Saunders Nursing And Rehabilitation Center
SAUNDERS NURSING AND REHABILITATION CENTER in WYNNEWOOD, PA — inspection on April 24, 2026.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of written
revealed Licensed nurse reported she heard the resident screaming as she was at the nursing station.
in her wheelchair with one of her feet under the food cart.
During an interview with the Licensed nurse, Employee E4 on April 10, 2026 at 11:03 a.m. the licensed nurse revealed she heard the resident scream, my foot, my foot, and observed the resident sitting in the doorway of her room on the 1st floor with her foot under the food truck the dietary aide was pushing.
Licensed nurse, Employee E4 revealed the resident's toe was eventually found to be fractured and reported that the dietary aide was maneuvering his dietary cart around medication carts, etc. that were in the hallway.
The facility failed to ensure that a meal cart was handle in a safe manner.
This failure resulted in actual harm to Resident R1 when the meal cart rolled over the resident's foot resulting in a fracture of the right distal 3rd metatarsal (bone in toe). On April 7, 20206, the Nursing Home Administrator presented documentation, indicating that the facility initiated a plan of correction on March 25, 2026, to address safe transportation of meals.
Facility plan of correction included the following: The resident involved in the incident was immediately assessed by nursing staff.-Physician and responsible party were notified- 3/25/26-pain assessment and skin assessment were completed - 3/25/26-X-ray ordered and completed revealing a non-displaced fracture of the tip of the right metatarsal- 3/25/26The staff member (Employee E3), Dietary aide was:-Immediately removed from cart handling duties pending review- 3/25/26-Re-educated on safe meal cart handling and resident awareness- 3/26/26-Completed competency validation prior to returning to full duties- 3/26/26Staff Education & Competency-All dietary staff will receive mandatory in-service on safe meal cart handling and resident awareness- Completed 100% on 3/26/26The facility will implement the following monitoring plan:-5 random observations per week for 4 weeks, then monthly x 2 months to be conducted by dietary manager/designee, any observation unsafe practices will result in immediate corrective action.-Findings will be review in QAPI meetings.
Trends will be analyzed and additional interventions implemented as needed.
Review of facility documentation revealed that trainings and audits with the dietary staff on Safe Meal Cart Handling & Resident Safety were conducted.
The training included for dietary staff to maintain clear line of sight at all times; move carts at a slow controlled speed; be aware of resident feet and mobility devices; use caution at corners and in crowded hallways; stop immediately if unsure of surrounds and report hazards or equipment issues immediately. It was determined that the plan of correction was implemented and the deficiency was identified as past non-compliance. 28 Pa.
Code 201.18(b)(3)(e)(1) Management 28 Pa Code 211.10(d) Resident care policies
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.