Saunders Nursing and Rehabilitation Center

Inspectors wroteBased on review of facility documentation and interviews with staff, it was determined that the facility did not ensure one member of the nursing staff was appropriately licensed while providing care to residents on one of seven days reviewed ([DATE]).

Inspectors wroteBased on observations, review of policy and review of facility provided documentation, it was determined that facility did not ensure to provide clean, homelike environment for multiple residents on four units (1st floor unit, 2nd floor unit, 3rd floor unit, 4th floor unit)

Inspectors wroteBased on observations, resident and staff interviews, it was determined that the facility failed to provide food and drink that was palatable and served at palatable temperatures for nine of thirty-four residents reviewed (Residents R91, R202, R61, R137, R197, R200, R65, R157 and R13).

Inspectors wroteBased on clinical record reviews, resident and staff interviews, it was determined that the facility failed to provide appropriate ADL care including shaving, and a haircut for one resident and morning care and dressing for another, for a total of two of 34 residents reviewed (Resident R21 and R36) who were unable to carryout ADL care independently.

Inspectors wroteBased on clinical record review, facility policy, and interview with staff, it was determined the facility failed to ensure pain medication was administered in accordance with the physician's order for one of eight residents reviewed for pain management (Resident R 134). Findings Include: Review of Resident R134 's clinical record revealed Resident R134 was admitted to the facility on [DATE]with a diagnosis of senile degeneration of brain (brain slowly worsening), carcinoma in situ of prostate (D07.5) (early prostate cancer), major depressive disorder (feeling sad daily). [...]

Inspectors wroteBased on review of policy, review of clinical records and review of facility provided documentation, it was determined that facility did not ensure that a resident who requires dialysis received services according to professional standards of practice for one of 34 residents reviewed (Resident R82)

Inspectors wroteBased on observations and interviews with staff it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.

Inspectors wroteBased on review of facility assessment and staff interview, it was determined that the facility failed to ensure the direct care staff and input from residents, resident representatives, and/or family members was included when conducting the facility assessment.

Inspectors wroteBased 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.

Inspectors wroteBased on review of policies and employee files, and staff interviews, it was determined that the facility failed to ensure that Pennsylvania Nurse Aide Registry checks were obtained prior to hire for one of four nurse aides reviewed (Employee E3). Findings Include: The facility's policy titled Criminal Background Checks/Verification of License and Certifications Thru Nurse Aid Registry last revised July 7, 2023 states, Policy- All offers of employment at the facility are contingent upon results of a thorough criminal background check. In addition, for professionals or nurse aides who are required to have a license or certification issued by the respective state they are currently applying for employment, must have a current verification that their license or certification is active and in good standings. [...]

Inspectors wroteBased on review of resident records, facility policy, and staff interviews, it was determined that the facility failed to provide discharge instructions and prescription medication upon discharge (Resident R1).

Inspectors wroteBased on review of facility policy, observations, and staff interview, it was determined that the facility failed to ensure that all residents had access to a call bell for assistance from staff for 6 of 10 residents observed. (Resident R3, R4, R5, R6, R8, R10). Findings Include:On February 4, 2026, at 10:39 a.m., an observation was conducted with the Director of Nursing, Employee E2, regarding the following residents:Resident R8's call bell was located behind her nightstand dresser, covered with a pillow, and was not accessible to resident. Resident R3's call bell was observed on the dresser and was not within reach. Resident R7's call bell was behind the bed and not accessible to the resident. Residents R5 and R6's call bells were hanging down and out of reach. A family member sitting next to Resident R6 reported that her call bell is often found on the floor and not accessible. [...]

Inspectors wroteBased on review of facility documentation, observations, and resident and staff interviews, it was determined that the facility failed to serve food at the proper temperature. Findings Include:A review of the facility's policy titled Food Temperatures Policy, revised February 2025, revealed that all hot food items must be cooked to appropriate internal temperatures and held and served at a temperature of at least 135 F. Temperatures must be taken frequently to monitor safe food-holding ranges of at or below 41 F for cold foods and at or above 135 F for hot foods. On December 18, 2025, at 10:39 a.m., an interview was conducted with Resident R1, who reported that the breakfast received that morning included sausages and pancakes that were served cold. [...]

Inspectors wroteBased on review of facility policy, review of clinical records, and staff interviews it was determined the facility failed to ensure that residents were free from neglect for one of five residents reviewed. (Resident R1)

Inspectors wroteBased on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility did not ensure that all allegations of neglect were reported immediately to the Pennsylvania Department of Health for one of 5 residents reviewed. (Resident R1). Findings Include:A review of the facility policy titled Incident Reporting and investigation of accident hazards, supervision, assistive device, last updated October 2025, revealed It is the policy of the Facility to monitor and evaluate any adverse occurrence which is not consistent with the routine operation of the Facility or care of a resident(s). All accidents/incidents where there is mistreatment, neglect, abuse or injuries of unknown origin will be reported to the Director of Nursing (DON) and Administrator (NHA) immediately for further review and reporting based on State and Federal regulations. [...]

Inspectors wroteBased on review of facility policy, review of clinical record, review of facility provided documentation and interview with resident and staff, it was determined that facility did not ensure a resident received treatment and care in accordance with professional standards of practice related to heat therapy for one of five residents reviewed. (Resident R1)

Inspectors wroteBased on review of facility policy, review of facility documentation, and staff and resident interviews, it was determined that the facility failed to ensure residents were kept free from abuse and neglect for two of three residents reviewed (Resident R1 and R3). Findings Include: Review of facility policy Abuse Policy - Prevention and Management reviewed August 2024, revealed the facility prohibits the mistreatment, neglect, and abuse of residents. The facility must provide a safe resident environment and protect residents from abuse. Review of Resident R1's clinical record revealed a quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated May 3, 2025, which indicated the resident was cognitively intact, determined by a Brief Interview for Mental Status (BIMS) score of 15. [...]

Inspectors wroteBased 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. (Resident R24)

Inspectors wroteBased on a review of facility policy, resident clinical records, and staff interviews, it was determined that the facility failed to obtain a physician order and develop a comprehensive care plan for for hospice services for one of eight residents reviewed (Resident R8).

Inspectors wroteBased on observation, interview with residents and staff, review of clinical records and facility policy, it was determined that the facility failed to maintain resident dignity and respect three of 34 residents reviewed. (Resident R57, Resident 107 and Resident 114) Findings Include: Review of facility's policy Statement of Resident Rights revealed a resident has a right to be treated with respect and dignity. Review of facility policy Hearing Impaired Residents revised on September 22, 2022, revealed that staff will assist hearing impaired residents to maintain effective communication with clinicians, caregivers, other residents and visitors. When interacting with the hearing impaired or deaf resident, staff will: directly face the resident when speaking so he/she can follow facial expressions and lip read, if possible. [...]

Inspectors wroteBased on clinical record review, interviews with staff and residents and reviews of policies and procedures, it was determined that the facility failed to conduct complete and thorough investigations into allegations of abuse and neglect for six of 34 residents reviewed. (Residents R95, R55, R57, R104, R114 and R164)

Inspectors wroteBased on clinical record reviews, and staff interviews, it was determined that the PASRR (Pre-admission screening and resident review) was not updated for one of 34 resident reviewed. (Resident R97)

Inspectors wroteBased upon review of clinical records, interviews with staff and residents and reviews of policies and procedures, it was determined the facility did not ensure residents receive treatment and care in accordance with professional standards of practice, by failing to follow the physician's orders for medication administration for three of 34 residents reviewed (Resident R95, R24 and R172).

Inspectors wroteBased up observation, interviews with staff, review of clinical records and facility policy, it was determined that the facility did not implement appropriate interventions to prevent pressure ulcers for one of 34 resident records reviewed (Resident R172).

Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that weights were monitored for one of 34 residents reviewed (Resident R28).

Inspectors wroteBased on review of facility policies, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to ensure professional practice standards related to pain management for one of 34 residents reviewed (Resident R98).

Inspectors wroteBased on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure that call bells were answered in a timely manner for two of 34 residents reviewed. (Resident R107 and Resident R114)

Inspectors wroteBased on interviews with staff and residents, review of the facility tray audit form, and the completion of a lunch test tray, it was determined that the facility failed to provide food and drinks that were served at safe and appetizing temperatures on one of four nursing units (3rd floor nursing unit).

Inspectors wroteBased on staff interviews, and review of facility documentation, it was determined that the facility failed to ensure that resident grievances were investigated and resolved for 3 of 3 residents reviewed. (Resident R12 R15 and R14)

Inspectors wroteBased on interviews from staff and residents, and review of facility documentation, it was determined that the facility failed to act promptly upon resident grievances and recommendations, which included concerns related to the dietary department for 3 out of 3 months reviewed (September 2024, October 2024 and November 2024).

Inspectors wroteBased on staff interviews, review of facility policy, and the review of clinical records, it was determined that the facility failed to ensure that a person-centered plan of care was developed for a resident related to irritants (e.g. aerosol sprays, perfumes, bleach, dust mites) and the adverse reactions that they can have on the resident's health for 1 out of 1 residents reviewed (Resident R1).

Inspectors wroteBased on observations, interviews with staff and residents, review of clinical records and facility documentation, it was determined that the facility failed to ensure adequate supervision during medication administration for 1 out of 15 residents observed (Resident R2). Fimdings include: Review of the facility policy, Medication Administration/Disposition with a review date of June 2023, indicated that medications, both prescription and non-prescription, shall be administered under the orders of the attending physician, or the physician's designees. Review of Resident R2's December 2024 physician orders included diagnosisof kidney failure (a condition where the kidney reaches advanced state of loss of function); hypertension (high blood pressure); diabetes (a condition that affects an individual's blood sugar levels and can cause serious complications); cerebral infarction (a stroke); [...]

Inspectors wroteBased 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)

Inspectors wroteBased on review of residents' records and facility policy and interviews with staff, it was determined that the facility failed to ensure residents received treatment and care in accordance with professional standards of practice when the facility failed to inform the physician of blood sugars outside the acceptable parameters and when insulin medication was not administered for three of 35 resident records reviewed (Resident R57, R135 and R149).

Inspectors wroteBased on review of facility documents, review of facility policy, review of clinical records, and staff interviews, it was determined that the facility failed to conduct a thorough investigation of an allegation of abuse, neglect and injury of unknown origin for four of 35 resident records reviewed (Residents R120, Resident R51,R102, R33 and R371)

Inspectors wroteBased on review of clinical records and facility policy and staff interviews, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan regarding one resident's chronic condition of constipation for one of 35 resident records reviewed (Resident R57).

Inspectors wroteBased on staff interviews and the review of clinical records, it was determined that the facility failed to ensure that restorative nursing services was provided for one of 35 clinical records reviewed (Resident R47).

Inspectors wroteBased on observation, review of facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and Director of Nursing failed to effectively manage the facility resulting in an immediate jeopardy situation regarding a resident assessment, monitoring and supervision, and inappropriately providing a hot beverage to a resident whom was determined to need assistance (Resident R371).

Inspectors wroteBased on review of facility documents, observations, interviews with residents and staff, it was determined that the facility failed to ensure that medications were administered in accordance with professional standards for two of 12 residents' records reviewed. (Resident R1 and Resident R2)

Inspectors wroteBased on clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that a resident's representative was informed of and allowed to participate in decisions regarding the resident's care and treatment for one of three residents reviewed (Resident R1).

Inspectors wroteBased on clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that a resident's representative was informed in advance of changes to the resident's plan of care for one of three residents reviewed (Resident R1).

Inspectors wroteBased on review of facility policies and documentation, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that one resident remained free from abuse, of three residents reviewed (Resident R2).