Evangelical Home - Saline

In the surveyor’s words

From the most serious findings on record at Evangelical Home - Saline, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Aug 23, 2021

  This citation pertains to MI 597 Based on interview and record review, the facility failed to identify and intervene for an acute change in condition for one (Resident #7) of two reviewed for falls, resulting in Immediate Jeopardy when Resident #7 sustained a fall with head injury, changes in neurological status, and a delayed acute care intervention of transfer to the emergency room , death due to complications of subdural and intracerebral hemorrhage, and the likelihood for serious harm, serious injury, serious impairment or death for all 130 facility residents. Findings include: Review of the medical record revealed Resident #7 (R7) was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Immediate jeopardy, isolatedF686May 17, 2021

  This citation pertains to intake numbers MI 8279 and MI 9312. Based on observation, interview, and record review the facility failed to ensure two out of six residents (Resident #s 1 & 2) received necessary treatment, resulting in Immediate Jeopardy when Resident #2 developed a stage 4 pressure ulcer and worsening of existing pressure ulcers, placing five other residents identified to have pressure ulcers at risk for harm, injury, and/or death, and failed to ensure pressure ulcer treatments and interventions were documented as completed for Resident #1 resulting in the potential for pressure ulcers to develop. Findings Included: Resident #2 (R2): Per the facility face sheet R2 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF684Mar 2, 2023

  This citation pertains to intake numbers MI00131454, MI00134210 and MI00130635. Based on observation, interview and record review, the facility failed to 1) follow Physician's Orders for medications for one (Resident #2) of three reviewed for medications; 2) assess, monitor and promptly act on a change in condition for one (Resident #3) of three reviewed for assessment and monitoring; 3) ensure appropriate monitoring of blood glucose (sugar) levels for one (Resident #14) of three reviewed for assessment and monitoring; and 4) ensure insulin was administered according to Physician's Orders for two (Resident #14 and #16) of three reviewed for medications, resulting in medications not being administered according to Physician's Orders and/or manufacturer instructions, delayed recognition and… […]

• Actual harm, isolatedF742Aug 23, 2021

  This citation pertains to intake MI 895 Based on interview and record review the facility failed to perform a comprehensive assessment prior to the discontinuation of two antipsychotic medications and failed to provide mental health services for 1 resident (#10) of 1 resident reviewed for antipsychotic medications, resulting in resident #10 a severe level of mental distress, agitation, threats of suicide, physical aggression, paranoia and physical injury. Findings include: Review of the clinical record, including the Minimum Data Set, (MDS) with an assessment reference date of 08/07/2021, revealed resident #10 (R10) was admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF656May 17, 2021

  This citation pertain to intake numbers MI 8279 and MI 9312. Based on observation, interview, and record review the facility failed to develop and implement a comprehensive care plan for two out of five residents (Residents #1 and 2) that was resident center resulting in the development of stage four pressure ulcers and the potential for further pressure ulcer development and/or worsening of pressure ulcers. Finding Included: Resident #1 (R1) Per the facility face sheet R1 was admitted to the facility on [DATE]. Review of an MDS, dated [DATE], revealed R1 was at risk for pressure ulcer development, and treatments in place were a turning and repositioning program, and applications of ointments/medications. […]