ElderGrade

Inspection citations at Saunders Nursing And Rehabilitation Center

46 citations on record, 3 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2026 5 1
2025 15 1
2024 12 1
2023 14 0
D May 13, 2026 Tag F0839 Complaint investigation

Administration Deficiencies

Employ staff that are licensed, certified, or registered in accordance with state laws.

No actual harm, potential for more than minimal harm

G April 24, 2026 Tag F0689 Complaint investigation

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Actual harm to a resident

D March 11, 2026 Tag F0728 Complaint investigation

Nursing and Physician Services Deficiencies

Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.

No actual harm, potential for more than minimal harm

D February 4, 2026 Tag F0919 Complaint investigation Corrected Feb 2026

Environmental Deficiencies

Make sure that a working call system is available in each resident's bathroom and bathing area.

No actual harm, potential for more than minimal harm

D February 4, 2026 Tag F0627 Complaint investigation Corrected Feb 2026

Resident Rights Deficiencies

Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.

No actual harm, potential for more than minimal harm

D December 18, 2025 Tag F0609 Complaint investigation Corrected Jan 2026

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

No actual harm, potential for more than minimal harm

D December 18, 2025 Tag F0600 Complaint investigation Corrected Jan 2026

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

No actual harm, potential for more than minimal harm

E December 18, 2025 Tag F0804 Complaint investigation Corrected Jan 2026

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

No actual harm, potential for more than minimal harm

D September 17, 2025 Tag F0684 Complaint investigation Corrected Sep 2025

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D June 17, 2025 Tag F0600 Complaint investigation Corrected Jun 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

No actual harm, potential for more than minimal harm

D May 9, 2025 Tag F0919 Complaint investigation Corrected Jun 2025

Environmental Deficiencies

Make sure that a working call system is available in each resident's bathroom and bathing area.

No actual harm, potential for more than minimal harm

D May 9, 2025 Tag F0697 Complaint investigation Corrected Jun 2025

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

No actual harm, potential for more than minimal harm

D May 9, 2025 Tag F0692 Complaint investigation Corrected Jun 2025

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

No actual harm, potential for more than minimal harm

D May 9, 2025 Tag F0686 Complaint investigation Corrected Jun 2025

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

No actual harm, potential for more than minimal harm

D May 9, 2025 Tag F0684 Complaint investigation Corrected Jun 2025

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D May 9, 2025 Tag F0644 Complaint investigation Corrected Jun 2025

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

No actual harm, potential for more than minimal harm

D May 9, 2025 Tag F0610 Complaint investigation Corrected Jun 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

No actual harm, potential for more than minimal harm

D May 9, 2025 Tag F0550 Complaint investigation Corrected Jun 2025

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

No actual harm, potential for more than minimal harm

E May 9, 2025 Tag F0849 Corrected Jun 2025

Administration Deficiencies

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.

No actual harm, potential for more than minimal harm

G May 9, 2025 Tag F0656 Complaint investigation Corrected Jun 2025

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Actual harm to a resident

D December 3, 2024 Tag F0689 Complaint investigation Corrected Feb 2025

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, potential for more than minimal harm

D December 3, 2024 Tag F0656 Complaint investigation Corrected Feb 2025

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

D December 3, 2024 Tag F0565 Complaint investigation Corrected Feb 2025

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

No actual harm, potential for more than minimal harm

E December 3, 2024 Tag F0585 Complaint investigation Corrected Feb 2025

Resident Rights Deficiencies

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.

No actual harm, potential for more than minimal harm

F December 3, 2024 Tag F0804 Complaint investigation Corrected Feb 2025

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

No actual harm, potential for more than minimal harm

D July 19, 2024 Tag F0835 Corrected Aug 2024

Administration Deficiencies

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

No actual harm, potential for more than minimal harm

D July 19, 2024 Tag F0825 Corrected Aug 2024

Quality of Life and Care Deficiencies

Provide or get specialized rehabilitative services as required for a resident.

No actual harm, potential for more than minimal harm

D July 19, 2024 Tag F0656 Corrected Aug 2024

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

D July 19, 2024 Tag F0610 Corrected Aug 2024

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

No actual harm, potential for more than minimal harm

E July 19, 2024 Tag F0684 Corrected Aug 2024

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

J July 19, 2024 Tag F0689 Complaint investigation Corrected Aug 2024

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Immediate jeopardy to resident health or safety

D February 1, 2024 Tag F0755 Complaint investigation Corrected Mar 2024

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

No actual harm, potential for more than minimal harm

D November 8, 2023 Tag F0600 Complaint investigation Corrected Nov 2023

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

No actual harm, potential for more than minimal harm

D November 8, 2023 Tag F0553 Complaint investigation Corrected Nov 2023

Resident Rights Deficiencies

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

No actual harm, potential for more than minimal harm

D November 8, 2023 Tag F0552 Complaint investigation Corrected Nov 2023

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

No actual harm, potential for more than minimal harm

C September 21, 2023 Tag F0732 Corrected Nov 2023

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

No actual harm, minimal potential

D September 21, 2023 Tag F0926 Corrected Nov 2023

Environmental Deficiencies

Have policies on smoking.

No actual harm, potential for more than minimal harm

D September 21, 2023 Tag F0756 Corrected Nov 2023

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

No actual harm, potential for more than minimal harm

D September 21, 2023 Tag F0698 Corrected Nov 2023

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

No actual harm, potential for more than minimal harm

D September 21, 2023 Tag F0695 Corrected Nov 2023

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

No actual harm, potential for more than minimal harm

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.