Evangelical Home - Saline

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with dignity and respect for one resident (R1) of three residents reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to notify resident representative of a change of condition, in a timely manner for one resident (R3) of three reviewed.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment affecting 108 residents who consume food, resulting in the increased likelihood for cross-contamination and bacterial harborage.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant affecting 108 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise care plans and maintain accurate care plans for six (R2, R5, R32, R56, R91, and R101) of 22 reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to preserve the dignity of two residents (resident #78 and resident # 86) of three residents reviewed.

Inspectors wroteDuring an interview and observation, the facility failed to maintain privacy and confidential records for one resident (R#135) of one resident investigated. Findings IncludeResident #135 (R135)Review of the medical record reflected that R135 was admitted to the facility on [DATE]. Diagnoses of Cellulitis of Face, weakness, Chronic Kidney Disease, Muscle weakness and history of falls. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) was still being completed due to new admission and data was not available. During an observation and interview on 01/28/2026 at 7:20 AM, phlebotomist W was in the resident's room finishing a lab draw and writer noticed R135's personal health information laying open on the top of the lab draw cart outside of the resident's room. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide impactful and meaningful activities for four of four residents reviewed (Resident #'s 32, 56,86 and 101).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two (R72, R101) of four residents reviewed received care and services in accordance with professional standards of practice and the care plan.

Inspectors wroteBased on interview and record review the facility failed to provide ROM and repositioning to one resident (Resident #101) of two residents interviewed for ROM and mobility. Findings Include:Resident 101 (R101)Review of the medical record reflected that R101 was admitted to the facility on [DATE]. Diagnoses of Chronic Respiratory Failure, Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, Depression, Anxiety and Chronic Pain. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) revealed R101 had a Brief Interview of Mental Status (BIMS) of 14 (Cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R101 was dependent of all personal care. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement interventions to prevent falls for one (R5) of two reviewed.

Inspectors wroteBased on observations, interviews, record reviews, and 2 (#72, #132) of 22 sampled residents, the facility failed to provide palatable food products affecting 108 residents who consume food, resulting in the increased likelihood for resident decreased food acceptance and nutritional decline.

Inspectors wroteBased on interview and record review, the facility failed to administer influenza and pneumococcal immunizations per consent for one (R6) of five reviewed.

Inspectors wroteThis citation pertains to intake number MI00150684. Based on observation, interview, and record the facility failed to document one out of three resident's (Resident #3) condition per professional standards of practice, resulting in the potential for a delay in treatment. Findings Included: On 3/11/2025 at 2:50 PM, Resident #3 (R3) was observed in her room lying in bed. R3 stated she that about three weeks ago she had a stroke. R3 said she felt weird, and was not able to speak. R3 was noted to have a slight speech impairment, but was understood. In an interview on 3/12/2025 at 11:11 AM, Certified Nurse Aid (CNA) C stated that on 2/11/2025 R3 seemed off around breakfast time, and stated R3's speech was slurred, was not swallowing food, was drooling food on her gown and face, eating messy, and her speech was slurred enough that is was noticed. [...]

Inspectors wroteThis citation includes intake number MI00144468. Based on observations, interviews, record reviews, and 3 (#12, #40, and #89) of 20 sampled residents the facility failed to effectively provide palatable food products effecting 95 residents, resulting in the increased likelihood for decreased resident food acceptance and nutritional decline.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 95 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to securely store medication, resulting in the potential for misuse, and medication administration errors.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a comprehensive care plan was in place for prevention of skin breakdown for one (Resident 94) of 20 residents. Findings Included: Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed R94 was at risk for pressure ulcers (PU). The MDS also revealed R94 did not have any pressure ulcers, or other skin concerns. The MDS revealed R94 was admitted to the facility on [DATE]. Review of a quarterly MDS dated [DATE], revealed R94 was at risk for PU, and had one unstagable pressure injury (not stageable due to the wound bed not being visible) that presented as a deep tissue injury (DTI) (an area over a bone that appears dark/purple, soft, and the color does not return when pressed on which can indicate a deep wound underneath). [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement new interventions after a fall with injury for one resident (#28) of 20 reviewed for care plans.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services that met the acceptable standards of clinical practice for PICC (peripherally inserted central catheter) line dressings in 1 of 1 sampled resident (Resident #319) reviewed for PICC lines, resulting in the increased likelihood for infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent a skin tear from developing into a stage 3 pressure ulcer for one of one resident (Resident 94). Findings Included: Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed R94 was at risk for pressure ulcers (PU). The MDS also revealed R94 did not have any pressure ulcers, or other skin concerns. The MDS revealed R94 was admitted to the facility on [DATE]. Review of a quarterly MDS dated [DATE], revealed R94 was at risk for PU, and had one unstagable pressure injury (not stagable due to the wound bed not being visible) that presented as a deep tissue injury (DTI) (an area over a bone that appears dark/purple, soft, and the color does not return when pressed on which can indicate a deep wound underneath). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the attending physician documented in the medical record that identified medication irregularities were reviewed, the action taken, and/or the rationale for no changes to the medications for three (Resident #12, #28, and #63) of five reviewed.

Inspectors wroteBased on observation, interview and record review the facility failed to justify continued use of psychotropic medications for one residents (#28) of five residents reviewed.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a medication error rate was less than five percent when 2 medication errors were observed from a total of 25 opportunities for one resident (R319) of eight residents observed during medication administration, resulting in a medication error rate of 8%.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effective clean and maintain the physical plant effecting 97 residents, resulting in the increased potential for cross-contamination, bacterial harborage, and decreased air quality.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 104 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and plumbing water leaks.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 104 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one resident (Resident 75) of 1 resident reviewed was assessed for self-administration of medications resulting in unsupervised administration of medications and the potential for mismanagement of medication and potential for adverse side effects. Findings Include: Resident 75 (R75) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R75 admitted to the facility on [DATE] with diagnoses of end stage renal disease, dementia, depression, type 2 diabetes. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicates R75 was cognitively intact. During an interview on 09/12/23 at 08:12 AM, R75 was lying in bed. It was noted he had 8 pills in a pill cup on his bedside table. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to report an allegation of physical abuse for one resident (#20) of one resident sampled for abuse resulting in allegation of abuse not being reported to the State Agency and the potential for further allegations of abuse to go unreported and not thoroughly investigated. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to investigate, implement preventive measures, and take correction action for an allegation of physical abuse with one resident (#20) of one resident review for abuse resulting in the potential of further abuse to residents. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to implement interventions to maintain or increase range of motion for two (Resident #3, #69) of two reviewed, resulting in the potential for a reduction in range of motion and worsening contractures.

Inspectors wroteBased on interview and record review the facility failed to ensure one out of one resident (Residents #21) received the necessary behavioral health care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being, resulting in the potential for unmet emotional and/or mental well-being care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow pharmacy policy and acceptable practice for maintaining controlled medication for three out of 9 medications carts resulting in the potential for controlled medication diversion. Findings Included During observation of Redie hall medication cart on 09/12/2023 at 07:46 a.m. it was observed that facility Controlled Substance Inventory document was signed by the out-going nurse for the date of 09/13/2023 (11 p.m. to 7 a.m.) but was not signed by the on-coming nurse. In an interview on 09/13/2023 at 08:38 a.m. Registered Nurse (RN) L explained that a physical count was to be completed for all controlled medication at the beginning of each shift when there is a change of nurses. RN L explained that the on-coming and off-going nurse would do a manual count of the controlled medication. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the medication regimen irregularities were reviewed, acted upon, and documented in the medical record for one (Resident #3) of five reviewed, resulting in the potential for unnecessary medications and adverse reactions.

Inspectors wroteBased on interview and record review, the facility failed to justify the continued PRN (as needed) use and/or provide a duration of use of a psychotropic medication for one (Resident #3) of five reviewed, resulting in the potential for unnecessary medications and adverse reactions.

Inspectors wroteBased on observation, interview, and record review the facility failed to label medication in accordance with accepted professional principles, dating of open medication for one out of nine medication carts resulting in the potential for residents to receive expired medication that is not providing its effective efficiency. Findings Included: During observation of the D wing medication cart on [DATE] at 10:19 a.m. it was observed that the following medications did not have a date when the medication was opened placed on the container of the medications: Timolo Maleate Opthalmic 0.5 precent eye drops, Azelastin HCL (hydrochloride) 0.05 percent eye drops, and Latanoprost Ophthalmic .005 percent eye drops. In an interview on [DATE] at 10:19 a.m. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to clean/disinfect the glucometer (machine used to determine blood sugar levels) used for two residents (#113, #322) of two residents sampled during observation of blood level glucose testing and failed to ensure hand hygiene was performed by a care giver during the collection of bodily fluids resulting in the potential to development and of infection and spread of infection to other residents. Findings Included: [...]