to the mistreatment of R2 and R3. R2 stated CNA M would not listen to her about a transfer and hurt her arm during the transfer, which caused her to have tremors. R3 stated that CNA M came into his room, throwing and slamming things around, and would not provide him assistance to the bathroom. [...]

Inspectors wroteThe facility identified a census of 58 residents with three residents reviewed for accidents and hazards. Based on record review, observation, and interview, the facility failed to identify risk for burns and provide adequate supervision to prevent accidental hot liquid burns for Resident (R) 1 and R2. On 10/07/24 at approximately 12:30 PM, R1 ate lunch in the dining room. R1 required staff assistance with eating and drinking. R1 took the plastic wrap off the coffee on his tray, lifted it towards his mouth, and lost control of the coffee cup, spilling hot coffee on his right thigh. R1 sustained a second-degree burn (potentially painful burn that affects the first and second layers of the skin) to his right thigh. On 12/03/24 at approximately 05:30 PM, Student Certified Nurse's Aide (CNA) GG took R2's supper tray to R2's room and placed the tray on the bedside table. [...]

Inspectors wroteThe facility had a census of 57 residents. The sample included 15 residents. Based on observation, record review, and interview the facility failed to prepare food in accordance with professional standards for food service safety when staff used contaminated gloves to transfer food items from one container to another while preparing the four residents pureed diets, failed to use gloves when cutting and handling food items, and failed to ensure clean and sanitary food prep areas. This placed the residents at risk for foodborne illness.

Inspectors wroteThe facility had a census of 57 residents. The sample included 15 residents. Based on observation, record review and interview, the facility failed to maintain a Quality Assessment and Assurance (QAA) Committee that met quarterly and had the required membership in attendance when the Medical Director (or designee) did not attend one quarterly meeting. This placed the residents at risk for decreased quality of care.

Inspectors wroteThe facility had a census of 57 resident. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to ensure licensed nursing staff had appropriate competencies and skill set to provide nursing related services to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This placed Resident (R) 40 at risk of injury during transfers and ongoing wound assessments and all residents at risk for decreased quality of care.

Inspectors wroteThe facility had a census of 57 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 four residents' pureed diets. This placed the affected residents at risk for impaired nutrition.

Inspectors wroteThe facility had a census of 57 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R)31 or his representative with written information regarding the facility bed hold policy when R31 was transferred to the hospital. This placed R31 at risk for not being permitted to return and resume residence in the nursing facility.

Inspectors wroteThe facility had a census of 57 residents. The sample included 15 residents. Based on observations, record review, and interview, the facility failed to develop a comprehensive care plan for Resident (R) 40 which addressed his edema and related needs. This placed the resident at risk for impaired care due to uncommunicated care needs.

Inspectors wroteThe facility had a census of 57 resident. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to revise Residents (R) 38's care plan to include fluid restriction quantities, which placed R38 at risk of complication related to hydration status, dialysis (procedure where impurities or wastes were removed from the blood) treatment and history of urinary tract infections (UTI-an infection in any part of the urinary system) due to uncommunicated care needs.

Inspectors wroteThe facility had a census of 57 residents. The sample included 15 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 completed recapitulation (a concise summary of the resident's stay and course of treatment in the facility) of the resident's stay and post discharge plan for Resident (R) 57. This placed the resident at risk for receiving inadequate care and missed care opportunities.

Inspectors wroteThe facility had a census of 57 residents. The sample included 15 residents, with four reviewed for non-pressure related skin conditions. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 40 had his physician-ordered compression socks on to his legs daily due to his edema (swelling resulting from an excessive accumulation of fluid in the body tissues). This placed the resident at risk for complications from edema.

Inspectors wroteThe facility had a census of 57 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to implement interventions placed to prevent, or promote healing of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) for Resident (R)1 when the facility failed to implement the pressure reducing cushion as directed by R1's plan of care and R1 developed a Stage 2 (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) pressure injury to the coccyx (area at the base of the spine) area. This also placed the resident at risk for further unhealed pressure injuries, pain and infection.

Inspectors wroteThe facility had a census of 57 residents. The sample included 15 residents, with nine reviewed for accidents. Based on observation, record review, and interview, the facility failed to provide adequate supervision and a safe environment, free from preventable accident hazards, for three sampled residents who had falls, Resident (R) 26, R40, and R41. This placed the resident's at risk for further falls and injury.

Inspectors wroteThe facility had a census of 57 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R) 1 with sanitary indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag) care which placed the resident at risk for urinary tract infections (UTI-an infection in any part of the urinary system).

Inspectors wroteThe facility had a census of 57 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to monitor Resident (R) 38's physician ordered fluid restriction. This placed R38 at risk of complication related to hydration status due to the need of dialysis (procedure where impurities or wastes were removed from the blood) treatment and history of urinary tract infections (UTI-an infection in any part of the urinary system).

Inspectors wroteThe facility had a census of 57 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 38 received care and services for dialysis (procedure where impurities or wastes were removed from the blood) consistent with professional standards of practice which included ongoing assessments of resident's condition, and ongoing communication and collaboration with the dialysis facility. This placed R38 at risk complications and unmet care needs related to dialysis treatments. Findings Included: [...]

Inspectors wroteThe facility had a census of 57 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported the lack of an appropriate indication for Resident (R)26's Zyprexa (antipsychotic-class of medications used to treat mental disorder characterized by a gross impairment in reality testing) placing the resident at risk for unnecessary medications and adverse side effects.

Inspectors wroteThe facility had a census of 57 residents. The sample included 15 residents. with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure an appropriate indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat mental disorder characterized by a gross impairment in reality testing) for Resident (R)26, who had a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). This placed the resident at risk for unnecessary psychotropic (alters perception, mood, consciousness, cognition, or behavior) medications and related complications.

Inspectors wroteThe facility had a census of 58 residents. The sample included 15 residents. Based on observation and interview, the facility failed to store, prepare, and serve food under sanitary conditions, placing the residents at risk for foodborne illness.

Inspectors wroteThe facility had a census of 58 residents. The sample included 15 residents with four reviewed for pressure ulcers (PU - localized injuries to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or frictions). Based on observation, interview and record review, the facility failed to provide services to prevent the development of a Stage 2 (partial-thickness skin loss into but no deeper than the skin including intact or ruptured blisters) PU on Resident (R) 52's right heel until after a pressure ulcer developed. This placed the resident at risk for further skin breakdown.

Inspectors wroteThe facility had a census of 58 residents. The sample included 15 residents with six reviewed for unnecessary medications Based on observation, record review and interview, the facility failed to ensure the Consultant Pharmacist identified and reported staff not adequately assessing elevated blood sugars greater than physician ordered parameters for two sampled residents, Resident (R) 4, and R23. This placed the residents at risk for continued elevated blood sugars and adverse side effects.

Inspectors wroteThe facility had a census of 58 residents. The sample included 15 residents with six reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to adequately assess elevated blood sugars above the physician ordered parameters for two sampled residents, Resident (R) 4 and R23. This placed the residents at risk for continued elevated blood sugars and adverse side effects.

Inspectors wroteThe facility had a census of 58 residents. The sample included 15 residents. Based on observation, record review, and interview the facility failed to provide proper infection control during wound care for Resident (R) 52. This deficient practice placed R52 at risk for infection.

Inspectors wroteThe facility had a census of 58 residents. The sample included 15 residents. Based on observation and interview, the facility failed to display staffing information in a prominent place accessible to residents and visitors. This placed the residents at risk to be uninformed of nursing staff hours.