Pennsylvania Department of Health
SAUNDERS NURSING AND REHABILITATION CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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SAUNDERS NURSING AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: - Component: -- - Tag: 0000
Based on an Emergency Preparedness Survey completed on May 6, 2026, it was determined that Saunders Nursing and Rehabilitation Center was not in compliance with the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(a)(1)-(2), 416.54(a)(1)-(2), 418.113(a)(1)-(2), 441.184(a)(1)-(2), 482.15(a)(1)-(2), 483.475(a)(1)-(2), 483.73(a)(1)-(2), 484.102(a)(1)-(2), 485.542(a)(1)-(2), 485.625(a)(1)-(2), 485.68(a)(1)-(2), 485.727(a)(1)-(2), 485.920(a)(1)-(2), 486.360(a)(1)-(2), 491.12(a)(1)-(2), 494.62(a)(1)-(2) STANDARD Plan Based on All Hazards Risk Assessment:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2)

[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:]

(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.*

(2) Include strategies for addressing emergency events identified by the risk assessment.

* [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.
(2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care.

*[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents.
(2) Include strategies for addressing emergency events identified by the risk assessment.

*[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:

(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients.
(2) Include strategies for addressing emergency events identified by the risk assessment.

Observations:
Name: - Component: -- - Tag: 0006 Based on documentation review and interview, it was determined the facility failed to ensure the Emergency Preparedness Plan was based on and included a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach and include strategies for addressing emergency events identified by the risk assessment. Findings include: 1. Document review on May 6, 2026, at 11:30 a.m., revealed the Facility's Emergency Preparedness Plan did not include a documented community-based risk assessment, utilizing an all-hazards approach and include strategies for addressing emergency events identified by the risk assessment. Exit Interview with the Administrator and Regional Maintenance Director on May 6, 2026, at 3:00 p.m., confirmed the missing community-based HVA.

Plan of Correction - To be completed: 07/05/2026

1. Facility's Emergency Preparedness Plan will include a documented community-based risk assessment, utilize an all-hazards approach and include strategies for addressing emergency events identified by the risk assessment.

2. Facilities NHA has been educated by the Regional RDO on importance of Facility's Emergency Preparedness Plan including a documented community-based risk assessment, utilize an all-hazards approach and include strategies for addressing emergency events identified by the risk assessment.

3. NHA or Designee will review quarterly to ensure EPP has an updated community base HVA

4. Results of the audits will be reviewed/reported to QA committee to determine trends and compliance. QA committee will determine need for continuance of audits

403.748(a)(4), 416.54(a)(4), 418.113(a)(4), 441.184(a)(4), 482.15(a)(4), 483.475(a)(4), 483.73(a)(4), 484.102(a)(4), 485.542(a)(4), 485.625(a)(4), 485.68(a)(4), 485.727(a)(5), 485.920(a)(4), 486.360(a)(4), 491.12(a)(4), 494.62(a)(4) STANDARD Local, State, Tribal Collaboration Process:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

§403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4)

[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:]

(4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. *

* [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency.

Observations:
Name: - Component: -- - Tag: 0009 Based on document review and interview, it was determined the facility failed to develop and maintain an emergency preparedness plan that included a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the facility's efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts, affecting the entire facility. Findings include: 1. Document review on May 6, 2026, at 11:30 a.m., revealed the facility failed to develop and maintain an emergency preparedness communication plan that included a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the facility's efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts. Exit Interview with the Administrator and Regional Maintenance Director on May 6, 2026, at 3:00 p.m., confirmed the documentation was not available.

Plan of Correction - To be completed: 07/05/2026

1. Facility will develop and maintain an emergency preparedness communication plan that included a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the facility's efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts.

2. Facilities NHA has been educated by the Regional RDO on importance of developing and maintaining an emergency preparedness communication plan that included a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the facility's efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts.

3. NHA or designee will review quarterly to ensure EPP communication plans are up to date

4. Results of the audits will be reviewed/reported to QA committee to determine trends and compliance. QA committee will determine need for continuance of audits

403.748(b), 416.54(b), 418.113(b), 441.184(b), 482.15(b), 483.475(b), 483.73(b), 484.102(b), 485.542(b), 485.625(b), 485.68(b), 485.727(b), 485.920(b), 486.360(b), 491.12(b), 494.62(b) STANDARD Development of EP Policies and Procedures:

§403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b).

(b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years.

*[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually.

*Additional Requirements for PACE and ESRD Facilities:

*[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years.

*[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area.

Observations:
Name: - Component: -- - Tag: 0013 Based on documentation review and interview, it was determined the facility failed to ensure emergency preparedness policies and procedures, based on the emergency plan, risk assessment and communication plan, were updated at least annually, affecting the entire component. Findings include: 1. Document review on May 6, 2026, at 11:30 a.m., revealed the facility could not provide an emergency preparedness plan community-based risk assessment which is one of the components required to update the emergency preparedness policies and procedures, and the facility-based risk assessment had not been updated annually. Exit Interview with the Administrator and Regional Maintenance Director on May 6, 2026, at 3:00 p.m., confirmed the missing confirmed the missing community-based HVA and the out-of-date facility-based HVA.

Plan of Correction - To be completed: 07/05/2026

1. Facility will provide an emergency preparedness plan community-based risk assessment which is one of the components required to update the emergency preparedness policies and procedures, and the facility-based risk assessment has been updated annually.

2. Facilities NHA has been in serviced by the Regional RDO to ensure emergency preparedness policies and procedures, based on the emergency plan, risk assessment and communication plan, have been updated and will be updated annually

3. NHA or Designee will review EPP quarterly to ensure policies and procedures are up to date

4. Results of the audits will be reviewed/reported to QA committee to determine trends and compliance. QA committee will determine need for continuance of audits

403.748(b)(7), 418.113(b)(5), 441.184(b)(7), 482.15(b)(7), 483.475(b)(7), 483.73(b)(7), 485.625(b)(7), 485.920(b)(6), 494.62(b)(6) STANDARD Arrangement with Other Facilities:

§403.748(b)(7), §418.113(b)(5), §441.184(b)(7), §460.84(b)(8), §482.15(b)(7), §483.73(b)(7), §483.475(b)(7), §485.625(b)(7), §485.920(b)(6), §494.62(b)(6).

[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:]

*[For Hospices at §418.113(b), PRFTs at §441.184,(b) Hospitals at §482.15(b), and LTC Facilities at §483.73(b):] Policies and procedures. (7) [or (5)] The development of arrangements with other [facilities] [and] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients.

*[For PACE at §460.84(b), ICF/IIDs at §483.475(b), CAHs at §486.625(b), CMHCs at §485.920(b) and ESRD Facilities at §494.62(b):] Policies and procedures. (7) [or (6), (8)] The development of arrangements with other [facilities] [or] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients.

*[For RNHCIs at §403.748(b):] Policies and procedures. (7) The development of arrangements with other RNHCIs and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of non-medical services to RNHCI patients.

Observations:
Name: - Component: -- - Tag: 0025 Based on documentation review and interview, it was determined the facility failed to provide arrangements with other facilities, affecting the entire component. Findings include: 1. Document review on May 6, 2026, at 11:30 a.m., revealed the facility failed to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. Exit Interview with the Administrator and Regional Maintenance Director on May 6, 2026, at 3:00 p.m., confirmed the missing transfer agreements.

Plan of Correction - To be completed: 07/05/2026

1. facility will provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients

2. facility NHA has been in-serviced by the Regional RDO to ensure that arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients is documented and in place.

3. NHA or Designee with review EPP quarterly to ensure arrangements with other facilities to receive patients is in place

4. Results of the audits will be reviewed/reported to QA committee to determine trends and compliance. QA committee will determine need for continuance of audits

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000
Facility ID #190402Component 01Main BuildingBased on a Medicare/Medicaid Recertification Survey completed on May 6, 2026, it was determined that Saunders Nursing and Rehabilitation Center was not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).This is a four-story, Type III (211), protected, ordinary building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Cooking Facilities:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324 Based on document review and interview, it was determined the facility failed to maintain and inspect the kitchen exhaust hood suppression system, affecting one of four levels within the facility. Findings include: 1. Document review on May 6, 2026, at 11:30 a.m., revealed the semi-annual kitchen suppression inspection reports stated the following deficiencies: a. report dated February 10, 2026, one of four containers failed their inspection. b. report dated August 22, 2025, one of three initiating devices failed their inspection. Evidence of corrective action was not available at time of survey. Exit Interview with the Administrator and Regional Maintenance Director on May 6, 2026, at 3:00 p.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 07/05/2026

1. The kitchen suppression inspection deficiencies have been corrected

2. Maintenance director has been educated by the Administrator on importance of kitchen suppression inspection deficiencies being corrected

3. NHA or Designee will review quarterly to ensure kitchen suppression inspection deficiencies have been corrected

4. Results of the audits will be reviewed/reported to QA committee to determine trends and compliance. QA committee will determine need for continuance of audits

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353 Based on document review, observation and interview, it was determined the facility failed to ensure automatic sprinkler system components were maintained, affecting the entire facility. Findings include: 1. Document review on May 6, 2026, at 11:30 a.m. revealed the quarterly sprinkler report dated, February 2, 2026, listed the following deficiencies: a. No hydraulic data plate found onsite. b. Anti-freeze results were not satisfactory. c. Customer must locate blueprints to have hydraulic data plate created. If not, we can send designer out to create one. Evidence of corrective action was not available at time of survey. Exit Interview with the Administrator and Regional Maintenance Director on May 6, 2026, at 3:00 p.m., confirmed lack of documentation. 2. Observation on May 6, 2026, between 1:30 p.m. and 1:50 p.m., revealed the following sprinkler deficiencies: a. 1:30 p.m., missing escutcheon, on the second floor, Physical Therapy Closet. b. 1:50 p.m., broken escutcheon, on the fourth floor, corridor near Social Services Office. Exit Interview with the Administrator and Regional Maintenance Director on May 6, 2026, at 3:00 p.m., confirmed the sprinkler deficiencies.

Plan of Correction - To be completed: 07/05/2026

1. The quarterly sprinkler report dated February 2, 2026, following deficiencies have been corrected.

a. No hydraulic data plate was found onsite.

b. Anti-freeze results were not satisfactory.

c. Customer must locate blueprints to have hydraulic data plate created. If not, we can send designer out to create one.

2. The missing escutcheon, on the second floor, Physical Therapy Closet was replaced.

3. The broken escutcheon, on the fourth floor, corridor near Social Services Office was replaced.

4. Maintenance director has been educated by the Administrator on importance of sprinkler inspection deficiencies being corrected and missing or broken escutcheons are replaced.

5. NHA or Designee will review quarterly to ensure kitchen suppression inspection deficiencies have been corrected and Maintenance director will perform monthly audits to ensure all broken or missing escutcheons are replaced.

6. Results of the audits will be reviewed/reported to QA committee to determine trends and compliance. QA committee will determine need for continuance of audits

NFPA 101 STANDARD Corridor - Doors:

Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0363 Based on observation and interview, it was determined the facility failed to ensure corridor doors were maintained to resist the passage of smoke and positively latch when tested, affecting one of four levels. Findings include: 1. Observation on May 6, 2026, at 1:20 p.m., revealed a door the failed to close and latch when tested, Kitchen Dry Storage Room. Exit Interview with the Administrator and Regional Maintenance Director on May 6, 2026, at 3:00 p.m., confirmed the door failed to close and latch.

Plan of Correction - To be completed: 07/05/2026

1. The door that failed to close and latch in Kitchen Dry Storage Room was made to close and latch

2. Maintenance director has been educated by the Administrator on importance of doors closing and latching

3. Maintenance director will perform quarterly audits to ensure doors properly close and latch.

4. Results of the audits will be reviewed/reported to QA committee to determine trends and compliance. QA committee will determine need for continuance of audits

NFPA 101 STANDARD Electrical Systems - Other:

Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 6 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0911 Based on observation and interview, it was determined the facility failed to maintain protection of electrical wiring, affecting one of four levels. Findings include: 1. Observation made on May 6, 2026, at 1:20 p.m., revealed an electrical panel with a broken latch that prevented the panel door from being opened, Kitchen panel PB-A 208V. Exit Interview with the Administrator and Regional Maintenance Director on May 6, 2026, at 3:00 p.m., confirmed the deficient electrical panel.

Plan of Correction - To be completed: 07/05/2026

1. The electrical panel with a broken latch that prevented the panel door from being opened in the Kitchen panel PB-A 208V was repaired.

2. Maintenance director has been educated by the Administrator on importance of electrical panels being able to open.

3. Maintenance director will perform quarterly audits to ensure electrical panels are able to open.

4. Results of the audits will be reviewed/reported to QA committee to determine trends and compliance. QA committee will determine need for continuance of audits

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