Inspection visit
Inspection
6 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 6 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0610
Respond appropriately to all alleged violations.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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)
Residents Affected - Few
Findings include:
Review of the policy titiled Abuse policy-Prevention and Management dated September, 2023 indicated that
the facility was responsible for prohibiting mistreatment, neglect and abuse of residents, misappropriation of
residents by staff, family friends and visitors. The policy also indicated that the facility was responsible for
implementation of policies and procedures to prevent abuse, neglect and injuries of unknown origin.
The policy indicated that neglect was the failure of the facility to provide goods and services necessary to
avoid physical harm, pain, mental anguish or emotional distress. Neglect occurs when the facility was
aware of or should have been aware of goods or services that a resident requires but the facility fails to
provide to each resident that may result in physical harm, pain, mental anguish or emtional distress.
Neglect includes cases where the facility's disreguard for resident care, comfort or safety resulted or
potentially resulted in physical harm, pain, mental anguish or emotional distress.
The policy also indicated that upon identification of possible abuse or neglect, the facility was responsible
for conducting a complete and thorough investigation into the root cause of the incident. The policy
indicated that the administrator and director of nursing were responsible for interviewing the person
reporting the incident, interview any witnesses to the incident, interview the resident and interview the
resident's roommate.
Review of facility policy Abuse Policy-Prevention and Management. revised in September 2023, ,,,,, The
same policy states possible indicators of physical abuse would include injuries that is suspicious because
the source of the injury is not observed, the extent or location of the injury is unusual. Examples of injuries
that could indicate abuse include injuries that are unexplained, fractures or dislocations
Review of the policy titled Elopement Prevention and Management dated August, 2023 indicated that it was
the facility's responsibility to prevent resident elopements by identifying residents at risk for unsafe exit
seeking behavior. The policy indicated that the facility was responsible for developing and implementing a
care plan to prevent elopement. Elopement was a risk to the resident's health
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 12
Event ID:
395380
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395380
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/19/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Saunders Nursing and Rehabilitation Center
100 Lancaster Avenue
Wynnewood, PA 19096
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0610
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
and safety that places a resident at risk for heat and cold exposure, dehydration, medical complications or
being struck by a motor vehicle.
Review of Resident R120 quarterly MDS dated [DATE], assessed the resident with severe cognitive
impairment, no upper or lower extremity limitations, dependent (required staff to do all the effort and the
resident none) for toilet hygiene showers and baths, was incontinent of bowel and bladder, diagnosed with
Dementia, anxiety, depression, and psychotic disorder.
Review of Resident R120's progress note revealed on December 1, 2023, the resident was found with facial
grimacing, holding onto right shoulder, yelling out in pain, even if the arm was lifted very little. The note
indicated the resident was alert to self with confusion and able to state the arm burned when she lifted it.
An order for an x-ray was obtained dated December 3, 2023, indicating the findings revealed a moderately
deformed fracture of undetermined age neck of right humerus. Recommend clinical correlation
Resident R120 was sent to a orthopedic specialist on December 13, 2023 that further diagnosed Resident
R120 with proximal humerus fractures (can occur in the elderly, fragility fracture).
Further review of Resident R120 clinical records revealed in the past three months, prior to the onset of
shoulder pain on December 1, 2023, noted no indication the resident experienced pain nor pain in her right
shoulder, indicating this was a new experienced pain. Further review of the resident's record revealed no
documented evidence this new onset of shoulder pain was investigated to rule out potential abuse.
Interview with the DON on July 16, 2024, at 11:30 a.m. confirmed the facility did not further investigate
Resident R120's shoulder pain to rule out abuse
and stated, It was an old fracture.
Clinical record review revealed an annual comprehensive assessment MDS (an assessment of care needs)
dated April 18, 2024 for Resident R51. The assessment indicated that this resident had modified
independence with cognition. The assessment indicated that Resident R51 was usually understood and
usually understand, having difficulty with some words to express his needs. This assessment also indicated
that Resident R51 was independent with ambulation walking ten feet.
Clinical record review revealed that Resident R55 had a quarterly comprehensive assessment MDS (an
assessment of care needs) dated June 13, 2024 that indicated this resident was cognitively intact.
Clinical record review for Resident R51 indicated that this resident had eloped from the facility on March 8,
2024. The facility incident report indicated that Resident R51 was found in the rear of the facility in the
parking lot of the facility by an employee of the facility. The facility documented in a report submitted to the
Department that Resident R51 removed an alarm bracelet before exiting the building on March 8, 2024.
There was no documentation to indicate that Resident R51' s rommate Resident R55 was interviewed
related to the circumstantial events surround the elopement that occurred on March 8, 2024. There was no
documentation to indicate that the person reporting the incident of elopement was interviewed and a
witness statement retained. According to the event report submitted to the Department, an
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395380
If continuation sheet
Page 2 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395380
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/19/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Saunders Nursing and Rehabilitation Center
100 Lancaster Avenue
Wynnewood, PA 19096
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0610
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
employee, who is a housekeeper, found Resident R51 in the rear of the facility, in the parking lot of the
facility.
There was no documentation to indicate how and why Resident R51 removed the alarm bracelet from his
person. There was no documentation to indicate how long Resident R51 was outside the building in the
rear parking lot of the facility on March 8, 2024. There was no documentation to indicated what exit route
Resident R51 used to leave the building on March 8, 2024.
Interview with the director of nursing, Employee E2, at 11:00 a.m., on July 17, 2024 confirmed that lack of
complete and thorough investigation of the elopement that occurred for Resident R51 on March 8, 2024.
Review of Resident R 33's Minimum Date Set dated on June 24, 2024, revealed that the resident entered
the facility on June 24, 2024, with diagnosis chronic respiratory failure, chronic pain syndrome, systemic
sclerosis, pathological fracture, subsequent encounter for fracture with routine healing, Raynaud's
syndrome and need for assistance with personal care. Resident R 33 had a BIMs (brief interview for mental
status) score of 15, indicating that resident R33 is cognitively intact.
Clinical record review for Resident R33 indicated that this resident reported to staff member that during the
11-7pm shift on June 24, 2024, she was not changed for a long period of time, had no access to the call
bell and when she was finally changed, the nursing aid waved the used wash rag in her face.
Reviewed the full investigation on July 17, 2024, revealed that not all documentation was collected. missing
statement from a nursing aid.
Interviewed director of nursing, Employee E2 on July 18, 2024, at 11:06 am and she confirmed and
interview and collected the nursing aid's statement.
Review of the facility policy titled Abuse Policy and Prevention and Management last revised September 8,
2022, revealed the intention of the policy is The Facility prohibits the mistreatment, neglect, and abuse of
residents/patients and misappropriation/exploitation of resident/patient property by anyone including staff,
family, friends, visitors, etc. The Facility has designed and implemented processes, which strive to ensure
the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or
misappropriation/exploitation of property. The facility must provide a safe resident environment and protect
residents from abuse.
Continued review of the policy revealed that possible indicators of physical abuse include an injury that is
suspicious because the source of the injury is not observed, the extent or location of the injury is unusual,
or because of the number of injuries either at a single point in time or over time.
Continued review of the policy revealed that Failure of the Facility, its employees, or service providers to
provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress.
Review of Resident R102's Quarterly Minimum Data Set (MDS - federally mandated resident assessment
and care screening) dated October 10, 2023, revealed that the resident entered the facility on January 11,
2023 with diagnosis' including diabetes, and Hyponatremia. Resident R 102 had a BIMs (brief
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395380
If continuation sheet
Page 3 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395380
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/19/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Saunders Nursing and Rehabilitation Center
100 Lancaster Avenue
Wynnewood, PA 19096
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0610
interview for mental status) score of 3, indicating that resident R102 had severe impaired cognition.
Level of Harm - Minimal harm
or potential for actual harm
Continued review of resident R 102's MDS revealed that this resident's functional abilities such as being
able to sit to stand, the ability to come to a standing position from sitting in a chair, wheelchair, or on the
side of the bed required substantial maximal assistance, meaning the helper does more than half the effort.
Resident R 102's ability to transfer from chair to bed was also noted as requiring substantial maximal
assistance.
Residents Affected - Few
Review of resident R102's care plan indicated that this resident requires increased assistance with
functional mobility and ADLs created on January12, 2023, and requires extensive assistance with bed
mobility and transfers dated January 13, 2023. Resident R102 is a total mechanical lift required with two
staff members for transfer which was created on September 3, 2023.
Review of facility reported document on December 31, 2023, resident R102 complained of right ankle pain.
On the day of December 31, 2023 the nurse aid left the resident in her wheelchair in the resident's rooms
while she attended to another resident. When she returned resident R102 was seated on her bed. The
facility interviewed the employee and resident and completed the investigations and ruled out any abuse or
neglect due to the resident having poor safety awareness and indicating that she transferred herself.
Phone interview with employee E56 stated on July 18, 2023 at approximately 12:45p.m., Employee E56
stated that she was aware that resident R102 required a Hoyer lift for all transfers. Employee E56 also
stated that resident was not able to stand or walk on her own, she left her in her wheelchair and when she
returned resident R102 was seated on her bed. Employee believes that someone must have come in and
moved her.
Interview with resident R102's family member stated that she was unable to stand and or walk on her own.
He determined that an employee transferred the resident without use of the required assisted Hoyer lift,
resulting with an injury to resident R 102.
Review of resident progress note, nursing note dated January 1, 2024, revealed that resident R102
complained of right ankle pain and reported that they bent her ankle backward while lifting her to the bed.
Review of resident R 102's progress note, nursing note dated January 1, 2024, revealed that the resident
complained of ankle pain, upon assessment the ankle appears swollen and painful to touch.
Review of the facility documentation / investigation did not include the residents' assessments, or any other
interviews and or determination of source of injury.
Review of Resident R371's Significant Change Minimum Data Set (MDS - federally mandated resident
assessment and care screening) dated January 18, 2024, after resident R 371 returned from hospital and
was readmitted into the facility January 13, 2024, revealed the resident was cognitively impaired with a
BIMS score of 4. Further review of the MDS indicated that resident R371 had impairment in range of motion
to upper extremity on one side. The MDS revealed the resident had diagnoses including Parkinson's
disease, Arthritis, and Malnutrition. Continued review of resident MDS evaluation revealed the MDS section
G0130 A. Eating - how resident eats and drinks, regardless of skill was coded as Substantial, Maximal
assistance -the resident is minimally involved in the activity, the helper does
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395380
If continuation sheet
Page 4 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395380
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/19/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Saunders Nursing and Rehabilitation Center
100 Lancaster Avenue
Wynnewood, PA 19096
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0610
more than half the work.
Level of Harm - Minimal harm
or potential for actual harm
Review of Hot Liquid Safety Evaluation dated February 1, 2024, revealed that resident R371 was
determined to be visually impaired, impaired cognition, altered level of conciseness, weakened upper
extremity strength, tremors, demonstrated difficulty handling eating equipment, has contractures, and
balance issues.
Residents Affected - Few
Review of Physical Therapy Evaluation dated January 15, 2024, resident R371 was refered to PT due to
exasperation of decrease in strength, decrease in functional mobility, decrease in transfers, reduced ability
to ambulate, decreased judgement, increased need for assistance from other and reduced ADLs (activities
of daily living).
Further review of this physical therapy evaluation revealed that resident R371 was identified to.
have Hypotonic(weak) muscle tone, kyphotic posture / gross motor coordination impaired.
Resident is total dependence for mobility and transfers.
Review of facility documentation reported to the Department of Health on February 1, 2024, revealed
Resident R371was dining in the common room and dropped a cup of hot water on his right thigh. Upon
further investigation, it was determined that lLicensed Nurse, employee E10 provided Resident R371with a
cup of hot water from the kitchen lunch truck and prepared hot tea for the resident. It was further identified
that the temperature of the beverage may not have been temped.
Interview with Dietary staff, Employee E50 on July 17, 2024, at 11:35 a.m. revealed coffee maker was not
working that day the heater element was broke he further stated the hot water and coffee dispensed from
the machine was not hot. Employee stated the temps reported in the tempeture log were inaccurate
Review of Resident R371's progress nurses note dated February1, 2024 revealed that the resident
presented with a 7.9 x 7.8 x 0.1 cm area flat fluid filled blister.
Review of facility documentation a written statement dated February 1, 2024, by Licensed nurse Employee
E10 revealed that this nurse gave Mr. [NAME] tea with hot water at lunchtime, I was not aware the water
was so hot. No, I did not heat the water up and no family was present.
Interview with Licensed nurse, Employee E10 on July 17 at 12:40 p.m. revealed that she handed the cup of
hot water to resident R1, she placed it on his lunch try. He picked it up and spilled it. Employee E10
immediately brought resident R 371 to his room, undressed him and applied cool compress.
The above interview was confirmed by unit manager licensed nurse Employee E7.
Review of facility documentation revealed a written statement dated February 1, 2024, by nurse aide,
Employee E55, stated Today at lunchtime Mr. [NAME] stopped me as I was collecting trays, He asked if I
could help him. I answered yes, how can I help? Mr. [NAME] explained that he had dropped his tea and that
he had spilled it on himself. I checked and then contacted the nurse on the floor to explain what Mr. [NAME]
had told me and what I have seen. The nurse verified what she was told and asked me to get a cold
compress and the nurse placed it on his leg and I went back on the floor and provided care and collect the
remaining trays.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395380
If continuation sheet
Page 5 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395380
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/19/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Saunders Nursing and Rehabilitation Center
100 Lancaster Avenue
Wynnewood, PA 19096
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0610
PA Code 201.14(a) Responsibility of license
Level of Harm - Minimal harm
or potential for actual harm
PA Code 201.18(b)(1)(3)(d) Management
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395380
If continuation sheet
Page 6 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395380
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/19/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Saunders Nursing and Rehabilitation Center
100 Lancaster Avenue
Wynnewood, PA 19096
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
Based 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).
Findings include:
Review of the facility's policy titled Care Planning Process and Care Conference revised on July 2023
stated it will develop the comprehensive resident centered plan of care for each resident. Each care plan
need/problem must have a goal and interventions to address the need of the resident.
Review of Resident R57's progress note, from the Certified Registered Nurse Practioner (CRNP) dated
April 15, 2024, revealed the CRNP was alerted that the resident had no bowel movement (BM) in 96 hours.
The resident was assessed and ordered Milk of Magnesia (MOM) given for constipation, and further
instructed if MOM was not effective to offer a suppository.
On May 6, 2024, CRNP seen Resident R57 for no BM for 48 hours and ordered nursing to initiate the bowel
protocol and to give MOM. During that time, a new order was placed for Docusate to be given once a day
for Resident R57's Chronic constipation.
Further review of Resident R57's clinical record revealed the facility failed to develop a plan of care for the
resident's diagnosis of constipation.
An interview on with the Director of Nursing on July 19, 2024 at approximately 1:30 p.m. confirmed that the
facility failed to develop a comprehensive care plan regarding Resident R57's chronic constipation.
28 Pa. Code 211.10(d) Resident care policies
28 Pa. Code 211.12(d)(5) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395380
If continuation sheet
Page 7 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395380
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/19/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Saunders Nursing and Rehabilitation Center
100 Lancaster Avenue
Wynnewood, PA 19096
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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).
Residents Affected - Some
Findings include:
Review of the facility policy for Medication Management for unavailable medication dated April 2024 states,
When medication are not received or are unavailable, the licensed nurse should initiate action in
cooperation with the attending physician and the pharmacy provider.
Review of Resident R57 order summary revealed an admission date of June 23, 2023 diagnosed with
diabetes (a disease in which the body's ability to produce or respond to the hormone insulin is impaired,
resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood).
Review of Resident R57 nursing note dated, May 29, 2024, indicated the resident's blood sugars (BS) were
being monitored due to the resident's insulin not arriving from the pharmacy. The note further stated the
pharmacy will deliver the insulin tomorrow.
Further review of Resident R57's clinical records revealed no documented evidence that the physician was
informed of the missed dose of insulin.
On July 19, 2024, at 10:30 a.m. the Director of nursing confirmed nursing failed to follow facility policy and
failed inform the physician of the missed medication.
Review of Resident R135 clinical record revealed an admission date of February 23, 2023, diagnosed with
diabetes.
Review of Resident R135 physician orders stated if blood sugars (BS) greater than 350 or physician
ordered parameter, repeat the BS monitoring. Contact physician if greater than 350 [if not on sliding scale
coverage] or physician ordered parameter and/or if signs/symptoms noted. Administer medications as
ordered and monitor resident's status. Repeat BS one hour after treatment given and notify physician with
update and any further guidance if needed. If resident's status is unchanged and physician orders resident
to be transferred to the hospital, EMS is as needed contacted; assist with transfer. Provide a full report of
the resident's condition including signs/symptoms, BS levels, most recent insulin or oral hypoglycemic
agent, and time[s] administered.
Review of Resident R135 clinical record revealed on the following days, the resident's blood sugars were
elevated and not within the acceptable parameters:
May 14, 2024, BS 360
March 26, 2024, BS 382
February 14, 2024, BS 354
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395380
If continuation sheet
Page 8 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395380
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/19/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Saunders Nursing and Rehabilitation Center
100 Lancaster Avenue
Wynnewood, PA 19096
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
January 10, 2024, BS 388
Level of Harm - Minimal harm
or potential for actual harm
Further review of Resident R135's clinical record revealed no documented evidence the physician was
notified as ordered.
Residents Affected - Some
On July 19, 2024, at 12:30 p.m. the Director of Nursing confirmed that there was no evidence of nursing
contacting the physician for further instructions.
Resident R149 was admitted to the facility on [DATE], diagnosed with diabetes and Obstructive uropathy (a
urinary tract disorder).
Review of Resident R149's physician orders for hypoglycemia (low bs) instructed if blood sugar, less than
70mg or less than the physician's ordered parameter, as needed for asymptomatic, responsive resident:
give 1 tube of glucose gel, 4oz of juice or 5-6oz soda, check BS in 15min, if greater than 130, give diabetic
medications, if blood sugar is less than 70, repeat oral glucose and check blood sugar in 15 minutes or if no
improvement, call physician. Hyperglycemia instructs if blood sugar is greater than 350 or physician
ordered parameter, repeat the BS monitoring. Contact physician if greater than 350 [if not on sliding scale
coverage] or physician ordered parameter and/or if signs/symptoms noted. Administer medications as
ordered and monitor resident's status. Repeat BS one hour after treatment given and notify physician with
update and any further guidance if needed. If resident's status is unchanged and physician orders resident
to be transferred to the hospital, EMS.
Review of Resident R149's electronic medication administration record (EMAR) revealed a hypoglycemic
episode and the resident's blood sugar was documented at 47 on December 20, 2023. Further review of
Resident R149's, clinical record revealed no documented evidence the hypoglycemic protocol was followed.
Further review of Resident R149's EMAR revealed on 7/15/24 BS was 365, 7/13/24 BS was 364, 6/16/24
BS was 380, 3/30/24, BS was 369, 12/6/23, BS was 467, 11/14/23, BS was 392 and 388, and on 11/9/23,
BS was 393, with no documented evidence the hyperglycemic protocol was followed.
On July 19, 2024, at 1:15 p.m. the Director of Nursing confirmed no documented evidence the
hyper/hypoglycemic protocol was followed for Resident R149.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395380
If continuation sheet
Page 9 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395380
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/19/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Saunders Nursing and Rehabilitation Center
100 Lancaster Avenue
Wynnewood, PA 19096
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0825
Provide or get specialized rehabilitative services as required for a resident.
Level of Harm - Minimal harm
or potential for actual harm
Based 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).
Residents Affected - Few
Findings include:
Resident R47 was admitted to the facility status post aftercare for right-sided neurosurgery for a brain
tumor, diagnosed with seizures, and hemiplegia (one-sided weakness).
Review of Resident R47 quarterly MDS (minimum data set, an assessment of resident's needs) dated May
29, 2024, indicated the resident was alert, oriented able to make her own personal decisions.
Interview with Resident R47 on July 16, 2024, at 11:00 a.m. stated, I really want to walk again. When I went
to PT (Physical Therapy), they would hold on to me and I would walk. I was doing really good but since
therapy ended no one has helped me try to walk again.
Review of Resident R47's plan of care indicated that the resident had an activity of daily living (ADL)
performance deficit due to her one-sided weakness, having impaired balance, limited mobility, and limited
range of motion. Interventions that were initiated on March 30, 2021 revised October 4, 2022, included
Restorative Nursing Program (used to maintain the skills learned in physical therapy to prevent a decline )
for ambulating 200 feet using a quad cane with nursing providing contact guard assistants (type of
assistance where a caregiver places one or two hands on a patient's body to help with balance but does
not help the patient perform the task, only steady the patient's body.
Physician note dated. April 22, 2024, noted Resident R47 was seen and examined in follow-up to her
physical therapy with the physician noting that Resident R47 Does bear weight when attended by someone
assisting with her walking and gait
Review of Resident R47's progress notes, June 5, 2024, care conference indicated rehab reported the
resident was on PT maintenance program.
Further review of Resident R47's clinical record revealed no documented evidence nursing was providing
restorative therapy.
On July 19, 2024, at 12:8 p.m. the Director of Nursing confirmed Resident R47'a should have been on the
restorative program but the facility failed to coordinate such care with therapy.
28 Pa. Code 201.29(j) Resident rights
28 Pa Code 211.10(a) Resident care polices
28 Pa Code 211.12(d)(4)(5) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395380
If continuation sheet
Page 10 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395380
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/19/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Saunders Nursing and Rehabilitation Center
100 Lancaster Avenue
Wynnewood, PA 19096
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0835
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Level of Harm - Minimal harm
or potential for actual harm
Based 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).
Residents Affected - Few
Findings include:
Review of the job description of the Nursing Home Administrator (NHA) revealed that, the primary
responsibility is to establish and maintain systems that are efficient and effective to operate the nursing
home in a manner to safely meet residents needs in accordance with the current federal, state, and local
guidelines and regulations that govern long term care facilities.
The job description of the Director of Nursing (DON) revealed that, the employee is responsible for effective
overall management of the nursing department personnel, policies and procedures and coordination with
other discipline to ensure the efficacy of nursing services. The DON ensures that all nursing interventions
meet the personal, physical, and cognitive needs of each resident.
Resident R371 who had been identified as have a diagnosis of Parkinson's disease with associated
tremors was not adequately assessed and supervised. This resident was provided a hot beverage which
spilled and sustained a serious burn injury.
Review of MDS Review of Resident R371's Significant Change Minimum Data Set (MDS - federally
mandated resident assessment and care screening) dated January 18, 2024, after resident R371 returned
from hospital and was readmitted into the facility January 13, 2024, revealed the resident was cognitively
impaired with a BIMS score of 4. Further review of the MDS indicated that resident R371 had impairment in
range of motion to upper extremity on one side. The MDS revealed the resident had diagnoses including
Parkinson's disease, Arthritis, and Malnutrition. Continued review of resident MDS evaluation revealed the
MDS section G0130 A. Eating - how resident eats and drinks, regardless of skill was coded as Substantial,
Maximal assistance -the resident is minimally involved in the activity, the helper does more than half the
work.
Review of Hot Liquid Safety Evaluation dated February 1, 2024, revealed that resident R371 was
determined to be visually impaired, impaired cognition, altered level of conciseness, weakened upper
extremity strength, tremors, demonstrated difficulty handling eating equipment, has contractures, and
balance issues.
Review of facility documentation reported to the Department of Health on February 1, 2024, revealed
Resident R 371 was dining in the common room and dropped a cup of hot water on his right thigh. Upon
further investigation, it was determined that Licensed Nurse, employee E10 provided Resident R371 with a
cup of hot water from the kitchen lunch truck and prepared hot tea for the resident. It was further identified
that the temperature of the beverage may not have been temped.
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. Continued review of the facility
policy revealed that residents will be evaluated up admission, readmission,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395380
If continuation sheet
Page 11 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395380
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/19/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Saunders Nursing and Rehabilitation Center
100 Lancaster Avenue
Wynnewood, PA 19096
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0835
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
quarterly and change on condition to ensure appropriate precautions will be implemented. If the resident
triggers for any risk factors such as: weakened strength, impaired cognition, contractures of upper
extremities, vision impairment, balance issues and nerve of muscular conditions (termers, cerebral Palsy,
multiple sclerosis, Parkinson disease, cerebrovascular accident, Huntington's disease, and traumatic brain
injury. Further eval should be completed by occupational therapy physical therapy and or speech therapy.
Continued review of the facility policy of hot liquid safety revealed that it is the facility staff responsibility to
implement interventions such as serving temperatures at point of service no greater than 140 degrees
Fahrenheit, serving hot beverages in a cup with a lid, providing protective lap covering, staff supervision or
assistance.
Observation of the fourth floor (dementia unit) common area lunch revealed residents were served hot
coffee and hot tea. Steam from atop of the cup was observed. The dietary director Employee E43 tested the
tempeture of the cart carafe, the temp was reported as 152 degrees Fahrenheit.
Based on the deficiencies identified in the report, the NHA and DON failed to fulfill essential duties and
responsibilities of their position contributing to the immediate Jeopardy situation [refer to 689].
Pa Code 201.14 (a)Responsibility of Licensee
Pa. Code 201.18 (a)Management
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395380
If continuation sheet
Page 12 of 12
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Back to topCitations
6 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F825 - Specialized rehabilitative services
Provide or get specialized rehabilitative services as required for a resident.
F835 - Administration
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
FAQ · About this visit
Common questions about this visit
What happened during the July 19, 2024 survey of SAUNDERS NURSING AND REHABILITATION CENTER?
This was a inspection survey of SAUNDERS NURSING AND REHABILITATION CENTER on July 19, 2024. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SAUNDERS NURSING AND REHABILITATION CENTER on July 19, 2024?
Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Respond appropriately to all alleged violations."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.