Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Saline Care Nursing & Rehab during CMS and state inspections, most recent first.
Failure to Follow Planned Meal Menu: Staff did not follow the pre-planned menu, with lunch items substituted because ingredients were unavailable or not prepared in time. A cook stated the evening shift does not follow the menu and prepares foods based on what is available, and several residents said they were not served what their tray cards listed or notified of the planned meals.
Failure to provide meal alternatives and acceptable food options. Residents reported they were not informed in advance what meals were planned, tray tickets often did not match the food served, and only limited substitutes such as leftovers or sandwiches were available. During meal observations, the steam table had no other hot options, and residents stated the meatballs were too hard to eat and the vegetables were overcooked and mushy; one resident with poor dentition said she could barely bite the meatballs.
A facility failed to obtain proper physician orders, consent, and restraint assessments for wheelchair seat belts used on multiple residents with severe cognitive impairment. Records showed inconsistent or missing restraint documentation, conflicting staff statements about whether the belts were restraints or enablers, and residents observed in wheelchairs with seat belts in place and unable to remove them on command.
Unnecessary Psychotropic Medication Use Without Supporting Diagnosis: A resident with dementia, psychosis, and anxiety received ziprasidone, Depakote, and lorazepam for dementia-related behaviors. Pharmacy requested a supporting dx for ziprasidone per CMS guidelines, but the DON could not locate behavior tracking and confirmed there was no supporting dx for the medication.
A facility failed to accurately code annual MDS assessments for two residents with psychiatric diagnoses, including schizophrenia, depression, anxiety, and delusions. The MDS documented that both residents were not currently considered level II PASRR cases, while records also showed PASRR level II approvals with no special services and care plans reflecting ongoing psychiatric symptoms and psychotropic medication use. Staff stated a remote MDS staff member completed all assessments and reviewed PASRR information before coding the annual MDS.
A resident with diagnoses including unspecified psychosis, dementia, and altered mental status was admitted after a PASARR Level I screen found no Level II needed and no serious mental illness. The MDS nurse stated the psychosis diagnosis was coded incorrectly on the admission MDS and should have been included on the initial PASARR screen, which would have prompted a new screen request to the screening service.
Room Size Below Required Minimum: Surveyors found that four residents were assigned to waivered double-occupancy rooms that measured 12.5 by 12 feet, or 150 sq ft total, which provided only 75 sq ft per bed instead of the required 80 sq ft per resident. The rooms contained two beds and two nightstands, and the measurements did not include the closet or bathroom. Two residents were present during measurement and stated they had no issue with the room size.
Two residents with psychiatric and cognitive conditions were involved in separate physical altercations with peers, resulting in one resident being pushed and falling after a dispute over coffee, and another being pushed in the chest during a hallway encounter. Staff were present and attempted to intervene but were unable to prevent the incidents, despite existing care plans addressing behavioral risks.
A resident with severe cognitive impairment and multiple health conditions did not receive adequate fingernail care, resulting in a large amount of black substance under their nails. Despite requests from the family, staff failed to clean the nails, and interviews revealed inconsistencies in the facility's nail care practices. The facility's policy on regular nail cleaning and trimming was not followed.
A resident with multiple diagnoses, including pressure ulcers, was found to have several untreated and undocumented wounds during a survey. The facility staff failed to fully assess and document all wounds, and proper infection control procedures were not followed during treatment. The facility's documentation did not reflect all observed wounds, and the Director of Nurses acknowledged the need for proper assessment and reporting of new wounds.
The facility failed to provide the required 80 square feet of living space per resident for four residents, with rooms measuring only 150 square feet in total. The Administrator confirmed that certain rooms have a waiver assessment and are certified for two residents despite not meeting size requirements. Residents expressed no issues with the room size, and no concerns were noted in Resident Council meeting minutes.
The facility failed to maintain clean shower rooms, with surveyors observing black and orange substances in the shower areas. A family member had previously raised concerns about mold, but facility staff believed the discoloration was due to glue. Despite attempts to clean the areas, the issue persisted, and the facility was preparing for a remodel.
Failure to Follow Planned Meal Menu
Penalty
Summary
The facility failed to follow the pre-planned meal menu based on the Diet Spreadsheet. On 5/26/26, the planned lunch meal was brown sugar pork loin, lemon wedge, garlic parslied rice, sauteed summer squash, cornbread, and ambrosia, but the meal served did not include a lemon wedge, frozen greens were used instead of squash, and oranges and pineapple were served instead of ambrosia. A cook stated that marshmallows were not available for the ambrosia salad and that the evening shift does not follow the menu, causing the cook to prepare foods based on what he wanted rather than what was scheduled. On 5/27/26, the planned lunch menu was spaghetti and meatballs, Italian blend vegetables, breadstick, and fruited gelatin with whipped topping. The Administrator was observed bringing frozen vegetables and boxes of gelatin into the facility that morning. The cook stated the gelatin had not been made and firmed up in time for lunch, so the lunch and dinner desserts were switched, California blend vegetables were used instead of Italian vegetables, and bread slices were served in place of breadsticks because they were not available. Several residents stated they were not served what their meal tickets listed and said they were not notified of the planned meals.
Failure to Provide Meal Alternatives and Acceptable Food Options
Penalty
Summary
The facility failed to provide food alternatives of similar nutritive value at meals and did not consistently offer appealing substitute options when residents did not want or could not eat the meal served. During a lunch meal observation, the steam table contained only pork loin, greens, corn bread, and rice, and the cook confirmed those were the only hot food options available. The cook stated that substitutes were limited to leftovers from the previous meal if available, or a grilled cheese, peanut butter and jelly, or bologna sandwich, and that if those items had to be made, residents would have to wait until the serving was complete. During resident council and meal observations, alert and oriented residents stated they were not told what was being served until the meal was delivered, and that the food on the tray often did not match the meal ticket. One resident reported keeping ramen noodles in her room because there was nothing else offered as an alternate and stated she used that for dinner when no other option was available. On another lunch observation, the steam table contained spaghetti and meatballs, mixed vegetables, and sliced bread with no other hot alternate foods available. Multiple residents stated the meatballs were too hard to eat, one described them as like a hockey puck, and another stated the vegetables were overcooked and mushy; one resident with poor dentition stated she could barely bite into the meatballs because they were so hard.
Failure to Obtain Proper Orders, Consent, and Restraint Assessments for Wheelchair Seat Belts
Penalty
Summary
The facility failed to obtain a physician order and consent for physical restraints and failed to assess adaptive equipment to ensure safety and freedom of normal movement for 4 residents reviewed for physical restraints. The report identifies concerns with self-releasing seat belts used on residents in wheelchairs, including residents with severe cognitive impairment and limited ability to follow commands or remove the belts independently. For one resident, the record showed diagnoses including psychosis, dementia, bipolar disorder, muscle weakness, chronic fatigue, and cerebral infarction, with a BIMS score of 02 indicating severe cognitive impairment. The resident had a physician order for a self-releasing belt for proper wheelchair positioning and safety, and the care plan referenced the belt as an intervention for falls. However, the restraint evaluation and consent documentation was inconsistent, including a form that documented verbal consent from a family member without clear documentation of who obtained it, and later documentation showing verbal consent was obtained from the family member rather than the resident. The resident was observed multiple times sitting in a wheelchair with the seat belt on and was unable to unbuckle it on repeated attempts. For another resident, the record showed severe cognitive impairment with a BIMS score of 06 and use of a self-releasing seat belt in the wheelchair, but the physician order summary did not document an order for the belt. The care plan listed an alarming self-releasing seat belt, but there were no restraint assessments or restraint consents found in the record. The resident was observed in the wheelchair with the seat belt attached, and staff stated the belt was used because the resident stood up and could fall. For a third resident, the record showed severe cognitive impairment with a BIMS score of 03, no restraint documentation in the MDS, and a physician order to ensure the seatbelt was functioning properly every shift. The resident’s record did not contain restraint assessments or restraint consents, and staff reported the seatbelt had been removed because the resident no longer needed it, while the resident had previously been observed with the seatbelt in place. For a fourth resident, the record showed dementia, psychotic disturbance, mood disturbance, anxiety, hypertension, and breast cancer, with severe cognitive impairment and substantial/maximal assistance needed for transfers. The physician order summary documented a self-release seat belt when up in the wheelchair, and the care plan included the seat belt as an intervention for falls. The restraint assessment identified the seatbelt as a restraint and listed unsafe mobility, postural instability, and agitated behavior as reasons for use, while another evaluation described the device as an enabler and documented verbal consent from the resident’s son. Survey observations showed the resident seated in a wheelchair with the seat belt in place and unable to release it when asked. Staff and management gave conflicting statements about whether restraint assessments were completed annually or quarterly and whether the documentation was correct.
Unnecessary Psychotropic Medication Use Without Supporting Diagnosis
Penalty
Summary
The facility failed to ensure that one resident was free from unnecessary psychotropic medications. The resident’s admission record listed diagnoses including altered mental status, unspecified dementia with anxiety, unspecified dementia with severe psychotic disturbance, and unspecified psychosis not due to a substance or known physiological condition. The physician’s order summary included ziprasidone 20 mg twice daily for dementia, Depakote 125 mg three times daily for dementia, Depakote 250 mg three times daily for dementia, and lorazepam 0.5 mg at bedtime for unspecified dementia with psychotic disturbance. A consultant pharmacist’s medication regimen review requested a supporting diagnosis for ziprasidone because the medication required a diagnosis such as bipolar I disorder or schizophrenia. The physician response documented “dementia with psychosis.” A consulting pharmacy progress note stated that a monthly medication regimen review was completed and that a supporting diagnosis was requested for ziprasidone per CMS guidelines. During interview, the DON stated that she could not locate any behavior tracking for the resident related to the psychotropic medications ordered for dementia and psychotic disorders, and confirmed that there was not a supporting diagnosis for ziprasidone as requested by the pharmacy recommendation.
Inaccurate MDS Coding for PASRR Status
Penalty
Summary
The facility failed to accurately code the MDS for 2 residents, R10 and R30, during annual assessments. R10’s record showed an admission diagnosis history that included major depressive disorder, anxiety disorder, schizophrenia, and other specified depressive episodes. However, the annual MDS documented that the resident was not currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or related condition. The record also showed care plan focus areas for psychotropic, antianxiety, and antidepressant medications, along with depression occurring 3 times a week and diagnoses including schizophrenia, major depressive disorder, unspecified dementia with behavioral disturbances, and anxiety. R10’s PASRR level II screening later documented an outcome of level II approved with no special services. R30’s record showed an admission diagnosis history that included paranoid schizophrenia, depression, and insomnia. The annual MDS also documented that the resident was not currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or related condition, while Section I0020B identified the primary medical condition as paranoid schizophrenia. The care plan documented delusions 7 times a week and diagnoses including paranoid depression, with medications aripiprazole and trazodone, and a goal to reduce episodes of delusions. R30’s PASRR level II screening later documented an outcome of level II approved with no special services. Staff interviews showed the facility had no in-house MDS coordinator, that a remote MDS staff member completed all assessments, and that the remote MDS staff member reviewed PASRR information in the system before completing the annual MDS section.
Failure to Refer Resident for Level II PASARR Evaluation
Penalty
Summary
The facility failed to ensure that a resident with a mental illness was referred to the appropriate state designated authority for a Level II PASARR evaluation and determination of need for specialized services. The resident’s admission record documented an admission date of 11/21/2025 and listed diagnoses including unspecified psychosis, dementia, and altered mental status. However, the 11/10/2025 Notice of PASARR Level I Screen Outcome documented that no Level II was required and that there was no serious mental illness. During interview on 05/28/2026, the Corporate Minimum Data Set Nurse stated the person who completed the admission MDS coded section I incorrectly and that the psychosis diagnosis should have been listed on the initial PASARR screen completed on 11/10/25. She stated that once the facility received all the information and saw the diagnosis, they should have called the screening service and requested a new screen. The facility policy titled Resident Assessment - Coordination with PASRR Program states that all individuals with a mental disorder or intellectual disability who apply for admission to the facility will be screened in accordance with the State's Medicaid rules for screening.
Room Size Below Required Minimum
Penalty
Summary
The facility failed to provide at least 80 square feet of living space per resident for 4 of 4 residents reviewed for room size in a sample of 70. Surveyors observed that Side 2 of the facility had a room size waiver assessment, and the owner stated that the rooms on that side were Medicaid certified for two residents. The administrator identified multiple rooms, including rooms 203-206, 208-209, 211-212, 215-220, 222-227, 229-231, 234-235, 238-239, 241-242, and 244-248, as waivered rooms that did not meet the proper room size. The maintenance director measured each of the four residents’ rooms and found them to be 12.5 by 12 feet, or 150 square feet total, which equals 75 square feet per bed. The measurements did not include the closet or bathroom. Each room contained two beds and two nightstands. One resident was present during measurement and stated they had no issues with the room size, and another resident was present and also stated they had no issue with the room size; the other two residents were not present. A room roster provided by the administrator documented that all four residents lived in the waivered rooms, and review of six months of Resident Council meeting minutes showed no concerns related to room size.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident physical abuse involving two separate incidents among four residents. In the first incident, a male resident with a history of traumatic subdural hemorrhage, bipolar disorder, anxiety disorder, heart failure, osteoarthritis, and chronic kidney disease, and with moderately impaired cognition, was involved in an altercation in the dining room with another male resident diagnosed with major depressive disorder, anxiety disorder, insomnia, paranoid schizophrenia, and unspecified psychosis. The cognitively intact resident, who was on a fluid restriction, became agitated over not receiving additional coffee, exhibited delusional behavior, and after a verbal exchange, pushed the other resident, causing him to fall and complain of hip pain. Staff attempted to intervene but were unable to prevent the physical contact. The incident was witnessed by staff, and both residents were assessed for injuries. In the second incident, a female resident with Alzheimer's disease, major depressive disorder, schizophrenia, generalized anxiety, and pica, who exhibited wandering behavior and memory problems, was pushed in the chest by a male resident with schizoaffective disorder, vascular dementia, and anxiety. The male resident, who was cognitively intact and ambulatory, encountered the female resident in a hallway he considered to be for males only. After a verbal exchange, he pushed her in the chest to get her to leave the area. This event was witnessed by a housekeeper, and staff immediately separated the residents and assessed them for injuries. The male resident later stated he had a urinary tract infection at the time, which may have affected his behavior. In both cases, the facility's staff were present and attempted to intervene, but were unable to prevent the physical altercations. The residents involved had documented histories of cognitive impairment, psychiatric diagnoses, and behavioral issues, which contributed to the incidents. The facility's care plans for these residents included interventions for behavioral management and supervision, but these measures were not sufficient to prevent the physical abuse from occurring.
Failure to Provide Adequate Fingernail Care
Penalty
Summary
The facility failed to provide adequate fingernail care for a resident with severe cognitive impairment and multiple health conditions, including Type 2 Diabetes and psychomotor deficits. The resident required substantial assistance for personal hygiene, as documented in their care plan. Despite this, the resident's family member observed a large amount of black substance with a strong odor under the resident's fingernails, indicating neglect in nail care. The family member reported having asked for nail cleaning for two weeks without any action taken by the staff. Interviews with various Certified Nursing Assistants (CNAs) and the Director of Nursing revealed inconsistencies in the facility's approach to nail care. CNAs stated that nail cleaning typically occurs during showers, which are scheduled twice a week, but none could recall when they last cleaned the resident's nails. The Director of Nursing admitted there was no specific schedule for nail care, and it was dependent on staffing levels. The facility's policy on nail care, which emphasizes regular cleaning and trimming to prevent infections, was not adhered to, as evidenced by the lack of documentation on the resident's shower sheets regarding nail care.
Failure to Identify and Treat Resident Wounds
Penalty
Summary
The facility failed to properly identify, assess, and treat wounds for a resident, leading to a deficiency in care. The resident, who was admitted with multiple diagnoses including cellulitis, sepsis, and pressure ulcers, was observed to have several untreated and undocumented wounds during a survey. Despite having a care plan in place to address skin integrity, the staff did not fully assess or document all of the resident's wounds, including a skin tear in the groin and an open area below the buttock, until prompted by the surveyor. During the observation, the registered nurse and certified nursing assistant initially identified and treated pressure ulcers on the resident's sacrum but failed to notice other wounds until they were pointed out by the surveyor. The wound specialist was called multiple times to assess and provide treatment orders for these newly identified wounds. Additionally, the nurse did not follow proper infection control procedures, as they did not change gloves or sanitize hands between treating different wound sites on the resident's ankle. The facility's documentation was incomplete, as the resident's skin and wound evaluations did not reflect all the wounds observed during the survey. The Director of Nurses acknowledged that newly identified wounds should be measured, assessed, and reported, and that proper hand hygiene should be maintained during wound care. The facility's wound policy requires that any new areas identified should be reviewed and assessed within 24 hours, which was not adhered to in this case.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to provide the required minimum living space of 80 square feet per resident for four residents in a sample of 41. During the survey, it was observed that rooms occupied by these residents were only 150 square feet in total, providing just 75 square feet per resident. The measurements were confirmed by the Maintenance Director using a measuring tape, and the dimensions did not include the closet and bathroom areas. The rooms in question contained two beds and two nightstands, indicating a lack of adequate space per resident. The Administrator acknowledged that certain rooms in the facility, specifically those on Side 2, have a room size waiver assessment and are Medicare/Medicaid certified for two residents despite not meeting the standard room size requirements. Residents in these rooms, who were alert and oriented, expressed no issues with the room size. Additionally, a review of six months of Resident Council meeting minutes showed no concerns related to room size, suggesting that the deficiency was not previously reported by the residents.
Deficiency in Maintaining Clean Shower Rooms
Penalty
Summary
The facility failed to maintain a clean and homelike environment in the resident care areas, specifically in the shower rooms, as observed during a survey. The surveyors noted a black and orange substance around the caulking strip area between the wall and the floor of the shower stall, as well as on the shower curtain liner and the legs of the shower chair. A family member expressed concerns about the cleanliness of the shower rooms, describing them as filled with mold, and had previously raised these issues during a care plan meeting. Despite these concerns, the facility staff, including the Director of Nursing and the Administrator, believed the discoloration was due to glue from the tiles and not mold. The Housekeeping Supervisor mentioned that the facility had attempted to clean the substance with various products, including bleach, but was unsuccessful. The facility was in the process of preparing to remodel the shower rooms, but the materials had not yet been delivered. The Administrator and Regional Nurse were shown the soap scum buildup on the shower curtain liner, which the Administrator was unaware of, and the buildup on the shower chair legs was identified as soap scum rather than mold. The facility's census sheet documented that several residents lived on the affected hall, but no specific medical history or conditions of the residents were mentioned in relation to the deficiency.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Illustrative
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Nursing homes near Harrisburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Axiom Healthcare Of Harrisburg | 0.5 mi | ★★★★★ | 4 | 0 |
| Carrier Mills Nsg & Rehab Ctr | 5.3 mi | ★★★★★ | 3 | 0 |
| Eldorado Rehab & Healthcare | 8 mi | ★★★★★ | 4 | 0 |
| Gallatin Manor | 16 mi | ★★★★★ | 1 | 0 |
| Integrity Hc Of Marion | 19.7 mi | ★★★★★ | 18 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.