Legacy at Salina

In the surveyor’s words

From the most serious findings on record at Legacy at Salina, in the surveyor’s own words.

• Actual harm, isolatedF689Nov 18, 2025

  The 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. […]

• Actual harm, isolatedF600Mar 4, 2025

  The 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. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully… […]

• Actual harm, isolatedF689Jul 16, 2024

  The 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. […]

• Actual harm, isolatedF692May 26, 2022

  The 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. […]

• No harm, potential for more than minimal, widespreadF801Sep 10, 2025

  The 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.Findings included:- On 09/08/25 at 12:00 PM, observation of the noon meal consisted of ham, scallop potatoes, peas, and fruit salad. Dietary Staff (DS) BB was observed overseeing the preparation of the noon meal. DS BB would also assist staff with taking meal trays to the residents.On 09/09/25 at 11:30 AM, DS BB verified she was not certified but had passed the course and just needed to take the test. […]