Saline Care Nursing & Rehab

Inspectors wroteBased on observation, interview and record review the facility failed to follow the pre-planned meals based on the Diet Spreadsheet. This failure has the potential to affect all 100 residents residing in the facility. The Findings Include: On 5/26/26 at 11:30 AM, V4 (Cook) stated that they do not have marshmallows for the ambrosia salad for dessert for lunch today and do not have the sauteed squash due to the evening shift does not ever follow the menu. V4 stated this causes issues due to the cook preparing what he wants rather than what is scheduled and uses up the food items scheduled for lunch meals. V4 went on to state that if the evening cook doesn't like what is scheduled, he just makes what he wants based on what he sees available in the freezer and refrigerator, not what is based off the planned menu. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide similar nutritive value food alternatives at meals. This has the potential to affect all 100 residents residing in the facility. The Findings Include:On 5/26/26 at 12:00 PM, the lunch meal observed in the steam table included pork loin, greens, corn bread and rice. There were no alternate meal selections available on the steam table for residents. V4 (Cook) confirmed this at this time those were the only hot food options available for residents at that meal. On 5/26/26 at 12:30 PM, V4 (Cook) stated that the only substitutes they offer residents are leftovers from the previous meal if there is any left, a grilled cheese, peanut butter and jelly or bologna sandwich. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain a physician order and consent for a physical restraint and assessed adaptive equipment to ensure safety and freedom for normal movement for 4 (R1, R2, R3, & R63) 4 residents reviewed for physical restraints in a sample of 70.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was free from unnecessary psychotropic medications for 1 of 5 residents (R99) reviewed for medications in a sample of 70. The Findings Include: R99's admission record documents an admission date of 11/21/25 and includes the following diagnosis: altered mental status, unspecified dementia/unspecified severity with anxiety, unspecified dementia with severe psychotic disturbance, unspecified psychosis not due to a substance or known physiological condition. R99's Physician's order summary report dated 5/29/26 documents orders including: ziprasidone 20 mg (milligrams) two times a day for dementia. Start date 1/21/26. Depakote 125 mg 1 tablet three times a day for dementia, Depakote 25o mg tablet three times a day for dementia. Started 1/21/26. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS) Assessment for 2 of 4 residents (R10 and R30), reviewed for MDS accuracy, in a sample of 70. Findings Included:1. R10's admission Record documented an admission date to the facility on 7/16/2020 with diagnoses including major depressive disorder, recurrent, unspecified, anxiety disorder, schizophrenia, unspecified and other specified depressive episodes. R10's Annual Minimum Data Set (MDS) dated [DATE] documented under A1500: Preadmission Screening and Resident Review (PASRR): is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition? No. Documented under Psychiatric/Mood Disorder, R10 has anxiety disorder, depression disorder, and schizophrenia. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a resident with a mental illness was referred to the appropriate state designated authority for a Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination of need for any specialized services for 1 (R99) of 7 residents reviewed for PASARR requirements in the sample of 70. The findings Include:R99's admission Record documented an admission date to the facility of 11/21/2025. Diagnoses listed include unspecified psychosis, dementia, and altered mental status. R99's 11/10/2025 Notice of PASARR Level I Screen Outcome documented no level II required and no serious mental illness. Rationale: The level 1 screen indicates that a PASRR disability is not present because of the following reason: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide at least 80 square feet of living space for 4 of 4 residents (R1, R22, R24, and R36) reviewed for room size in a sample of 70. The Findings Include: On 5/29/26 at 9:44 AM, V18 (Owner) stated that Side 2 of the facility has a room size waiver assessment. V1 stated these rooms are Medicaid certified for two residents. V1 stated rooms 203-206, 208-209, 211-212, 215-220, 222-227, 229-231, 234-235, 238-239, 241-242, 244-248 are all waivered rooms and don't meet the proper room size. On 5/29/26 at 1:06 PM, V13 (Maintenance Director) stated R1's room was less than 80 square feet per resident, which is less than the requirement. V13 used the measuring tape to measure the length and width of R1's room and stated, 12.5 by 12 feet, indicating that the room was 150 square (sq.) feet (ft.), or 75 sq. ft. per bed. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent resident to resident physical abuse for 2 of 4 residents (R1, R3) reviewed for abuse in the sample of 4. The past non-compliance occurred between 03/31/25 and 04/07/25.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide fingernail care for one (R81) of one resident reviewed for hygiene in the sample of 41.

Inspectors wroteBased on observation, interview, and record review the facility failed to identify, assess, and treat wounds for 1 of 5 (R92) residents reviewed for wounds in the sample of 41. Findings Include: R92's admission Record with a print date of 4/3/25 documents R92 was admitted to the facility on [DATE] with diagnoses that include cellulitis, sepsis, hypertension, hypotension, chronic obstructive pulmonary disease, cirrhosis of liver, and urinary retention. R92's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score of 15, indicating R92 is cognitively intact. This same MDS documents R92 requires substantial/maximal assistance of staff for bed mobility and has pressure ulcers, deep tissue injuries, and skin tears. R92's current Care Plan documents a Focus area of At risk for alteration in skin integrity. Date Initiated: 10/25/24. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide at least 80 square feet of living space for 4 of 4 residents (R1, R13, R56, and R97) reviewed for room size in a sample of 41.

Inspectors wroteBased on observation, interview and record review, the facility failed to keep resident care areas clean and in a good state of repair for 5 (R3, R4, R6, R8 - R20) of 16 residents reviewed for homelike environment in a sample of 20. Findings Include: On 09/24/2024 at 9:54 A.M. an observation in the 100-hall shower room revealed the following: shower stall had a black / orange substance around the caulking strip area between the wall and the floor. The black substance was observed as being around both side walls and the back wall of the shower stall. The vinyl liner for the shower curtain was observed as having black speckles on the bottom 12 inches. The vinyl liner also had an orange / brown substance on the bottom 6 inches of it. The legs of the shower chair had a orangish / black substance above the wheels. On 09/24/2024 at 11:32 A.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Practitioner Orders for Life-Sustaining Treatment (POLST) status reflected resident wishes as desired throughout the Electronic Health Record for 1 (R56) of 2 residents reviewed for advanced directives in the sample of 43. The Findings Include: R56's Facesheet with a print date of [DATE] documents R56 was admitted to the facility on [DATE] with diagnoses that include schizophrenia, anxiety disorder, major depressive disorder, chronic obstructive pulmonary disease, hypothyroidism, benign prostatic hyperplasia, anemia, gastroesophageal reflux disease, and influenza. R56's POLST form dated [DATE] documents under Orders for Patient in Cardiac Arrest, a check mark next to, No CPR (cardiopulmonary resuscitation): Do Not Attempt Resuscitation . [...]

Inspectors wroteBased on interview and record review the facility failed to accurately report Registered Nurse (RN) hours to the payroll-based journal. This has the potential to affect all 104 residents residing in the facility. Findings Include: Review of Staffing Data Submission Payroll Based Journal (PBJ) found at, https://www.cms.gov/medicare/quality/nursing-home-improvement/staffing-data-submission and last modified 9/23/23 stated, .CMS (Centers for Medicare & Medicaid Services) has developed a system for facilities to submit staffing information - Payroll Based Journal (PBJ). This system allows staffing information to be collected on a regular and more frequent basis than previously collected. It is auditable to ensure accuracy. Review of the facility's PBJ report for Fiscal Year Quarter 1 2024 (October 1 - December 31), documented No RN hours on the following dates: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide at least 80 square feet of living space for 5 of 5 residents (R3, R23, R46, R64, R72) reviewed for room size in a sample of 43.