Holiday Resort of Salina: Medication Order Failure - KS
The failure came to light during a complaint inspection on September 2, 2025. Federal inspectors reviewed the electronic medical record for the resident, identified in the inspection report as R2, and found no documentation that anyone had ever ordered the medication stopped. Nobody had. It had simply disappeared in the transfer from hospital to facility.
Mounjaro, the brand name for tirzepatide, is a prescription injectable medication used to manage blood sugar in people with type 2 diabetes. Missing doses is not a trivial matter for patients who depend on it for glucose control.
Licensed Nurse H confirmed the situation plainly at 10:55 that morning. The Mounjaro order was in R2's hospital discharge paperwork. It should have been continued at the facility. It was not.
The breakdown happened at the transcription step. When a resident arrives from a hospital, nursing staff are responsible for entering the physician's ordered medications into the facility's computer system. That list then goes to the pharmacy, which fills the orders. If a medication doesn't make it into the computer, it doesn't make it to the pharmacy. If it doesn't make it to the pharmacy, the resident doesn't get it.
That is exactly what happened here.
Consultant Pharmacist GG, reached by inspectors that afternoon, confirmed that what the facility sent over did not include Mounjaro. The pharmacy filled what it received. Licensed Nurse I, interviewed at 2:55 PM, confirmed that R2's physician had ordered Mounjaro 0.5 mg at the time of admission and had never discontinued the order. Administrative Staff A acknowledged at 3:15 PM that nursing staff were responsible for transcribing physician orders correctly.
The facility's own medication administration policy, last updated in January 2021, states that medications are to be administered in accordance with written physician orders. The written physician order for Mounjaro existed. The administration did not follow it.
Inspectors cited the deficiency under F0760, which addresses medication errors, and classified the level of harm as minimal harm or potential for actual harm. The citation noted that few residents were affected.
What the inspection report does not say is how long R2 went without the medication before the complaint triggered the inspection, or what effect, if any, the missed doses had on the resident's condition. The record is silent on that.
What it does say is that a physician ordered a medication, a hospital sent the patient home with that order intact, a facility received the patient and the order, and then the medication vanished somewhere between the keyboard and the pharmacy. No one caught it. No one corrected it until an outside complaint forced inspectors through the door.
R2's physician never said stop. The pharmacist never received the order. The nurses who should have entered it did not enter it correctly. And by the time anyone was asking questions, the gap between what the doctor ordered and what the resident received had already opened wide.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Holiday Resort of Salina from 2025-09-02 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 26, 2026 · Our methodology
HOLIDAY RESORT OF SALINA in SALINA, KS was cited for violations during a health inspection on September 2, 2025.
The failure came to light during a complaint inspection on September 2, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.