Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Evangelical Home - Saline during CMS and state inspections, most recent first.
Food service equipment was not effectively cleaned and maintained, and storage practices did not match facility policy. Two 16-inch fry pans and four 8-inch non-stick fry pans were observed with etched, scored, and particulate buildup, with one fry pan also out-of-round. A scoop was stored directly in dry food, and numerous soup cups and saucers were stored in a black plastic tub on a cart without being inverted.
Facility failed to effectively clean and maintain the physical plant, affecting 108 residents. Surveyors observed damaged and soiled flooring in the laundry area, non-functional light assemblies in clean linen rooms, a corroded microwave door face plate exposing inner metal, stained ceiling tiles from moisture exposure, a loose board on a mobile table, and a light lens cover with dust, dirt, and dead insect carcasses. A resident room also had a roof leak with missing ceiling tiles, plastic sheeting collecting water, towels used to absorb moisture, and a partially filled waste bin. Record review showed the facility’s environmental and cleaning policies required regular monitoring and routine cleaning/disinfection, and WorxHub had no specific work orders for the cited concerns.
Care plans were not kept current for multiple residents. One resident with stroke-related deficits and another with chronic respiratory and cognitive conditions had outdated activity plans and little documented enrichment, while a resident with epilepsy and developmental delay had an activity plan that did not match the activity assessment. Other records still showed C. diff isolation after the infection had resolved, psychotropic use after an antipsychotic was discontinued, and fall-risk interventions that did not match what was observed in the room. Staff acknowledged the plans should have been updated.
Failure to Preserve Resident Dignity: Two residents were observed or described in ways that showed a lack of dignity and respect. One cognitively intact resident with significant communication and physical limitations reported that some CNAs were not nice, that staff had turned off her call light and left without providing care, and that staff did not always know her routine; staff confirmed she relied on a binder with detailed care instructions and no communication board was available. Another resident with dementia and Parkinson’s disease was repeatedly observed with chocolate on his face and neck while staff walked by, and an LPN did not assist with cleaning him despite acknowledging that staff were expected to help clean his face.
Failure to protect a resident’s PHI occurred when a phlebotomist left the resident’s name, DOB, diagnosis, physician orders, and lab information open on a cart outside the room where it was visible to passersby. The resident had diagnoses including cellulitis of the face, weakness, CKD, muscle weakness, and a history of falls.
Failure to Provide Meaningful Resident Activities: Several residents with varying cognitive and physical needs were observed without meaningful activity options, including residents left with only TV or no leisure items in their rooms, a resident not taken to bingo, and residents on one unit unable to use a lounge area unless staff were present. The AD and unit staff stated there were no evening or weekend activities, limited one-on-one visits, and activity documentation and care plans were incomplete or outdated, despite residents’ documented preferences for bingo, conversation, music, pets, and other engagement.
Two residents did not receive care according to orders and the care plan. One resident who was dependent for all personal care reported not getting ordered repositioning or ROM, and staff confirmed he needed repositioning every 2 hours, but the record showed it was not being done as planned. Another resident with a PICC line had a dressing change completed late, beyond the facility’s 5- to 7-day interval, and the record did not show the resident was offered another dressing change after refusing one earlier.
Failure to Provide Ordered ROM and Repositioning: A resident with chronic respiratory failure, DM, COPD, CKD, depression, anxiety, and chronic pain was dependent for all personal care and could not reposition himself. The resident stated he was not receiving ROM or repositioning as required, and staff confirmed he needed repositioning every 2 hours. Record review showed repositioning was only done 3 times per shift instead of every 2 hours, and ROM was provided only once for 10 minutes in the last 30 days, despite care plan directions for active and passive ROM during ADLs.
Failure to update fall interventions after repeated unwitnessed falls. A resident with severe cognitive impairment, dementia, and prior femur/knee fractures had multiple unwitnessed falls. Documentation showed the resident was found on the floor after reaching for a walker from bed, later fell while not wearing proper footwear, and later became wedged between the bed and wall. The care plan was repeatedly noted as continued, with existing interventions for gripper socks and proper footwear, but no clear documented change tied to the causes of the falls.
Cold and Unpalatable Meal Service: Surveyors observed lunch trays delivered to resident rooms and units with several food items below the facility’s hot-holding standard, and one transport cart was left open between deliveries. Two residents reported that meals were served cold; one said the food tasted less than desirable, the lemonade was weak, and the meat was dry and tough. Tray checks showed multiple items on both residents’ meals were below 135 degrees Fahrenheit, with some items at room temperature or low beverage temperatures.
Failure to Administer Consented Flu and Pneumonia Vaccinations. A resident admitted with acute respiratory failure with hypoxia, pleural effusion, AFib, COPD, dementia, and pneumonia initially declined both the pneumonia and influenza vaccines, then later consented to receive both after a hospital transfer and return. The MAR/record showed neither vaccine was given, and the IP confirmed via the state immunization registry that the resident had prior pneumococcal 23 and influenza vaccinations but the facility had no record of either vaccine being administered after consent.
A resident exhibited new stroke-like symptoms, including slurred speech and difficulty swallowing, which were observed and reported by multiple CNAs to LPNs. Although orders for neurological and blood pressure checks were given, there was no documentation in the electronic medical record to confirm these assessments were performed. The only progress note was entered in the evening after the resident was sent to the hospital, and the DON confirmed the lack of required documentation.
The facility failed to provide palatable and properly prepared food, affecting 95 residents. Issues included inconsistent menu distribution, dissatisfaction with meal choices, and improperly cooked food. Observations noted cold, clumpy mashed potatoes and tasteless powdered eggs. The General Manager of Dining Services explained the menu process, but inconsistencies in execution contributed to the deficiency.
The facility failed to maintain and clean food service equipment, affecting 95 residents. Observations revealed missing light bulbs in a cooler, soiled equipment, and improper use of hair restraints by staff, violating the 2017 FDA Model Food Code. These deficiencies indicate a lack of adherence to cleaning protocols and hygiene practices, increasing the risk of contamination.
The facility failed to securely store medications, with treatment carts and medication bins left unlocked and unattended in areas accessible to residents. On several occasions, medication carts were observed unlocked in hallways, and the charge nurse office containing an open bin of medications was left unoccupied with the door open. These actions violated the facility's policy requiring medication carts to be locked when not in view.
A facility failed to implement a comprehensive care plan for a resident at risk for pressure ulcers, resulting in the development of an unstageable pressure ulcer. Despite being marked at risk upon admission, no care plan was put in place, and communication delays further hindered timely intervention. The resident's skin condition was inconsistently documented, and the care plan was not updated until weeks after the initial identification of the pressure ulcer.
A resident with severe cognitive impairment fell while attempting to go to the bathroom, resulting in bruising. Despite the incident, the care plan was not updated with new interventions to prevent further falls. Interviews with CNAs and an LPN revealed that no new measures were communicated or added, highlighting a deficiency in care planning and implementation.
A resident with a PICC line did not receive dressing changes according to facility policy, which requires changes every 7 days with a clear opsite dressing. Observations showed the use of gauze under the dressing, contrary to guidelines, increasing infection risk. Interviews with staff confirmed the deviation from expected practices.
A resident at risk for pressure ulcers developed a stage 3 ulcer due to inadequate preventive care and delayed communication among staff. Initially assessed with no skin issues, the resident's condition worsened without timely intervention or a comprehensive care plan, despite known risk factors.
The facility failed to document the physician's rationale for not implementing medication regimen review recommendations for three residents. A resident with dry eyes was suggested to discontinue Cetirizine, another with severe cognitive impairment was advised to separate calcium and iron intake, and a third was recommended to trial discontinuation of Flonase. The physician disagreed with these recommendations, but no rationale was documented.
A facility failed to justify the continued use of psychotropic medication for a resident with severe cognitive impairment, who was observed to be socially engaging and pleasant. The resident has been on Celexa 20 mg daily since 2021 without a gradual dose reduction. Despite a pharmacy review recommending a dose reduction, the physician disagreed based on the resident's son's preference, but no clinical justification was documented. A request for documentation was made to the NHA, but none was provided before the survey exit.
A resident was involved in two medication errors, resulting in an 8% error rate. An LPN administered only 200 mg of Hydroxychloroquine instead of the prescribed 400 mg and did not follow the SASH method for flushing the PICC line. The resident, with multiple health conditions, was cognitively intact. The errors were confirmed by staff interviews, revealing a deviation from physician orders and facility protocol.
The facility failed to maintain cleanliness and address maintenance issues, affecting 97 residents. Heavily soiled ventilation grills and a dirty drain funnel were observed, along with maintenance issues in resident rooms. Despite having a work order system, no records addressed these concerns.
Food Service Equipment and Storage Deficiencies
Penalty
Summary
Food service equipment was not effectively cleaned and maintained, affecting 108 residents who consume food. During an initial tour of the food service area with the Director of Dining Services, two 16-inch fry pans were observed with etched, scored, and particulate buildup, and one of the two pans was also out-of-round. Four 8-inch non-stick fry pans were also observed with etched, scored, and particulate buildup. The Director of Dining Services stated that employment had only begun on November 17th. Additional food service storage practices were observed that did not match the facility's stated procedures. A clear plastic handled scoop was stored inside a dry food bin resting directly on the panko breadcrumbs instead of being stored on the inside hanger as described by the Director of Dining Services. Numerous soup cups and saucers were also observed stored in a black plastic tub resting on the top surface of a transportation cart without being inverted. Record review showed the facility's policies required pots, dishes, flatware, utensils, and food supplies to be stored to prevent contamination, with dry storage procedures directing that scoops be hung or stored in bins on a scoop holder.
Facility Failed to Maintain Clean and Safe Environmental Conditions
Penalty
Summary
The facility failed to effectively clean and maintain the physical plant, affecting 108 residents. During an environmental tour of the laundry service area, the clean laundry room flooring was observed etched, scored, and particulate, and the soiled laundry room flooring had black electrical tape adhered to the surface. The soiled laundry room also had wall/floor junctures and entrance door frames soiled with accumulated and encrusted dust and dirt deposits. Facility staff stated a maintenance request would be entered into WorxHub. Additional environmental concerns were identified throughout the facility, including non-functional overhead light assemblies in clean linen rooms, a microwave oven in a clean linen room with an etched, scored, bubbled, chipped, and corroded interior door face plate exposing inner metal, a stained acoustic ceiling tile from a previous moisture leak, a loose laminate wood grain board on a mobile table, and an overhead light plastic lens cover with accumulated dust, dirt, and dead insect carcasses. A resident room had a roof leak with missing acoustic ceiling tiles, plastic sheeting capturing water into a receptacle, towels placed to absorb moisture, and a waste bin partially filled with water. Other findings included a loose commode seat, additional non-functional lighting, and stained ceiling tiles in a beauty shop. Record review showed the facility policy required regular monitoring and routine cleaning and disinfection, and review of WorxHub maintenance work orders for the prior 60 days revealed no specific entries related to the cited maintenance concerns.
Care Plans Not Revised or Kept Accurate
Penalty
Summary
The facility failed to revise and maintain accurate care plans for multiple residents, including residents with changes in condition, medication status, and individualized needs. The report states that care plans were not updated or revised for six of 22 residents reviewed, and that several plans had not been changed for years despite ongoing assessments and care conferences. Staff interviews indicated that care plans were expected to be multidisciplinary and updated by department staff and MDS nurses, but the records reviewed did not reflect that this occurred consistently. For one resident with hemiplegia and hemiparesis following cerebral infarction, dysarthria, expressive language disorder, major depression, bilateral hearing loss, and chronic right knee instability, observations showed the resident sitting in a wheelchair watching TV with no meaningful activity items available and no visible activity calendar. The resident stated there was only TV and was not aware of anything else going on. Record review showed only a few short one-on-one visits and activity rounds in the prior 30 days, no one-on-one visit documented for January 2026, and the last life enrichment progress note dated 10/15/2024. The resident’s care plan had not been updated since 2020 and still contained older interventions such as encouraging participation in unit activities, communication approaches, and general supportive measures without new interventions added during quarterly assessments or care conferences. Another resident with chronic respiratory failure, diabetes, COPD, CKD, depression, anxiety, and chronic pain was observed watching TV in bed with no activity calendar or in-room activity items available. The resident had not had a one-on-one visit in the last 30 days and had only three activity rounds. The care plan still stated the resident had no interest in out-of-room group activities, yet also included independent activity materials, encouragement to attend group activities, and one-on-one visits, with staff noting the resident enjoyed conversation, dogs, family, and pet visits. The report also identified a resident with epilepsy and delayed psychological development whose activity care plan did not match the activity assessment: the assessment documented a preference for television, coloring, friends and family, and Bon Jovi music, while the care plan only stated the resident liked self-directed activities of choice without identifying what those activities were or how staff should assist. Staff further reported the resident was social, liked to attend activities, and needed transport and reminders. The report also found inaccurate or outdated care plan entries for other residents. One resident’s fall-risk care plan still included contact isolation interventions for C. diff even though the resident no longer had an active C. diff infection and contact precautions were not in place. Another resident’s psychotropic care plan still reflected antipsychotic use after quetiapine had been discontinued. For another resident, the fall-risk care plan included keeping the bed against the wall, keeping the bed low, and keeping the walker in reach, but observation showed the bed was not against the wall and the walker was not in the room. Staff acknowledged that the care plans should have been revised to reflect current conditions and medication changes.
Failure to Preserve Resident Dignity
Penalty
Summary
The facility failed to preserve the dignity of two residents. One resident was cognitively intact with a BIMS of 15, had diagnoses including Friedreich ataxia, dysphagia, spinal stenosis, major depression, anxiety, bilateral sensorineural hearing loss, expressive language disorder, irritability, and anger, and was dependent for all personal care. During interviews, the resident stated that some staff treated her with respect and dignity and some did not, that she had reported concerns before but nothing was done, and that day and afternoon CNAs were not always nice. She also stated that staff had turned off her call light and left her room without providing care, that many CNAs did not know her or her routine, and that she wanted staff trained to care for her. Staff interviews confirmed she had concerns about staff not knowing her needs, that she had a binder with detailed care instructions on the medication cart, and that a communication board was no longer present even though she had difficulty communicating. The same resident was observed with a red binder on the medication cart labeled as a reference book containing specific instructions for her morning care, showering, lotion, teeth brushing, dressing, computer setup, and stress relief exercises when upset. One LPN stated she could not provide care for the resident because of things the resident had said to her, and another nurse from a different floor came down to provide care. The unit manager stated the resident was particular about who provided care and that the binder helped staff care for her the way she liked it done. The grievance log did not show that the resident’s concerns had been reported or addressed. A second resident with dementia and Parkinson’s disease had a BIMS score of 3, indicating severe cognitive impairment. He was observed wandering in his wheelchair with chocolate dripping from his lip to his chin and neckline and a toothbrush-style mustache, and multiple staff walked by without assisting him. An LPN pointed out the chocolate on his face but did not help clean it. The resident was later observed with the same chocolate residue around his mouth and face on subsequent days. The unit manager stated the resident drooled and was constantly in food, and when asked what staff were expected to do when they passed him in the hall or during routine checks, stated staff were expected to assist him in cleaning his face.
Failure to Protect Resident Health Information
Penalty
Summary
The facility failed to maintain privacy and confidentiality of a resident’s personal and medical records when a phlebotomist left the resident’s health information open on top of a lab draw cart outside the resident’s room. The resident was admitted with diagnoses including cellulitis of the face, weakness, chronic kidney disease, muscle weakness, and a history of falls. During observation, the resident’s name, date of birth, diagnosis, physician orders, and labs being drawn were visible to anyone walking by the cart and room. When questioned, the phlebotomist stated she was just the phlebotomist and did not work there. An LPN unit manager later stated she would follow up because the phlebotomist was a lab employee who comes in to do lab draws.
Failure to Provide Meaningful Resident Activities
Penalty
Summary
The facility failed to provide impactful and meaningful activities for four residents reviewed. Resident 32 was a female with epilepsy and delayed psychological development who scored 5 out of 15 on the BIMS, indicating severe cognitive impairment. She was observed in her room and later in the hallway without television, radio, books, puzzles, or other leisure items at bedside. Her activity assessment showed she liked television, coloring, time with friends and family, and music by Bon Jovi, and the Life Enrichment Director stated she was very social and liked to attend activities if staff got her up and dressed. Resident 86 was a male with dementia and Parkinson's disease who scored 3 out of 15 on the BIMS. He was observed wandering the hall, sitting alone in the atrium, and later in his room while the lounge at the end of the hall remained closed. His activity assessment showed he was at ease interacting with others and particularly enjoyed bingo and entertainment. Staff stated the unit lounge could not be used unless staff were in the room the entire time, and the Life Enrichment Director stated the residents on the unit were no longer able to use the living room area unless nursing staff were present. Resident 56 was a cognitively intact female with hemiplegia and hemiparesis following cerebral infarction, dysarthria, expressive language disorder, major depression, bilateral hearing loss, and chronic instability of the right knee. She was observed sitting in her wheelchair watching TV with no meaningful activity items available and stated she had nothing to do but watch TV. She was not taken to bingo when it was scheduled. Record review showed only a few short one-on-one visits and activity rounds in the prior 30 days, no January one-on-one visit documentation, and no updated care plan interventions since 2020 despite existing preferences for conversation, dogs, family, pet visits, and in-room activity handouts. Resident 101 was a cognitively intact male with chronic respiratory failure, diabetes mellitus, COPD, CKD, depression, anxiety, and chronic pain. He stated he usually watched TV and had no activity calendar or in-room activity materials available, and record review showed no one-on-one visit in the prior 30 days and only three activity rounds. His care plan stated he had no interest in out-of-room group activities, enjoyed independent activities of choice, and liked pet visits, but the care plan had not been updated for two years and pet visits were not provided on a routine basis. The activity director also stated weekend and evening activities were not offered and that the facility had not had evening or weekend activities in two years.
Failure to Follow Repositioning, ROM, and PICC Dressing Orders
Penalty
Summary
The facility failed to provide care and services in accordance with orders and the care plan for two residents. One resident with chronic respiratory failure, diabetes mellitus, COPD, chronic kidney disease, depression, anxiety, and chronic pain was documented as dependent for all personal care and stated he was not receiving the range of motion and repositioning he was supposed to get. He reported he could not reposition himself, and staff interviews confirmed he required repositioning every two hours because he was unable to do so independently. Staff interviews and record review showed the resident’s repositioning was not being carried out as planned. A CNA stated the resident needed to be repositioned every two hours, and an LPN stated the resident needed repositioning every two hours and that the wound care nurse followed up on red areas related to not being repositioned. The record review indicated the repositioning was on the kardex and care plan but was not being done, with the resident repositioned only three times per shift rather than every two hours. The resident also received ROM for 10 minutes only one time in the last 30 days, and the care plan did not show updates or new interventions reflecting changes in ability to participate. A second resident with endocarditis, UTI, and chronic respiratory failure with hypoxia had a PICC line with a dressing dated 1/19/26 while receiving IV antibiotics. The resident stated the dressing was supposed to be changed every week and expected it to be changed that day. Record review showed an order for PICC line maintenance and documentation that the resident refused an IV PICC dressing change on 1/22/26, but the record did not show the resident was offered another dressing change. Staff later changed the dressing on 1/28/26, which was 9 days after the prior dressing change, and the DON confirmed the dressing change was late even though the facility policy required PICC/midline dressings to be changed every 5 to 7 days.
Failure to Provide Ordered ROM and Repositioning
Penalty
Summary
The facility failed to provide range of motion (ROM) and repositioning for one resident who was dependent for all personal care. The resident had diagnoses including chronic respiratory failure, diabetes mellitus, COPD, chronic kidney disease, depression, anxiety, and chronic pain, and the most recent MDS showed a BIMS of 14 and dependence in ADLs. During interview, the resident stated he was not getting ROM or repositioning as he was supposed to and said he could not reposition himself, so staff knew they had to do it. Staff interviews confirmed the resident required repositioning every two hours because he could not reposition himself. An LPN stated the resident needed repositioning every two hours and that the wound care nurse followed up on red areas from not being repositioned every two hours. Record review showed repositioning was on the kardex and care plan but was not being done, with the resident repositioned only 3 times per shift instead of every 2 hours. ROM was also limited in practice, with only 10 minutes of ROM provided one time in the last 30 days. The care plan identified decreased mobility, right foot drop, chronic pain, and other conditions, and listed active and passive ROM during ADLs, but the record did not show updates or new interventions to reflect changes in ability to participate.
Failure to Update Fall Interventions After Repeated Unwitnessed Falls
Penalty
Summary
The facility failed to implement interventions to prevent falls for one resident with severe cognitive impairment and a history of fractures. The resident had diagnoses including vascular dementia, Alzheimer's disease, and a right femur/periprosthetic knee fracture. The Quarterly MDS reflected a BIMS score of 3 out of 15. On observation, the resident was seen in bed with the bed in a low position and personal items not consistently within reach. The record showed an unwitnessed fall in which the resident was found on the floor near the bed after reaching for the walker storage compartment while sitting in bed and rolling off the foot of the bed. The incident report noted the resident had asked to use the bathroom and had last been toileted sometime between midnight and 6:00 AM, while the intervention documented was to continue the plan of care related to impaired physical mobility/fall risk. The resident had another unwitnessed fall in which they were found on the floor and stated that a man told them it was time for breakfast, so they were trying to get ready. The incident report documented that the resident was not wearing proper footwear at the time of the fall. The care plan already included interventions to offer and encourage gripper socks and proper footwear, but the documentation and interview reflected uncertainty about why the resident was not wearing appropriate footwear and no documented change to the care plan beyond continuing existing interventions. A later unwitnessed fall occurred when the resident was found pinned between the bed and the adjacent wall, with documentation indicating the resident appeared to have rolled in bed and become wedged there as the mattress may have moved. For that event, the notation was again to continue the current fall care plan, and the DON stated interventions were continued unless a new intervention matched the cause of the fall.
Cold and Unpalatable Meal Service
Penalty
Summary
The facility failed to provide food and drinks that were palatable, attractive, and served at a safe and appetizing temperature. During observations of lunch meal tray delivery on 01/27/2026 and 01/28/2026, surveyors observed multiple insulated food transport carts leaving the kitchen and arriving on units, and in two instances the North Hall cart was left with access doors open between tray deliveries. Food temperatures were taken from resident trays after delivery and several items were below the facility’s stated hot-holding standard of 135 degrees Fahrenheit, including pork loin fricassee, mashed potatoes, carrots, cheddar dinner roll, peach crisp, hamburger, cottage cheese, garden salad, and pumpkin pie. One tray also included a beverage that was weak in taste per resident report, and another tray included apple sauce at room temperature. Resident #132, who had diagnoses including endocarditis, UTI, and chronic respiratory failure with hypoxia, was observed in their room and stated meals were always cold. When their lunch tray was checked, the resident’s pork loin fricassee, mashed potatoes, carrots, cheddar dinner roll, and peach crisp were all below 135 degrees Fahrenheit, while coffee was 148.4 degrees Fahrenheit and lemonade was 48.0 degrees Fahrenheit. The resident also stated the food tasted less than desirable, the lemonade was generally weak in taste, the food tended to be on the cool side, and the meat was generally dry and somewhat tough. Resident #72, who had diagnoses including cellulitis, chronic kidney disease, and moderate protein-calorie malnutrition, was observed eating meals in their room and reported that all meals were served cold. Their lunch tray was later checked and the hamburger, cottage cheese, garden salad, and pumpkin pie were all below 135 degrees Fahrenheit, with apple sauce at room temperature and coffee at 130.2 degrees Fahrenheit. The facility’s policies stated that food and drinks are to be palatable and served at a safe and appetizing temperature, and that meal service should preserve temperatures and nutrient content, but the observed tray temperatures and resident statements showed meals were being served cold and not meeting those standards.
Failure to Administer Consented Flu and Pneumonia Vaccinations
Penalty
Summary
Develop and implement policies and procedures for flu and pneumonia vaccinations. The facility failed to administer influenza and pneumococcal immunizations per consent for one resident who was admitted with acute respiratory failure with hypoxia, pleural effusion, atrial fibrillation, chronic obstructive pulmonary disease, dementia, and pneumonia. The resident initially declined both the pneumonia and influenza vaccinations, then after transfer to the hospital and return to the facility, the resident consented and wished to receive both vaccinations upon readmission. Review of the medical record showed the resident did not receive either vaccination. A health status note dated 1/10/26 documented that a chest x-ray showed pneumonia and antibiotics were started. During interview, the Infection Preventionist reviewed the state immunization registry and reported the resident had received a pneumococcal 23 vaccination in 2011 and an influenza vaccination in 2022, and also confirmed the resident had consented to both vaccinations and was due for them, but the facility had no record of either vaccine being administered.
Failure to Document Change in Condition and Neurological Assessments
Penalty
Summary
The facility failed to document a resident's change in condition according to professional standards of practice, resulting in the potential for a delay in treatment. A resident reported experiencing stroke-like symptoms, including slurred speech, difficulty swallowing, drooling, and confusion, which were observed by multiple CNAs. These changes were reported to LPNs on duty, but there was a delay in assessment and documentation. Although orders were given for neurological and blood pressure checks every four hours, there was no documentation in the resident's electronic medical record to confirm that these assessments were completed. The only progress note for the day shift was entered in the evening, after the resident was assessed and subsequently sent to the hospital for possible stroke. Interviews with staff revealed that several CNAs and LPNs were aware of the resident's symptoms and communicated these changes to each other and to the nurse practitioner. However, the required documentation of the resident's condition and the neurological checks was not completed or entered into the electronic medical record. The Director of Nursing confirmed the lack of documentation regarding the resident's condition on the day in question.
Deficiency in Food Service and Menu Management
Penalty
Summary
The facility failed to provide palatable and properly prepared food to its residents, affecting 95 individuals and increasing the likelihood of decreased food acceptance and nutritional decline. Observations and interviews revealed that residents did not consistently receive daily menus to select their meals, leading to dissatisfaction when they did not receive the meals they anticipated. One resident reported not receiving a menu daily and being served meals they did not choose, while another resident described the food as terrible, with issues such as burnt hamburgers and dried-out, tough meat. Additionally, a taste test conducted during lunch found the baked garlic butter cod to be chewy and not thoroughly cooked, and the pinto beans were hard and undercooked. Further observations noted that mashed potatoes were served cold with clumps, and powdered eggs were cold and tasteless. During a monitored lunch meal, wheat rolls and starch options like fluffy rice or mashed potatoes were missing from some test trays. The General Manager of Dining Services explained the process for ensuring food portion sizes and menu selections but acknowledged that residents were provided a weekly menu to make selections, which may not align with daily preferences. Record reviews of the facility's policies indicated that menus should meet nutritional needs and reflect residents' cultural and dietary preferences, but the execution of these policies appeared inconsistent, contributing to the deficiency.
Deficiencies in Food Service Equipment Maintenance and Hygiene Practices
Penalty
Summary
The facility failed to maintain and clean food service equipment effectively, impacting 95 residents. During an initial tour, it was observed that the True two-door reach-in cooler was missing interior fluorescent light bulbs, which is a violation of the 2017 FDA Model Food Code that requires specific light intensity levels in food storage and preparation areas. Additionally, several pieces of equipment, including a Bizerba meat slicer, Frymaster fryers, a Continental pull drawer refrigerator, and dual convection ovens, were found to be soiled with accumulated and encrusted food residue, indicating a lack of proper cleaning and maintenance. Further observations revealed that numerous fry pans were heavily soiled with caramelization and were also dented and out of round, which compromises their functionality and cleanliness. The facility's policies and procedures for cleaning and maintaining equipment, such as ovens and dish machines, were reviewed, but the actual practices did not align with these guidelines. This discrepancy suggests a failure in adhering to established cleaning protocols, which are essential for preventing cross-contamination and ensuring food safety. Additionally, a dietary prep staff member was observed not wearing appropriate hair restraints, as his mustache was not covered, which is a requirement under the 2017 FDA Model Food Code to prevent hair from contacting food and clean equipment. This oversight further highlights the facility's failure to enforce proper hygiene practices among food service employees, increasing the risk of contamination and compromising the safety and quality of food served to residents.
Medication Storage Deficiency
Penalty
Summary
The facility failed to securely store medications, leading to potential misuse and medication administration errors. On multiple occasions, treatment carts and medication bins were observed unlocked and unattended in areas accessible to residents. Specifically, on 11/20/24, a treatment cart in hall D was left unlocked without staff presence, and residents were seen moving around the area. Similarly, on 11/22/24, the Redies East medication cart was found unlocked in the hall with no nurse in sight, while residents were present in the vicinity. Additionally, the charge nurse office, which contained an overflowing open bin of medications, was repeatedly left unoccupied with the door open. On 11/21/24, the nurse manager left the office unattended, and on 11/22/24, LPN K was observed leaving the office with unsecured medications. Despite LPN K's claim that medications were moved to the medication room, the surveyor confirmed that the medications remained unsecured in the office. The facility's Medication Administration Policy mandates that medication carts be locked when not in view, a procedure that was not followed, contributing to the deficiency.
Failure to Implement Comprehensive Care Plan for Skin Breakdown Prevention
Penalty
Summary
The facility failed to ensure a comprehensive care plan was in place for the prevention of skin breakdown for a resident identified as being at risk for pressure ulcers. Upon admission, the resident was assessed as having no skin issues, but was marked as at risk for impaired skin integrity. Despite this, no comprehensive care plan addressing the risk for skin integrity was implemented. The resident was admitted to hospice care with diagnoses including protein-calorie malnutrition and a need for observation and assessment of skin integrity. Over time, the resident developed an unstageable pressure ulcer on the right buttocks, which was not documented in the care plan until several weeks later. The deficiency was further compounded by a lack of timely communication and documentation. A skin evaluation on 7/31/2024 identified a new pressure ulcer, but the wound nurse was not informed until 8/5/2024, delaying the implementation of necessary interventions. Subsequent evaluations showed inconsistencies in documenting the resident's skin condition, with a pressure ulcer being noted and then later described as a skin tear, and eventually not documented at all. The comprehensive care plan was not updated to reflect the resident's skin issues until 8/21/2024, indicating a significant delay in addressing the resident's needs for skin breakdown prevention.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement new interventions after a fall with injury for a resident on the dementia unit. The resident, who was severely cognitively impaired, fell while attempting to go to the bathroom unassisted, resulting in bruising to both hands. Despite the fall, the care plan was not updated with new interventions to prevent further falls. The care plan had been last revised months prior, with no new measures added after the incident. Interviews with staff, including CNAs and the LPN/Unit Manager, revealed that no new interventions were communicated or added to the care plan following the resident's fall. The LPN/Unit Manager acknowledged that it was the responsibility of the floor nurse to update the care plan with new interventions after a fall, but this was not done. The interdisciplinary team, which reviews fall reports and care plans, also did not ensure the addition of new interventions, leading to a deficiency in care planning and implementation.
PICC Line Dressing Deficiency
Penalty
Summary
The facility failed to provide services that met the acceptable standards of clinical practice for PICC line dressings for a resident. The resident, a cognitively intact female with multiple diagnoses including infection post joint removal, was observed with a PICC line dressing that was not changed according to the facility's policy. The dressing was dated 11/13/24, and the resident reported that the nurse planned to change it that evening. However, during a subsequent observation, the dressing was dated 11/20/24, and gauze was used under the clear opsite dressing, which is against the facility's policy and standard clinical practice. Interviews with the LPN and Unit Manager revealed that the facility's policy required PICC line dressings to be changed every 7 days using a clear opsite dressing to allow visualization of the insertion site. The use of gauze under the transparent dressing was not expected, as it hinders the ability to assess the site for signs of infection. According to clinical guidelines, gauze dressings should be changed every 48 hours, indicating that the facility's practice did not align with these standards, increasing the likelihood of infection for the resident.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to prevent a skin tear from developing into a stage 3 pressure ulcer for a resident identified as R94. Initially, upon admission, R94 was assessed to be at risk for pressure ulcers but had no skin issues. However, subsequent evaluations revealed the development of a pressure ulcer on the right buttocks, which was initially documented as unstageable and later as a skin tear. Despite being at risk, no comprehensive care plan or interventions for skin breakdown prevention were implemented until after the ulcer had developed. The deficiency was exacerbated by a lack of communication and documentation among the nursing staff. A Licensed Practical Nurse (LPN) was not informed of the skin change until several days after it was first observed by a Registered Nurse (RN). This delay in communication prevented timely assessment and intervention, allowing the skin tear to progress into a pressure ulcer. The facility's practice required immediate reporting of skin changes, but this protocol was not followed, contributing to the deficiency. The resident's medical history, including terminal illness, protein-calorie malnutrition, and other chronic conditions, increased the risk for skin integrity issues. Despite these risk factors, the facility did not establish a care plan for skin integrity until after the pressure ulcer had developed. The ulcer was eventually documented as a stage 3 pressure ulcer, indicating a significant lapse in preventive care and timely intervention by the facility.
Failure to Document Physician's Rationale for Medication Irregularities
Penalty
Summary
The facility failed to ensure that the attending physician documented the review of identified medication irregularities, the actions taken, or the rationale for not making changes to the medications for three residents. Resident #12, who was cognitively intact, had been receiving Cetirizine for allergies, which was suggested to be discontinued or changed to PRN due to potential contribution to dry eyes. The physician disagreed with the recommendation, but no rationale was documented in the medical record. Similarly, Resident #28, with severe cognitive impairment, was taking both calcium and iron at the same time, which could decrease iron absorption. There was no documented response from the physician regarding the recommendation to separate the administration times. Resident #63, also with severe cognitive impairment, had been on long-term Flonase for allergies, and a trial discontinuation was suggested. The physician disagreed with this recommendation as well, but again, no clinical rationale was documented. Despite requests for documentation from the Nursing Home Administrator, no explanations were provided for why the medication regimen review recommendations were not implemented for these residents before the survey exit.
Failure to Justify Continued Use of Psychotropic Medication
Penalty
Summary
The facility failed to justify the continued use of psychotropic medication for a resident, identified as Resident #28, who was observed to be pleasant, socially engaging, and up daily for meals during the survey period. The resident, who is [AGE] years old, has diagnoses including dementia, depression, iron deficiency, and osteoporosis, and scored 3 out of 15 on the Brief Interview for Mental Status, indicating severe cognitive impairment. Despite a pharmacy review noting the use of the antidepressant Celexa 20 mg daily since September 2021 without a gradual dose reduction, the physician disagreed with the recommendation for a dose reduction based on the resident's son's preference to maintain the current dose. However, there was no clinical justification documented in the resident's medical record to support the continued use of Celexa at this dosage without a gradual dose reduction. A request for clinical documentation was made to the Nursing Home Administrator, but no documentation was provided before the survey exit.
Medication Administration Errors and Protocol Deviation
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by two medication errors observed out of 25 opportunities, resulting in an error rate of 8%. The errors involved a resident who was prescribed Hydroxychloroquine 400 mg but was only administered 200 mg by an LPN. Additionally, the LPN did not follow the prescribed SASH method for flushing the resident's PICC line after administering IV antibiotics, using an incorrect sequence of saline, antibiotic, heparin, and saline instead of the required saline, medication, saline, heparin. The resident involved was a cognitively intact female with multiple diagnoses, including infection post joint removal, anemia, heart failure, hypertension, kidney disease, and chronic obstructive pulmonary disease. The errors were confirmed through interviews with the LPN, another LPN, and the Unit Manager, who all acknowledged the deviation from the physician's orders and the facility's protocol. The Unit Manager also noted that the resident had been receiving an incorrect dosage of Heparin due to a misunderstanding of the medication schedule.
Deficiencies in Facility Maintenance and Cleaning
Penalty
Summary
The facility failed to effectively clean and maintain the physical plant, impacting 97 residents and increasing the potential for cross-contamination, bacterial harborage, and decreased air quality. During an environmental tour, several areas were found with heavily soiled and encrusted dust/dirt deposits on ceiling-mounted return-air-exhaust ventilation grills, including locations adjacent to resident rooms on Bridgeway Boulevard, [NAME] Court, Dovecote Drive, and in the Redies (North) restroom. Additionally, the drain funnel beneath the ice/water dispensing machine on Redies (South) was observed to be heavily soiled with accumulated dirt and grime. Further observations during a tour of sampled resident rooms revealed maintenance issues such as a missing pull string extension on an overbed light assembly in room D4 and a loose-to-mount hand sink faucet assembly in room D8. Despite having a maintenance work order system, the facility's records for the past 60 days showed no specific entries addressing these maintenance concerns. The facility's policies on routine cleaning and disinfection, as well as routine bathroom cleaning, emphasize the importance of maintaining a safe and sanitary environment to prevent infections, yet these deficiencies indicate a lapse in adherence to these policies.
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What surveyors actually found near you
We read the 207 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Saline
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Optalis Health And Rehabilitation Of Ann Arbor | 9.3 mi | ★★★★★ | 2 | 0 |
| Regency At Bluffs Park | 9.3 mi | ★★★★★ | 2 | 0 |
| Glacier Hills | 9.9 mi | ★★★★★ | 0 | 0 |
| The Gilbert Residence | 10.3 mi | ★★★★★ | 10 | 0 |
| The Villa At Parkridge | 10.8 mi | ★★★★★ | 16 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 July 2026) and official state health department websites.