Legacy At Salina
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
dated 10/16/25 at 08:31 PM documented Resident R1 cried earlier in the shift due to pain in her right leg, and the nurse had administered pain medication.The late entry Progress Note dated 10/16/25 at 10:14 PM documented Resident R1 told staff all about her fall. Resident R1 rated her pain at a five out of 10 on the pain scale. The nurse documented no visible injuries and noted the resident was in a low bed, a CNA assisted the nurse with pulling Resident R1 up in bed, and the resident tolerated it well.The Progress Note dated 10/17/25 at 01:23 AM documented Resident R1 had ROM deficits. The LN assessed and attempted ROM, but Resident R1 could not move her legs
on her own. Resident R1 said it was painful, but did not yell out or seem in any increased distress than her normal demeanor. Resident R1's legs appeared the same length, and Resident R1 assisted the staff with turning.The Progress Note dated 10/17/25 at 09:16 AM documented the nurse called the physician's office due to Resident R1's increased tearful episodes and complaints of pain related to her 10/16/25 fall. The physician ordered the staff to send Resident R1 to the emergency room for evaluation and treatment for right leg pain.On 10/27/25 at 09:30 AM, Resident R1's bed had a perimeter mattress; however, Resident R1 was not in the building for observation.On 10/27/25 at 09:30 AM, LN H stated the previous mattress on Resident R1's bed before the fall was a plain air mattress.On 10/27/25 at 10:45 AM, LN G stated she was on the telephone when Resident R1 fell out of bed on 10/16/25. LN G said she saw
the resident seated on the floor, by her bed, with her legs straight out, and a CNA at her back helping her sit. The resident held onto the bed cane rail on that side of the bed. She verified two staff were to provide cares for Resident R1 and said Resident R1 had an air mattress. She verified the CNA should not have rolled the resident without the assistance of another staff person.On 10/27/25 at 11:11 AM, CNA M stated she did not know Resident R1 required two staff assistance for dressing, but she knew Resident R1 required two staff assistance for transfers.
CNA M stated she used the walkie to request assistance to get Resident R1 up and transferred to her wheelchair.
CNA M stated all the other staff replied they were busy in other rooms so she thought she could start providing activities of daily living (ADL) cares to Resident R1, such as dressing, while she waited for help. CNA M stated when she finished dressing the resident, she told the resident she was going to roll her over to her side to pull her dress down and place a lift sling under her. Resident R1 grabbed the cane rail and assisted (rolling to her side), but Resident R1 pulled on the rail too much, and when rolled, she slid out of her bed. CNA M said Resident R1 had
an air mattress at that time, and Resident R1 was still holding onto the rail when she sat on the floor (after falling out of the bed). CNA M said the other staff came into the room, and the nurses assessed the resident before
we transferred her back to bed.On 10/27/25 at 08:22 AM, Administrative Nurse D stated Resident R1 was still in the hospital due to a fractured femur. Administrative Nurse D stated the facility educated CNA M post fall, and with a separate in-service on 10/17/25. On 10/27/25 at 09:35 AM, Administrative Staff A stated CNA M had
an in-service regarding falls on 08/23/25, as part of her orientation to the facility. On 10/27/25 at 09:40 AM, Administrative Nurse D stated Resident R1's mattress was a plain air mattress prior to the fall, but post-fall the facility added a concave mattress. Administrative Nurse D stated before the fall, Resident R1 required two staff members for most ADL. Administrative Nurse D verified CNA M was the only staff in Resident R1's room at the time of the fall, and verified CNA M had not followed the care plan. The facility's Fall Prevention Program dated 12/23/21 stated all staff were to be aware of fall interventions for residents and know the residents who were at risk for falls.
The facility identified, implemented, and completed the following corrective actions by 10/17/25:1. The facility placed a perimeter mattress on Resident R1's bed on 10/16/25. 2. All nursing staff attended or completed an in-service for the transfer of residents on 10/17/25.The facility completed corrective actions by 10/17/25, prior to the onsite survey; therefore, the deficient practice was deemed past noncompliance, at the scope and severity of a G (isolated, actual harm).
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If continuation sheet
LEGACY AT SALINA in SALINA, KS inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SALINA, KS, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from LEGACY AT SALINA or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.