Salina Presbyterian Manor: Fall Safety Failure, Immediate Jeopardy - KS
The finding against Salina Presbyterian Manor, issued following a complaint inspection, represents the most serious classification available to federal regulators. Immediate jeopardy means inspectors determined that the facility's failure had placed a resident in a situation where serious injury, harm, or death was likely unless something changed fast.
In this case, one resident, identified in inspection records only as R1, was the person at risk. The specific nature of any fall or injury R1 experienced is not detailed in the inspection records, but the severity of the regulatory finding tells its own story. Inspectors do not reach for the immediate jeopardy designation lightly. It is reserved for situations where the gap between what a facility should be doing and what it is actually doing is wide enough to put someone in real danger.
Salina Presbyterian Manor had a falls policy. That much is clear from the inspection record. The policy, which the facility had revised, laid out a structured approach: identify residents at risk, put interventions in place to reduce that risk, complete a fall risk evaluation tool on admission and again every quarter, after any significant change in a resident's condition, and after any fall. High-risk status was supposed to be documented in the resident's care plan. Staff were supposed to review a fall prevention reference sheet for ideas and document what they tried.
The policy existed on paper. What the inspection found was that it had not been followed for R1.
The specific failure, as inspectors characterized it, was that staff had not provided R1 with adequate supervision and assistance. In the language of fall prevention, that phrase carries a particular weight. It means someone was left in a position, in a bed or a chair, without the level of watching and help they needed, given what the facility already knew about their risk. The care plan was supposed to capture that risk. The staff were supposed to act on it.
They did not.
At 3:30 in the afternoon on the day inspectors made their finding, they sat down with two members of the facility's leadership: Administrative Staff A and Administrative Nurse D. Inspectors handed them the Immediate Jeopardy Template, the formal document that puts a facility on notice that what inspectors have found is not a paperwork problem or a technical deficiency. It is a situation where someone could get seriously hurt.
What followed was the facility's attempt to get out from under the designation. Salina Presbyterian Manor implemented education and retraining for staff, focused on providing the appropriate level of assistance and supervision. The corrections, the facility said, were completed before the onsite survey wrapped up.
Inspectors accepted that. The immediate jeopardy was deemed past noncompliance, meaning the specific danger to R1 had been addressed. The citation remained at what regulators call scope and severity J, which sits at the intersection of immediate jeopardy and isolated, meaning inspectors found the problem affected only a small number of residents. In this case, few residents, the record says. Perhaps only R1.
That word, isolated, can be misleading. It describes the reach of the problem as inspectors documented it, not the gravity of what happened to the person at the center of it. A fall in a nursing home, for an elderly resident with the kind of health vulnerabilities that put someone on a high-risk list in the first place, can mean a broken hip. It can mean surgery that a fragile body struggles to survive. It can mean a cascade of complications, infections, immobility, that reshapes or ends a life. The inspection record does not say whether R1 fell. It does not say whether R1 was hurt. What it says is that the situation was serious enough to warrant the most urgent finding federal inspectors can make.
The mechanism that was supposed to prevent exactly this kind of situation was already in place at Salina Presbyterian Manor. The fall risk evaluation tool, the care plan documentation, the reference sheet with intervention ideas, the requirement that high-risk status follow a resident through their record and into the daily decisions staff make about how much help to give and how closely to watch. None of that was invented in response to this inspection. It was already the facility's own policy.
That is the detail worth sitting with. This was not a facility that lacked a framework for keeping fall-risk residents safe. It was a facility where that framework existed and was not used, not for R1, not when it mattered.
Fall prevention in nursing homes is not a passive process. It requires staff to look at a care plan before they position a resident and walk away. It requires them to know which residents need more eyes on them, more help getting up, more time before they are left alone. It requires that the information gathered at admission, and updated every quarter, and revised after every fall, actually reach the people providing care and actually change what those people do.
When that chain breaks, an immediate jeopardy finding is what it looks like from the outside.
Salina Presbyterian Manor is a continuing care retirement community operated under the Presbyterian Manors of Mid-America system, a nonprofit organization with facilities across Kansas and Missouri. The Salina location serves both long-term residents and those in shorter-term rehabilitation. The inspection at issue was triggered by a complaint, not a routine survey, which means someone, a resident, a family member, a staff member, reached out to regulators with a concern specific enough to send inspectors through the door.
The complaint process exists because what happens inside a nursing home is often invisible to anyone not living or working there. Family members visit when they can. They see their person in a bed or a chair, and they may not know what the care plan says, or whether the staff who were just in the room knew what it said either. When something goes wrong, or when someone worries something is about to, the complaint line is sometimes the only lever available.
In this case, whatever prompted the complaint led inspectors to a finding that the facility's own leadership had to sit across a table and receive on a formal template. Administrative Staff A and Administrative Nurse D were in that room at 3:30 in the afternoon. The immediate jeopardy template was placed in front of them. The message it carried was not ambiguous.
The retraining happened. The designation was lifted. The citation stands.
R1 is still there, or was at the time of the inspection. The record does not say more than that. It does not say whether R1 has family who knows what was found, or whether anyone has explained to them what immediate jeopardy means and why it was applied to the person they love. It does not say whether the staff members who failed to provide adequate supervision that day are still working the same unit, now retrained, now expected to do what they did not do before.
What the record says is that for at least one resident at Salina Presbyterian Manor, the system designed to keep them safe from falling failed at the moment it was needed. And that the gap between the policy on paper and the care actually delivered was wide enough that federal regulators used the most serious language they have to describe it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Salina Presbyterian Manor from 2026-05-27 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: August 11, 2026 · Our methodology
SALINA PRESBYTERIAN MANOR in SALINA, KS was cited for immediate jeopardy violations during a health inspection on May 27, 2026.
In this case, one resident, identified in inspection records only as R1, was the person at risk.
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.