Salina Presbyterian Manor

Based on record review and interview, the facility failed to ensure nursing staff possessed current licensure as required.

This deficient practice placed all the residents in the facility at risk for not attaining or maintaining the highest practicable physical, mental, and psychosocial well-being.

Findings included:- The Kansas Nurse Aide Registry, printed on [DATE], documented Certified Medication Aide (CMA) R license expired on [DATE] and CMA S license expired on [DATE].The Facility's Working Schedule for the month of [DATE] documented CMA R worked six days in the facility and passed medications to residents after CMA R's license had expired. CMA R was suspended and taken off the schedule until her license was reinstated.The Facility's Working Schedule for the month of [DATE] documented CMA S worked two days in the facility and passed medications to residents after CMA S's license had expired. CMA S was suspended and taken off the schedule until her license was reinstated.On [DATE] at 10:00 AM, Human Resources Staff V stated she was responsible for sending out the dates of the nursing staff's license expiration to Administrative Nurse D, and they were both responsible for reviewing the license expirations to ensure staff were notified in plenty of time to renew their licensure.

Human Resources Staff V stated this time, CMA R and CMA S fell through the cracks, and neither she nor Administrative Nurse D had caught the license expirations for CMA R and CMA S.On [DATE] at 10:15 AM, Administrative Nurse D stated they had devised and new procedure for monitoring staff licensure.

All staff licensure expiration dates were placed on a spreadsheet, and Human Resources Staff V, the facility scheduler, and Administrative Nurse D would meet every Tuesday to go over staff licensure expiration dates, and staff would be notified of their licensure expiration date two months before the expiration and then weekly thereafter. If staff did not renew their license, they would be taken off the schedule until their license was renewed.

Administrative Nurse D stated she expected all nursing staff to have current licensure to take care of residents in the facility.The facility's Nursing Facility Nursing Service Policy, revised [DATE], documented the goal of nursing service is to provide each resident admitted to the health care center with the appropriate level of care to attain his/her optimum level of functioning.

Nursing service is staffed, organized, and equipped to provide nursing care on a 24-hour-a-day basis.

The health care center is licensed and certified in accordance with state and federal regulations governing long-term care.The facility identified the above deficient practices and implemented immediate corrective actions, which were all completed on [DATE] and included: CMA R and CMA S were suspended upon discovery of the expired certification.

The facility implemented a tracking spreadsheet to alert administration staff when certifications were set to expire.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/11/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Salina Presbyterian Manor

2601 E Crawford Street Salina, KS 67401

SUMMARY STATEMENT OF DEFICIENCIES