Sauer Health Care

In the surveyor’s words

From the most serious findings on record at Sauer Health Care, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Nov 18, 2021

  Based on interview and document review, the facility failed to ensure residents were free of mental abuse when resident photographs were attached to a power point presentation that was derogatory and demeaning in nature were shared on social media for 2 of 2 residents (R1 and R2) reviewed for allegations of mental abuse, resulting in an immediate jeopardy (IJ) situation for both R1 and R2. The IJ began on 11/11/21, when facility staff shared an inappropriate power point presentation at a party that included residents and later posted on Snapchat (social media). The administrator and director of nursing were notified of the immediate jeopardy at 12:14 p.m. on 11/18/21. […]

• Actual harm, isolatedF686Sep 29, 2022

  Based on record review, interview, and policy review, the facility failed to consistently monitor and document the progression of pressure ulcers for one (Resident (R) 25) out of two residents reviewed for the development of pressure ulcers in the total sample of 21 residents. The facility staff failed to monitor a pressure ulcer identified on a care plan on 05/10/22 through 07/12/22 when the pressure ulcers progressed to the depth of exposed tendon and bone resulting in harm to R25. Findings include: Review of a document provided by the facility titled Skin Management Policy, dated 02/03/09, indicated . To identify residents at risk for impaired skin integrity, and to provide direction for proper prevention, treatment, and documentation of skin impairments. Full Body Skin Assessment . […]

• No harm, potential for more than minimal, widespreadF713Mar 19, 2026

  Based on interview and document review, the facility failed to ensure the provision of 24-hour on-call physician services to respond to 1 of 1 resident (R2) needs, including non-emergent situations that did not require transfer to an alternative setting. This had the potential to affect all 47 residents residing in the facility. Findings include:See F684: R2 who was on blood thinners had a change in condition after a fall (frank blood) and provider was not notified immediately. During an interview on 3/18/26 at 3:13 p.m., licensed practical nurse (LPN)-A indicated she was responsible for R2 when the resident fell on 2/4/26 at 7:15 p.m. R2 was new to the facility and taking blood-thinning medication. The fall caused an existing wound on the resident's bottom to reopen. […]

• No harm, potential for more than minimal, widespreadF812Jan 7, 2026

  Based on observation, interview and record review, the facility failed to ensure food stored in the refrigerator were labeled, dated and free of expired foods. This deficient practice had the potential to affect all residents, staff and visitors who received food from facility kitchen.Findings include:During the initial kitchen tour on 1/5/26 at 11:41 a.m., dietary (D)-A greeted surveyor inside the kitchen. The following items were observed in the fridge and freezer expired, undated food, and uncovered food:-Marinara sauce dated 9/29/25 with crystallization on top of marinara and lid of container-Pepperoni dated 6/30/25, was brown in color with crystallization on container lid-3 to 5 chicken breasts in an unmarked plastic bag thawing with a date of 12/27 (indicated pulled from… […]

• No harm, potential for more than minimal, widespreadF801Oct 19, 2023

  Based on interview and document review, the facility failed to employ either a full-time registered dietitian (RD) or a qualified dietary manager (DM) to carry out the functions of the food and nutrition service since 8/21/23, which had the potential to affect all 40 residents who resided in the facility. Findings include: The facility's undated list of new hires identified the dietary supervisor (DS) was hired on 8/21/23. The DS's undated employment and certification history lacked the required qualifications for a dietary manager. The DS's undated Dietary New Employee Orientation Checklist lacked completion of the required qualifications for a dietary manager. […]