A list of the most recent deficiencies for Evangelical Home - Saline. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-09-13 | 2023-10-13 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-13 | 2023-10-13 | N |
| Respond appropriately to all alleged violations. | Health | 2023-09-13 | 2023-10-13 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-09-13 | 2023-10-13 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-09-13 | 2023-10-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-13 | 2023-10-13 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-09-13 | 2023-10-13 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-09-13 | 2023-10-13 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-09-13 | 2023-10-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-13 | 2023-10-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-13 | 2023-10-13 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-09-13 | 2023-10-13 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-09-12 | 2023-10-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-12 | 2023-10-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-12 | 2023-10-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-09-12 | 2023-10-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-09-12 | 2023-10-13 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-29 | 2023-07-27 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-29 | 2023-07-27 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-06-29 | 2023-07-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-29 | 2023-07-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-29 | 2023-07-27 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-02 | 2023-03-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-02 | 2023-03-28 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-03-02 | 2023-03-28 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-03-02 | 2023-03-28 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-03-02 | 2023-03-28 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-03-02 | 2023-03-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-02 | 2023-03-28 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-03-02 | 2023-03-28 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-02 | 2023-03-28 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-07-26 | 2022-08-24 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-07-26 | 2022-08-24 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-26 | 2022-08-24 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-07-26 | 2022-08-24 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-07-26 | 2022-08-24 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-07-26 | 2022-08-24 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-07-26 | 2022-08-24 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-07-26 | 2022-08-24 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-07-26 | 2022-08-24 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-07-26 | 2022-08-24 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-07-26 | 2022-08-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-26 | 2022-08-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-26 | 2022-08-24 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-07-26 | 2022-08-24 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-07-26 | 2022-08-24 | Y |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-07-21 | 2022-08-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-07-21 | 2022-08-24 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-07-21 | 2022-08-24 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-04 | 2022-01-31 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-01-04 | 2022-01-31 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-04 | 2022-01-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-04 | 2022-01-31 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-01-04 | 2022-01-31 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-01-04 | 2022-01-31 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-08-23 | 2021-09-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-23 | 2021-09-21 | Y |
| Provide or arrange emergency care by a doctor 24 hours a day. | Health | 2021-08-23 | 2021-09-21 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2021-08-23 | 2021-09-21 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-08-23 | 2021-09-21 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-05-17 | 2021-06-15 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-17 | 2021-06-15 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-17 | 2021-06-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-17 | 2021-06-15 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2020-02-18 | 2020-03-18 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2020-02-18 | 2020-03-18 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2020-02-18 | 2020-03-18 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2020-02-18 | 2020-03-18 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-02-18 | 2020-03-18 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-02-18 | 2020-03-18 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-02-18 | 2020-03-18 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2020-02-18 | 2020-03-18 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-02-18 | 2020-03-18 | N |
| Provide activities to meet all resident's needs. | Health | 2020-02-18 | 2020-03-18 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-02-18 | 2020-03-18 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2020-02-18 | 2020-03-18 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2020-02-18 | 2020-03-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-02-18 | 2020-03-18 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-02-18 | 2020-03-18 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2020-02-18 | 2020-03-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-18 | 2020-03-18 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2020-02-18 | 2020-03-18 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2020-02-18 | 2020-03-18 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2020-02-13 | 2020-03-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-02-13 | 2020-03-18 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2020-02-13 | 2020-03-18 | N |
