Saugus Center

In the surveyor’s words

From the most serious findings on record at Saugus Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF580Jun 16, 2025

  Based on observations, record review and interviews, the facility failed to notify one Resident's (#172) physician and legal guardian of a change in condition out of a total sample of 27 residents. Specifically, the facility failed to notify the physician of Resident #172's refusing medication, exit seeking behavior, an elopement from the facility and multiple other attempts of elopements from the facility, including through a second story window, resulting in Resident #172 from falling out of a second-floor window and requiring acute hospitalization with a fracture of the fourth lumbar vertebrae with mild retropulsion into the spinal canal (bone fragments in spinal cord), fractures of the second and third lumbar vertebrae, hematoma of the psoas muscle (lower back muscle), and fractures of… […]

• Immediate jeopardy, isolatedF689Jun 16, 2025

  Based on observations, record reviews and interviews, the facility failed to keep three Residents (#172, #56 and #35 free from accidents while at the facility. Specifically, 1. For Resident #172, with a known history of elopement from a window, the facility failed to ensure it provided appropriate supervision and safety resulting in the Resident falling from his/her second-floor bedroom window during an elopement attempt, resulting in an acute hospitalization with a fracture of the fourth lumbar vertebrae with mild retropulsion into the spinal canal (bone fragments in spinal cord), fractures of the second and third lumbar vertebrae, hematoma of the psoas muscle (lower back muscle), and fractures of the ninth through 12 ribs; 2. […]

• Immediate jeopardy, isolatedF726Jun 16, 2025

  Based on observation, record review, and interviews, the facility failed to ensure licensed nursing staff were trained and competent in managing wandering behavior and elopement, subsequently, one Resident (#172) eloped and fell from a second-floor bedroom window and requiring acute hospitalization with a fracture of the fourth lumbar vertebrae with mild retropulsion into the spinal canal (bone fragments in spinal cord), fractures of the second and third lumbar vertebrae, hematoma of the psoas muscle (lower back muscle), and fractures of the ninth through 12 ribs. […]

• Immediate jeopardy, isolatedF835Jun 16, 2025

  Based on record review and interviews, the facility failed to ensure it provided appropriate administrative oversight, specific to clinical management and building safety, when one Resident (#172) fell from his/her second-floor bedroom window during an elopement attempt, resulting in an acute hospitalization with a fracture of the fourth lumbar vertebrae with mild retropulsion into the spinal canal (bone fragments in spinal cord), fractures of the second and third lumbar vertebrae, hematoma of the psoas muscle (lower back muscle), and fractures of the ninth through 12 ribs. Specifically, the facility administration failed to: 1. Ensure the facility's environment was safe for a Resident with a known risk of elopement from a window; 2. […]

• Actual harm, isolatedF656Apr 1, 2024

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose comprehensive plan of care indicated he/she required two staff members for assistance with bed mobility, which included turning and repositioning when in bed, and for incontinence care, the Facility failed to ensure staff implemented and followed interventions identified in his/her care plan, when on 03/11/24 Certified Nurse Aide (CNA) #1 provided care to Resident #1 unassisted by another staff member, Resident #1's upper body rolled off the bed, and his/her head hit the floor. […]