Legacy at Salina: Resident Left Alone, Falls, Fractures Femur - KS
The resident, identified in inspection records only as R1, required two staff members for most activities of daily living. Her care plan said so. CNA M knew it for transfers, she told inspectors, though she said she didn't know it applied to dressing as well. With no help coming, she began dressing R1 alone, figuring she could manage the lighter tasks while she waited.
She finished dressing her. Then she told R1 she was going to roll her to her side to pull her dress down and slide a lift sling underneath her. R1 reached out and grabbed the bed's cane rail to help. She pulled too hard. When CNA M rolled her, R1 slid off the edge of the air mattress and down to the floor, still holding the rail as she landed.
R1 was seated on the floor with her legs straight out when a nurse arrived. She was crying. She told staff about the fall. She rated her pain at a five out of ten.
The nurse who assessed her that evening documented no visible injuries. A late-entry note from 10:14 p.m. recorded that R1 had told staff all about the fall, that she was placed in a low bed, and that a CNA had helped pull her up. The note said she tolerated it well.
By 1:23 in the morning, another nurse documented that R1 had range-of-motion deficits. The nurse attempted to assess her movement, but R1 could not move her legs on her own. She said it was painful. The nurse noted her legs appeared the same length and that R1 had assisted with turning. The note recorded that R1 did not yell out or seem in any increased distress beyond her normal demeanor.
Nobody sent her to the hospital that night.
The next morning, at 9:16 a.m., a nurse called the physician's office because R1 had been tearful and was still complaining of pain from the fall. The physician ordered her sent to the emergency room. She had a fractured femur.
When inspectors visited the facility on October 27, eleven days after the fall, R1 was still in the hospital. An administrative nurse confirmed it. The bed in R1's room now had a perimeter mattress, a concave design meant to keep residents from rolling to the edge. Before the fall, the mattress had been a plain air mattress, a surface that offers less resistance and makes rolling to the edge easier. The facility added the perimeter mattress the same day R1 fell.
CNA M told inspectors she had used the walkie to call for help before she started. All the other staff replied they were busy in other rooms. She thought she could begin the ADL cares while she waited. She did not describe any supervisor being contacted, any escalation, any second attempt to get another body in the room before she rolled a resident who needed two people to move safely.
LN G, who was on the telephone when R1 fell, told inspectors she saw the resident seated on the floor with her legs out and a CNA supporting her back. She confirmed that two-staff assistance was required for R1's cares and that the CNA should not have rolled her alone.
The facility's own fall prevention program, dated December 2021, required all staff to know the fall interventions in place for at-risk residents. Administrative Nurse D confirmed CNA M had not followed the care plan.
The corrective actions came fast, at least on paper. The facility placed a perimeter mattress on R1's bed on October 16, the day of the fall. All nursing staff completed a transfer in-service on October 17. CNA M received individual education after the fall and again as part of a separate session the following day. Inspectors noted the facility had completed its corrective actions before the survey visit, and the deficiency was recorded as past noncompliance, a G-level citation reflecting isolated actual harm.
R1 was still in the hospital when inspectors documented all of this. Fractured femurs in elderly residents carry serious risks, extended immobility, muscle loss, pneumonia, blood clots. The inspection report does not say when she came home, or whether she did.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Legacy At Salina from 2025-11-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
LEGACY AT SALINA in SALINA, KS was cited for violations during a health inspection on November 18, 2025.
The resident, identified in inspection records only as R1, required two staff members for most activities of daily living.
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.