Salina Presbyterian Manor: Wound Care Error Harms Resident - KS
The resident, identified in inspection records only as R3, was already in serious medical trouble before the error occurred. She had osteomyelitis — a bone infection — in her right foot, a PICC line, and a wound vacuum device managing an open wound. Her care required specific dressing changes three times a day, with precise materials applied in a precise sequence.
On April 29, 2026, she was transferred to the emergency room. The wound care clinic called Salina Presbyterian Manor that evening to report what had happened: Aquacel AG, a wound dressing material, had been placed in her wound bed. It clogged the wound vac. The right foot wound had deteriorated.
She returned to the facility in the early hours of April 30. The hospital had obtained a wound culture, applied a wet-to-dry dressing, and was waiting on scan results before sending her back.
The nurse who changed the dressing, identified in inspection records as LN G, explained what happened when federal inspectors spoke with her on May 27. There were two sets of orders — one in the TAR, the facility's medication and treatment administration record, and one on the 24-hour shift sheet. The 24-hour sheet said to take moistened Aquacel AG and place it in the wound bed. That was the order she followed. She did not double-check with anyone about which order was correct.
Administrative Nurse D told inspectors that afternoon that she expected nurses to follow the orders in the TAR and, when they found discrepancies, to verify and clarify before acting.
Nobody had flagged the conflict before LN G encountered it.
A second nurse, LN H, was also part of the conversation with inspectors. She started crying. She told them she had been a nurse for 29 years and had never had anything like this happen to her. She said she could not stop thinking about it.
The inspection report does not specify LN H's precise role in the incident, but her presence in the interview and her distress suggest she was close to it.
Federal inspectors rated the violation at scope and severity level G — actual harm, isolated. That is the first level on the CMS scale at which a deficiency is considered to have caused real injury to a resident rather than the potential for it.
By the time inspectors arrived on May 27, the facility had already moved to address what happened. LN G was prohibited from performing wound dressing changes independently and was required to complete wound care competency validation before resuming that work on her own. All nurses at the facility completed wound vac competencies before being permitted to change wound vac dressings going forward. Because those corrective actions were completed before the inspection, the deficiency was classified as past noncompliance rather than ongoing.
The facility's own wound vac policy, dated February 26, 2026, required nurses to review the medical order before applying wound vac therapy, including checking the ordered pressure settings. The policy existed. The competing orders existed alongside it, and no system caught the conflict before it reached the bedside.
R3 was not available for observation or interview when inspectors were on-site.
What the inspection record does not say is how she is doing now, whether the bone infection in her foot responded to treatment, or what the deterioration of her wound during those hours ultimately cost her.
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 12, 2026 · Our methodology
SALINA PRESBYTERIAN MANOR in SALINA, KS was cited for violations during a health inspection on May 27, 2026.
The resident, identified in inspection records only as R3, was already in serious medical trouble before the error occurred.
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.