Saunders Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Saunders Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 19, 2024

  Based on review of facility policy, review of facility documentation, review of clinical records, and interviews with staff, it was determined that the facility failed monitor and serve hot beverages at a safe temperature. This failure resulted in Immediate Jeopardy situation to Resident R371 who spilled a hot beverage and sustained a second degree on the right thigh for one of four residents reviewed. (Resident R371) Findings include: Review of facility policy Hot Liquid Safety last revised February 24, 2023, the intention of the policy was to minimize the risk for potential injury related to burns caused by hot liquids. […]

• Actual harm, isolatedF689Apr 24, 2026

  Based on staff interviews, review of clinical records, and facility documentation, it was determined the facility failed to ensure the safe handling of meal carts for one of one resident reviewed (Resident R1). This failure resulted in actual harm to Resident R1 when the meal cart rolled over resident's foot resulting in a fracture of the right distal 3rd metatarsal. This deficiency was identified as past non compliance.Findings include: Review of Resident R1's April 2026 physician orders revealed the diagnoses of Hypertension (high blood pressure); Peripheral Vascular Disease (poor circulation of the extremities); Congestive Heart Failure (excessive body/lung fluid caused by a weakened heart muscle), and Alzheimer's disease (progressive degenerative disease of the brain). […]

• Actual harm, isolatedF656May 9, 2025

  Based on review of clinical records, facility policy, facility investigative reports, and interview with staff, it was determined the facility failed to ensure hospice staff implemented care-planned interventions for one of 34 residents reviewed, who was identified as a fall risk. This failure resulted in actual harm to Resident R24 who sustained a fall out of bed during care, required transfer to the hospital via emergency medical services and sustained four sutures to left forehead/eyebrow and back of the head. […]

• Actual harm, isolatedF655Dec 2, 2021

  Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to developed interventions in Resident R108's baseline care plan, who was identified at high risk for falls. This failure resulted in actual harm to Resident 108 who sustained a fall and a left [CONDITION(S)]. The facility failed to develop baseline care plans within 48 hours of admission related to falls, [CONDITION(S)] medications, transmission based precautions, diabetes and cardiac conditions for six of 37 residents reviewed (Residents R108, R97, R270, R271, R273 and R83). Findings include: Review of facility policy, Baseline Care Plan - Guidelines undated, revealed that, Baseline Care Plan must be completed within 48 hours of admission to the facility. […]

• Actual harm, isolatedF689Dec 2, 2021

  Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to properly supervised a resident who was identified at high risk for falls (Resident R108). This failure resulted in actual harm to Resident 108 who sustained a fall and a left [CONDITION(S)]. The facility failed to ensure the proper transfer for a resident from bed to chair (Resident R83) for two of 37 residents reviewed (Resident R108 and Residents R83). […]