Salina Presbyterian Manor

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689May 27, 2026

  Based 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. […]

• Immediate jeopardy, isolatedF600Jan 15, 2025

  The 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. […]

• Actual harm, isolatedF684May 27, 2026

  Based 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. […]

• Actual harm, isolatedF686May 27, 2026

  Based 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). Findings included:- R2's Electronic Medical Record (EMR) documented he admitted to the facility on [DATE]. […]

• Actual harm, isolatedF689Dec 10, 2024

  The 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. […]