Deficiency Records for Saunders Nursing and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Saunders Nursing and Rehabilitation Center. 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? |
|---|---|---|---|---|
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-11-08 | 2023-11-24 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-11-08 | 2023-11-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-11-08 | 2023-11-24 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-09-21 | 2023-11-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-21 | 2023-11-08 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-09-21 | 2023-11-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-21 | 2023-11-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-21 | 2023-11-08 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-09-21 | 2023-11-08 | N |
| Post nurse staffing information every day. | Health | 2023-09-21 | 2023-11-08 | 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 | 2023-09-21 | 2023-11-08 | N |
| Have policies on smoking. | Health | 2023-09-21 | 2023-11-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-09-25 | 2023-11-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-09-25 | 2023-11-08 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-09-25 | 2023-11-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-09-25 | 2023-11-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-05 | 2023-08-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-05 | 2023-08-01 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-05-19 | 2023-06-14 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-19 | 2023-06-14 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-04-25 | 2023-05-30 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-02-10 | 2023-03-07 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-23 | 2023-02-21 | 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 | 2023-01-23 | 2023-02-21 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-11-22 | 2023-01-15 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2022-11-22 | 2023-01-15 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-11-22 | 2023-01-15 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-11-22 | 2023-01-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-22 | 2023-01-15 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-11-22 | 2023-01-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-11-22 | 2023-01-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-11-22 | 2023-01-15 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-11-22 | 2023-01-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-11-22 | 2023-01-15 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-11-18 | 2023-01-09 | 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 | 2022-11-18 | 2023-01-09 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-11-18 | 2023-01-09 | 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 | 2022-11-18 | 2023-01-09 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-11-18 | 2023-01-09 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-11-18 | 2023-01-09 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-11-18 | 2023-01-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-18 | 2023-01-09 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-11-18 | 2023-01-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-18 | 2023-01-09 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-11-18 | 2023-01-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-18 | 2023-01-09 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-11-18 | 2023-01-09 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-11-18 | 2023-01-09 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-11-18 | 2023-01-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-18 | 2023-01-09 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-11-18 | 2023-01-09 | 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 | 2022-11-18 | 2023-01-09 | 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 | 2022-11-18 | 2023-01-09 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-18 | 2023-01-09 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2022-11-18 | 2023-01-09 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-28 | 2022-08-24 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-02-17 | 2022-04-06 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-12-02 | 2022-01-27 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-12-02 | 2022-01-27 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-02 | 2022-01-27 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-02 | 2022-01-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-12-02 | 2022-01-27 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-12-02 | 2022-01-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-02 | 2022-01-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-02 | 2022-01-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-02 | 2022-01-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-02 | 2022-01-27 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-12-02 | 2022-01-27 | 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 | 2021-12-02 | 2022-01-27 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2021-12-02 | 2022-01-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-02 | 2022-01-27 | 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 | 2021-12-27 | 2022-01-27 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-12-27 | 2022-01-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-12-27 | 2022-01-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-27 | 2022-01-27 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-12-27 | 2022-01-27 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-12-27 | 2022-01-27 | N |
