Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Legacy At Salina during CMS and state inspections, most recent first.
Three residents with significant medical needs, including urinary catheters and dependence on staff for toileting, were denied necessary incontinent care by a CNA who refused to assist or change them as required. The incidents were not immediately reported to administration as per facility policy, and the staff member was not promptly suspended or segregated from residents during the investigation, resulting in feelings of fear and belittlement among the affected residents.
A resident with a urinary catheter and dependent on staff for toileting reported to a licensed nurse that a CNA refused to provide incontinence care, resulting in the resident remaining in a soaked brief. The licensed nurse did not immediately report the allegation to administration as required by policy, delaying protective actions and investigation.
A resident with diabetes, dementia, and atrial fibrillation, requiring extensive assistance for transfers, fell and broke a thumb when a CNA attempted a solo transfer using a sit-to-stand lift, contrary to the care plan and facility policy requiring two staff members.
Failure to Protect Residents from Neglect and Inadequate Incontinent Care
Penalty
Summary
The facility failed to protect three residents from neglect and potential abuse by not providing necessary incontinent care and failing to follow internal reporting and response protocols. One resident, who had diagnoses including anxiety disorder, neuromuscular bladder dysfunction, and urinary retention, was dependent on staff for toileting and had a urinary catheter. This resident reported that a CNA refused to change her when requested, stating she was not wet due to the catheter, despite evidence of leakage. The resident expressed fear of the CNA, and the incident was not immediately reported to administration as required by facility policy. Another resident with chronic kidney disease, anxiety disorder, muscle weakness, and a urinary catheter also required substantial staff assistance with toileting. This resident was denied assistance by the same CNA, who told her she did not need to go to the bathroom again after already being assisted twice. The care plan for this resident required staff to provide perineal care for every incontinent episode and to monitor intake and output, but these instructions were not followed. A third resident, diagnosed with cerebral palsy, muscle weakness, and neuromuscular bladder dysfunction, was dependent on staff for most activities of daily living and required two staff for toileting. The CNA in question did not check or change this resident’s brief for an entire eight-hour shift, despite the resident’s request. In all three cases, the facility’s policy required immediate reporting and suspension or segregation of staff accused of abuse or neglect, but this was not done when the allegations were first reported to a nurse. The failure to provide necessary care and to follow abuse prevention and reporting protocols resulted in feelings of belittlement, fear, and placed the residents at risk for neglect and psychosocial harm.
Failure to Immediately Report and Respond to Allegation of Neglect
Penalty
Summary
A resident with diagnoses including anxiety disorder, neuromuscular bladder dysfunction, and urinary retention, who was dependent on staff for toileting and had a urinary catheter, reported to a licensed nurse that a certified nurse aide refused to provide necessary urinary care. The resident stated that when she requested to be changed due to being wet, the aide told her she did not need to be changed because she had a catheter and then left the room. The resident's brief was later found to be soaked, and she expressed fear of the aide involved. The resident had intact cognition and was able to clearly communicate her needs and the incident. The licensed nurse who received the allegation did not immediately report the incident to administrative staff as required by facility policy. Instead, the issue was only brought to the attention of administration when the nurse asked the administrative nurse to speak with the resident upon arrival for work. Facility policy required immediate reporting and separation of the accused staff member from residents upon receiving an allegation of abuse or neglect. The failure to promptly report the allegation and implement protective measures resulted in a delay in addressing the situation and in suspending the staff member involved.
Failure to Provide Safe Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to provide a safe environment for a resident during a transfer, resulting in a fall and injury. The resident, who had diagnoses of diabetes mellitus, dementia, and atrial fibrillation, required extensive assistance for transfers and was identified as a high fall risk. The resident's care plan specified the need for two staff members to assist with transfers using a sit-to-stand lift. However, on the day of the incident, a Certified Nurse's Aide (CNA) attempted to transfer the resident alone using the lift, which led to the resident's ankle buckling and the resident falling out of the lift sling. The resident sustained a broken left thumb as a result of the fall. The resident's medical records indicated that the resident had intact cognition but required a manual wheelchair and extensive assistance for various activities of daily living. The resident's care plan and assessments highlighted the need for two staff members during transfers due to the resident's unsteady balance and high fall risk. Despite these documented requirements, the CNA proceeded with the transfer alone, contrary to the facility's policy and the resident's care plan. The incident was witnessed, and the resident was found on the floor with no immediate head injury but complained of knee pain. Subsequent medical evaluation revealed a fracture in the resident's left hand, necessitating a splint and changes to the resident's transfer protocol. The facility's policy required at least two nursing assistants for safe transfers using mechanical lifts, which was not adhered to in this case, leading to the resident's fall and injury.
Removal Plan
- CNA M was retrained on proper mechanical lift protocol and placed on a performance improvement plan.
- An in-service was completed for all employees regarding when using any mechanical lift two staff members must be present per facility policy.
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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.
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Nursing homes near Salina
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kenwood View Healthcare And Rehabilitation Center | 0.5 mi | — | 0 | 0 |
| Smoky Hill Rehabilitation Center | 1 mi | — | 4 | 1 |
| Salina Presbyterian Manor | 2.2 mi | — | 2 | 2 |
| Holiday Resort Of Salina | 2.6 mi | — | 3 | 0 |
| Pinnacle Park Nursing & Rehab Center | 3.2 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.