Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 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.
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.
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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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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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 | — | 1 | 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 | — | 15 | 0 |
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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 August 2026) and official state health department websites.