Sanatoga Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pottstown, Pennsylvania.
- Location
- 225 Evergreen Road, Pottstown, Pennsylvania 19464
- CMS Provider Number
- 395904
- Inspections on file
- 21
- Latest survey
- July 30, 2025
- Citations (last 12 mo.)
- 33
Citation history
Health deficiencies cited at Sanatoga Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain required documentation for annual and periodic sprinkler system inspections and tests, including the annual sprinkler inspection, main drain test, dry system trip test, and 3-year full-flow trip test. This deficiency was confirmed by the Administrator and Maintenance Director.
The facility did not maintain the emergency generator annunciator panel, which was found to be without power and nonfunctional during testing at the first floor Nurses Station. This deficiency was confirmed by the Administrator and Maintenance Director, impacting the facility's ability to monitor emergency power systems as required.
Surveyors found that the facility did not maintain the required fire resistive rating on one floor, as missing rated ceiling tiles were observed in the second floor IT/Conference Room and confirmed by the Administrator and Maintenance Director.
The facility did not provide documentation for a semi-annual kitchen suppression system inspection and two semi-annual kitchen hood cleanings, as confirmed during interviews with the Administrator and Maintenance Director.
Surveyors found that documentation for required semi-annual fire alarm system testing was not available during review. The Administrator and Maintenance Director confirmed the missing records, resulting in a deficiency related to fire alarm system maintenance requirements.
A deficiency was identified when an unsealed penetration around data wires was observed in a smoke barrier wall on the second floor near the Rehabilitation Department. This issue was confirmed by the Administrator and Maintenance Director and affected one of two floors.
The facility did not maintain its HVAC system as required, as two failed fire dampers were identified in an inspection report and there was no evidence of corrective action taken at the time of the survey. This was confirmed by facility leadership.
The facility did not conduct or document six out of twelve required quarterly fire drills across various shifts, as confirmed by both the Administrator and Maintenance Director during the survey exit interview.
Surveyors identified multiple deficiencies in the protection of electrical wiring, including broken receptacle cover plates, open junction boxes, open wires not ending in a junction box, and unsecured electrical outlets in two smoke compartments. These issues were confirmed by facility leadership and cited as non-compliant with NFPA 70 and NFPA 99 standards.
Surveyors observed multiple environmental deficiencies, including damaged walls, peeling wallpaper, broken furniture, and unclean shower areas, across two nursing units. These issues demonstrated a failure to maintain a safe, clean, and comfortable environment for residents, as required by federal and state regulations.
Staff failed to follow physician orders for four residents, including not completing ordered weights for three residents with conditions such as diabetes, heart failure, and kidney disease, and administering or withholding a blood pressure medication for another resident without proper assessment or outside of prescribed parameters, as confirmed by the DON.
Surveyors found that four vials of lorazepam, a Schedule IV controlled substance, were stored in a locked box inside a medication room refrigerator, but the box was not permanently affixed and the refrigerator was not locked. The DON confirmed that the storage box should have been permanently attached, resulting in a failure to properly secure controlled medications.
Three residents with conditions such as polyneuropathy, Parkinson's disease, and diabetes, who required moderate assistance with personal hygiene, were repeatedly observed with long and dirty fingernails. Despite care plans indicating the need for help with grooming, staff did not provide necessary nail care, and residents reported not being offered assistance. The DON confirmed that nail care should have been provided during bathing and as needed.
A review of nursing schedules revealed that the facility did not meet the required minimum NA-to-resident ratios on several day, evening, and night shifts during a 21-day period. The deficiency was identified through schedule reviews and did not reference specific residents or their medical conditions.
A review of nursing schedules showed that, on multiple days, the facility did not provide the required minimum of 3.2 hours of direct nursing care per resident, with care hours falling below the standard on 13 out of 21 days reviewed.
The facility did not meet the required NA to resident ratios over a 21-day period, failing to maintain adequate staffing levels during day, evening, and night shifts. This included not having enough NAs per residents on several specific days across all shifts.
The facility did not meet the required 3.2 hours of direct nursing care per resident per day on 11 out of 21 days, with care hours ranging from 2.51 to 3.18. This shortfall indicates inadequate staffing levels necessary for resident care.
A resident with a history of eye-related conditions received Debrox ear drops in the eyes instead of the prescribed eye drops, causing a burning sensation. The LPN responsible for the error did not report it to the DON or the resident's provider, violating the facility's medication error policy and professional standards.
The facility failed to properly store food and maintain sanitary conditions in the dietary department, Bistro 1 unit kitchen, and 1st floor unit pantry. Observations revealed undated opened food items, improper food storage, and unsanitary conditions, such as dried food debris and rust. The Dietary Manager and Administrator confirmed the protocols for labeling and discarding food, but these were not followed, leading to multiple deficiencies.
The facility failed to follow physician's orders for two residents. A resident with hypertension received carvedilol outside the prescribed blood pressure parameters multiple times, while another resident with epilepsy did not receive their prescribed phenobarbital on one occasion. The DON confirmed these lapses in medication administration.
A facility failed to notify a resident's physician and representative of a change in condition, as required by policy. A resident with metabolic encephalopathy and repeated falls developed skin dermatitis, but there was no documentation of notification to the physician and representative. This was confirmed by an RN Supervisor.
A resident with hepatorenal syndrome and cirrhosis was not administered Rifaximin as ordered by the physician. Despite discharge instructions and a physician's order to receive the medication twice daily, the resident did not receive it until family intervention. This was confirmed by the Nursing Home Administrator.
Failure to Maintain Sprinkler System Inspection Documentation
Penalty
Summary
Surveyors determined that the facility failed to maintain required documentation for its automatic sprinkler system components. During a document review, it was found that records for the annual sprinkler inspection, annual main drain test, annual dry system trip test, and the 3-year full-flow trip test were missing. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director, who acknowledged the absence of the necessary inspection and testing documentation for the sprinkler system, which affects the entire facility. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
The annual sprinkler inspection was completed by vendor on 7/7/2025. Documents were sent to surveyor and placed in Life Safety binder. Maintenance director/designee in-serviced on tag K 0353 with focus on ensuring inspections are completed timely and kept in Life Safety binder. Maintenance Director/designee will complete weekly sprinkler inspections x 4 weeks, monthly x 2. Findings will be reported to QI committee monthly x 3 months.
Failure to Maintain Emergency Generator Annunciator Panel
Penalty
Summary
The facility failed to maintain the emergency generator system as required by NFPA standards. During an observation on July 30, 2025, at 11:50 a.m., it was found that the annunciator panel, located at the first floor Nurses Station, was not supplied with electricity and did not function when tested. This panel is a critical component for monitoring the status of the emergency generator system. The deficiency was confirmed during an exit interview with the Administrator and Maintenance Director on the same day. The lack of a functioning annunciator panel affected the entire facility, as it compromised the ability to monitor and respond to emergency power needs as outlined in regulatory requirements.
Plan Of Correction
Vendor out on 8/13/25 to replace annunciator panel. Maintenance director was reeducated by NHA/Designee on K0918 with focus on proper maintenance of emergency generator. Maintenance director/designee will monitor the monthly generator log for four months to ensure compliance. Results of the audits to be reviewed at the QAA committee to determine the need for further follow-up/monitoring.
Failure to Maintain Fire Resistive Rating Due to Missing Ceiling Tiles
Penalty
Summary
Surveyors determined that the facility failed to maintain the required fire resistive rating of the building construction, specifically affecting one of two floors. During an observation, missing rated ceiling tiles were identified in the second floor IT/Conference Room. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director, who acknowledged the absence of the required ceiling tiles. No information regarding residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
Maintenance director replaced missing rated ceiling tiles in the first floor mechanical room on 8/18/2025. The Maintenance Director will conduct a facility-wide audit for any missing rated ceiling tiles and replace tiles as indicated. Maintenance director to be reeducated on policy K0161 by the NHA or Designee. Compliance will be monitored by the Maintenance Director/Designee through 5 random audits weekly x 4 for any ceiling tiles that need to be replaced. Audit results to be reviewed at the QA Committee to determine the need for further follow-up/monitoring.
Failure to Maintain Required Kitchen Suppression System Inspections and Cleanings
Penalty
Summary
The facility failed to ensure that the kitchen suppression system was inspected and serviced at the required intervals. During a document review, it was found that there was no documentation available to show that a semi-annual inspection of the kitchen suppression system had been completed. Additionally, records for two required semi-annual kitchen hood cleanings were also missing. These findings were confirmed during an exit interview with the Administrator and Maintenance Director.
Plan Of Correction
Kitchen exhaust hood/duct cleaned on 8/12/2025 by Cintas. Documentation sent to surveyor and placed in life safety binder. Maintenance Director and kitchen staff will be in-serviced on K0324 with focus on the importance of ensuring deficiencies noted on the inspection report are followed up on and corrected, and the location of the fire suppression system manual pull station. Maintenance director will also be educated on the continued cleaning schedule of the kitchen exhaust hood/duct. Education to be completed by the NHA/Designee. Monthly audits, four in total, will be completed to ensure the kitchen exhaust hood/duct is clean. Maintenance Director/Designee will report findings of the inspection report to the QAPI meeting.
Missing Documentation for Fire Alarm System Testing
Penalty
Summary
The facility failed to maintain proper documentation for the fire alarm system's semi-annual testing as required by NFPA 70 and NFPA 72. During a document review, surveyors were unable to locate records demonstrating that the semi-annual fire alarm testing had been completed. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director, who acknowledged the absence of the required documentation. No information regarding residents or their medical conditions was included in the report, and the deficiency pertains solely to the facility's failure to provide evidence of required fire alarm system testing.
Plan Of Correction
The visual inspection of the fire alarm was completed. Maintenance director/designee will monitor fire alarm visual inspections are completed timely with proper documentation by using the TELS PM program. Weekly visual inspection of fire alarms will be conducted for 4 weeks, and then monthly for 2 months. Results are documented and placed in the Life Safety binder. Findings will be reported to the QI committee quarterly.
Unsealed Penetration in Smoke Barrier Wall
Penalty
Summary
The facility failed to maintain smoke barrier walls free of unsealed penetrations, as required by NFPA 101 standards. During an observation on the second floor above the double doors near the Rehabilitation Department, an unsealed penetration was found around data wires. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director. The issue affected one of two floors in the building. No information regarding residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
Unsealed penetration data wires around double doors by Rehabilitation office were sealed with fire stop compound. The maintenance director/designee will perform weekly safety rounds to ensure there are no ceiling penetrations that need to be sealed. Maintenance director/designee will report on the corrective action monthly x 6 months during QAPI.
Failure to Address Failed Fire Dampers in HVAC System
Penalty
Summary
The facility failed to maintain its Heating, Ventilating, and Air Conditioning (HVAC) equipment as required. During a document review, it was found that the April 2025 Fire Damper Inspection Report identified two failed dampers. At the time of the survey, there was no evidence available to show that corrective action had been taken to address these failed dampers. This deficiency was confirmed during the exit interview with the Administrator and Maintenance Director. No information about residents or their medical conditions was included in the report.
Plan Of Correction
Vendor scheduled for damper repair. The Maintenance Director will be reeducated by the NHA/Designee on K0521 with focus on the importance of ensuring fire damper inspections are being completed and checking to ensure building is in compliance. Monthly audits to be completed x 4 to ensure valid fire damper inspection in place. Maintenance director/Designee will report findings of inspection at QAPI meeting.
Failure to Conduct and Document Required Quarterly Fire Drills
Penalty
Summary
The facility failed to ensure that fire drills were conducted quarterly on each shift as required by NFPA 101 standards. Document review revealed that six out of twelve required fire drills were not documented as completed, specifically missing drills for the 1st quarter on the 1st and 2nd shifts, the 2nd quarter on the 2nd shift, the 3rd quarter on the 1st and 2nd shifts, and the 4th quarter on the 3rd shift. During an exit interview, both the Administrator and Maintenance Director confirmed the absence of documentation for these fire drills. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
Maintenance director completed all first, second, and third shift fire drills to be in compliance. Maintenance director reeducated by NHA/Designee on K0712 with focus on completing monthly fire drills, logging drills, and placing in life safety binder as per regulation. Maintenance director/designee to audit monthly x 4 to ensure that fire drills are completed and logged into life safety binder. Results of audits to be reviewed at QAA committee monthly to determine the need for further follow-up/monitoring.
Electrical Wiring Protection Deficiencies Identified
Penalty
Summary
Surveyors observed multiple electrical deficiencies in the facility, specifically related to the protection of electrical wiring in two of six smoke compartments. During a walkthrough, they identified a broken receptacle cover plate in the second floor dining room, several open junction boxes in various locations including above double doors near the first floor elevator room, above ceiling tiles across from the first floor mechanical room, above double doors near room 101, and above the suspended ceiling in the first floor elevator room. Additionally, open wires were found where a PAC unit had been removed in the first floor service hall corridor near the kitchen entrance, and an electrical outlet was not securely mounted to the wall in the first floor corridor across from the mechanical room. These deficiencies were confirmed during an exit interview with the Administrator and Maintenance Director. The findings reference non-compliance with NFPA 70, National Electric Code, and NFPA 99, section 6.3.2.1, which require proper protection and enclosure of electrical wiring and components. No information about residents or their medical conditions was included in the report.
Plan Of Correction
Maintenance director replaced the receptacle protective cover plate to second floor dining room. Open conjunction boxes closed on 8/13/2025 near first floor elevator and across from mechanical room. Exposed wires in PAC unit in back hallway near kitchen placed back inside the unit 8/13/2025. Electrical outlet securely mounted to wall on first floor corridor 8/13/2025.
Environmental Deficiencies Impacting Resident Comfort and Safety
Penalty
Summary
Sanatoga Center was found to be noncompliant with federal and state regulations regarding the provision of a safe, clean, comfortable, and homelike environment for residents. During observations conducted on two nursing units, surveyors identified multiple instances of environmental deficiencies. These included damaged walls in several resident rooms (such as between the door and dresser in one room, beside beds, and beneath towel racks), scuffed and peeling wallpaper, a broken dresser handle, and chipped wood on bedside tables. Additionally, the second floor bathing room shower stall was noted to have a thick black substance on the floor and molding, indicating a lack of proper cleaning and maintenance. The facility also failed to maintain sanitary and orderly conditions, as evidenced by dried liquid streaks on walls in resident rooms and damaged baseboards at closets. These findings demonstrate that the facility did not provide adequate housekeeping and maintenance services necessary to ensure a comfortable and safe environment for residents, as required by 42 CFR Part 483 and Pennsylvania state regulations. No specific information about the medical history or condition of individual residents was provided in the report.
Plan Of Correction
The wall in 114-A and 112-A was wiped down from noted streaks. Room 112 wallpaper was glued back from peeling and handle on dresser was replaced. Room 232 A and B bedside tables were replaced. The second floor shower room floor and right side of the shower stall were scrubbed by ESD. An initial audit will be completed by the Maintenance Director or designee to identify any other noted damaged walls, closets, and baseboards that require repair by the maintenance department. The ESD, maintenance, or designee will re-educate housekeeping and nursing staff to ensure we maintain a sanitary and home-like environment. The NHA or designee will complete 5 resident room audits weekly x 4, monthly x 2 to identify any other noted damaged walls, closets, and baseboards that require repair by the maintenance department. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly. The wall in 114-A and 112-A was wiped down from noted streaks. Room 112 wallpaper was glued back from peeling and handle on dresser was replaced. Room 232 A and B bedside tables were replaced. The second floor shower room floor and right side of the shower stall were scrubbed by ESD. An initial audit will be completed by the Maintenance Director or designee to identify any other noted damaged walls, closets, and baseboards that require repair by the maintenance department. The ESD, maintenance, or designee will re-educate housekeeping and nursing staff to ensure we maintain a sanitary and home-like environment. The NHA or designee will complete 5 resident room audits weekly x 4, monthly x 2 to identify any other noted damaged walls, closets, and baseboards that require repair by the maintenance department. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.
Failure to Implement Physician Orders for Weights and Medication Administration
Penalty
Summary
The facility failed to implement physician orders for four residents, as evidenced by clinical record reviews and staff interviews. For one resident with diabetes mellitus and dysphagia, staff did not complete ordered weights on three specified dates. Another resident with post-traumatic seizures, chronic systolic heart failure, and diabetes mellitus was not weighed as ordered on multiple occasions across three months. A third resident with hypertensive chronic kidney disease and diabetes mellitus was not weighed as ordered on a specified date. Additionally, a resident with congestive heart failure and chronic kidney disease received a medication (metoprolol succinate) outside of the prescribed parameters. The medication was administered twice when the resident's systolic blood pressure was below the ordered threshold, and on two occasions, the medication was either administered or held without documented assessment of blood pressure or heart rate. The Director of Nursing confirmed these failures to follow physician orders during interviews.
Plan Of Correction
Immediate action to correct the alleged deficient practice included notification to MD regarding missed weights on Residents 5, 8, and 9 with weights then taken and documented. The MD was notified of resident 10's BP medication being given outside parameters. An initial audit will be completed by the DON or designee of current residents receiving blood pressure medications with parameters and weight orders to ensure BP medication parameters are followed and weights are taken per MD orders. Licensed nursing staff will be re-educated by DON or Designee on FTag 684 with focus on following physician orders to ensure BP medication parameters are followed and weights are taken per MD orders. The DON/Designee will complete audits of 5 residents for weights and 5 residents on BP medication with parameters to be reviewed that physician order was followed weekly x 8, monthly x 2. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.
Improper Storage of Controlled Substances in Medication Room
Penalty
Summary
Surveyors observed that in the Second Floor medication room, four two-milligram vials of lorazepam, a Schedule IV controlled substance, were stored in a locked box inside the medication room refrigerator. However, the locked box was not permanently affixed to the refrigerator and could be easily removed. Additionally, the refrigerator itself was not locked. During an interview, the Director of Nursing confirmed that the controlled medication storage box should have been permanently affixed to the refrigerator, indicating that the facility failed to ensure proper security measures for controlled substances as required.
Plan Of Correction
The second floor controlled medication box was permanently affixed to the refrigerator. An initial audit was conducted by DON or designee on all other controlled medication storage boxes in the facility. Nursing staff will be in-educated by DON/designee on proper storage and ensuring all controlled medications are secured and locked, in a permanently affixed compartment at all times. The DON/Designee will complete audits weekly x 8, monthly x 2 to ensure controlled medication storage boxes are secured and locked, in a permanently affixed compartment. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.
Failure to Provide Required ADL Grooming Services for Dependent Residents
Penalty
Summary
Three residents who required moderate assistance with activities of daily living, including grooming and personal hygiene, were observed to have long and dirty fingernails on multiple occasions. Each resident had medical conditions such as polyneuropathy, cognitive communication deficits, congestive heart failure, shoulder pain, muscle weakness, Parkinson's disease, and diabetes, which limited their ability to perform personal hygiene tasks independently. Clinical record reviews and care plans confirmed their need for assistance with grooming and bathing. Despite these documented needs, staff did not provide the necessary services to maintain the residents' grooming, as evidenced by repeated observations of untrimmed and dirty fingernails. Interviews with the residents revealed that they preferred their nails short, wanted assistance, and had not been offered help with nail care prior to the survey. The DON confirmed that fingernails should have been trimmed during bathing and as needed, but this was not done for the residents in question.
Plan Of Correction
Resident 7 received assistance with her hair and fingernails. Resident 9 received assistance with nail care. Resident 116 received nail care. An initial audit will be completed by the DON or designee on current residents requiring assistance with ADLs to review they are being provided fingernails care. The nursing staff will be re-educated by the NPE/Designee to ensure that personal hygiene services will be provided to residents that require assistance with activities of daily living with focus on fingernails, hair grooming, and shaving. The DON/Designee will complete audits of 5 residents weekly x 8, monthly x 2 to ensure that personal hygiene services are being provided with the focus on fingernails care. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.
Failure to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required minimum nurse aide (NA) to resident ratios on multiple occasions over a 21-day period. Specifically, the review of nursing schedules from July 2 to July 22, 2025, showed that the day shift did not meet the minimum ratio of one NA per ten residents on five separate days. Additionally, the evening shift did not meet the minimum ratio of one NA per eleven residents on four days, and the night shift failed to meet the minimum ratio of one NA per fifteen residents on three days. These findings are based solely on the review of staffing schedules and do not include information about specific residents or their conditions.
Plan Of Correction
All residents received care in accordance with their plan of care and attending physician orders. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. Facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly x4 weeks then monthly for two months. Results will be taken to the QAPI for review and revision as needed.
Failure to Meet Minimum Nursing Care Hours Requirement
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per 24-hour period. A review of nursing schedules over a 21-day period revealed that on 13 separate days, the total nursing care hours provided fell below the mandated minimum. Specific days were identified where the care hours ranged from 2.78 to 3.18 per resident, all under the required threshold. These findings were based solely on the documented nursing time schedules for the specified period.
Plan Of Correction
All residents received care in accordance with their plan of care and attending physician orders. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. Facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly x4 weeks then monthly for two months. Results will be taken to the QAPI for review and revision as needed.
Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to comply with the required nurse aide (NA) to resident ratios over a 21-day period from February 28 through March 20, 2025. Specifically, the facility did not meet the minimum staffing levels on multiple occasions across different shifts. During the day shift, which runs from 7:00 a.m. to 3:00 p.m., the facility did not maintain the required ratio of one NA per ten residents on March 1, 2, 8, 14, 15, 16, 18, and 20, 2025. Similarly, during the evening shift from 3:00 p.m. to 11:00 p.m., the facility failed to meet the ratio of one NA per eleven residents on February 28, 2025, and March 2, 3, 14, 17, and 20, 2025. Additionally, the night shift, which is from 11:00 p.m. to 7:00 a.m., did not meet the required ratio of one NA per fifteen residents on March 3 and 14, 2025. These deficiencies indicate a consistent shortfall in staffing levels necessary to meet regulatory requirements.
Plan Of Correction
All residents received care in accordance with their plan of care and attending physician order. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly for 4 weeks, then monthly for two months. Results will be taken to the QAPI for review and revision as needed.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day. A review of nursing schedules from February 28 through March 20, 2025, revealed that on 11 out of 21 days, the facility did not meet this requirement. Specific days with deficiencies included February 28, March 1, March 2, March 3, March 6, March 9, March 13, March 14, March 15, March 17, and March 20, with care hours per resident ranging from 2.51 to 3.18, all below the mandated 3.2 hours. This indicates a consistent shortfall in staffing levels necessary to provide adequate care to residents during the specified period.
Plan Of Correction
All residents received care in accordance with their plan of care and attending physician order. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly x4 weeks then monthly for two months. Results will be taken to the QAPI for review and revision as needed.
Failure to Maintain Professional Standards in Medication Administration
Penalty
Summary
The facility failed to ensure that a licensed practical nurse (LPN) maintained professional standards of quality care in accordance with the Pennsylvania Code Title 49 Professional and Vocational standards. This deficiency was identified during a review of clinical records, facility policies, and interviews with residents and staff. Specifically, the LPN did not follow the facility's established policies and procedures regarding medication administration for one of the five residents sampled. The resident involved had a history of diplopia, bilateral cataract, and diabetes mellitus with complications related to the eyes. A physician's order required the administration of Natural Balance Tears ophthalmic solution into both eyes every six hours as needed. On November 26, 2024, the resident reported experiencing a burning sensation in the eyes after receiving medication. It was discovered that Debrox ear drops were mistakenly administered into the resident's eyes instead of the prescribed eye drops. The LPN acknowledged the error but failed to report it to the Director of Nursing (DON) or the resident's provider, as required by the facility's policy on medication errors. The DON confirmed that the medication error was not reported at the time it was identified, which was a breach of the facility's resident care policies and nursing services standards.
Plan Of Correction
Resident 1's attending physician was notified of a medication error. Resident 1 was monitored and treated following physician notification of the medication error. The resident was seen by an eye doctor. Disciplinary action was taken with the nurse due to failure to immediately report the medication error. The DON/designee will review all residents with orders for eye drops and conduct a medication pass observation with all residents receiving eye drops to identify any residents at risk. Education was provided to LPN/RN nursing staff on policy and procedure for medication administration and reporting medication errors. Attending physicians will be notified of each, if any, incorrect medication order. The DON/designee have reviewed policy and procedures for medication administration and notification of medication error with LPN/RN staff. The DON/designee will continue staff education on policy and procedures. The DON/designee will perform two medication pass observations weekly for 4 weeks, and then monthly for 2 months. Any and all negative findings will be corrected at the time of discovery, and disciplinary action will be taken as needed. All findings will be reviewed at QAPI for 6 months.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to properly store food and maintain sanitary conditions in the dietary department, Bistro 1 unit kitchen, and the 1st floor unit pantry. During an interview, the Dietary Manager stated that all opened food items should be labeled with a date, and the Administrator confirmed that refrigerated foods should be discarded after seven days, with foods in the unit pantry labeled with the resident's name and date. However, observations revealed multiple instances of non-compliance with these protocols. In the main kitchen, there were undated opened food items, such as a bottle of syrup, lunch meat, and garden burgers. Additionally, there were issues with food storage, including a box of raw pork dated August 1, 2024, and hamburger buns with ice on them. The can opener piercer in the food preparation area was found with thick dried food debris. In the Bistro 1 unit kitchen, there were multiple areas of dried, sticky food debris on the drawers under the steam table, and undated food items in the refrigerator, such as turkey lunch meat and meat salad. The freezer had dried food particles, and the refrigerator's exterior had dried food debris and rust. In the 1st floor unit pantry, the freezer contained bottles of water without names or dates, and the refrigerator had several unlabeled and expired items, including a salad with a use-by date of August 8, 2024, and chocolate milk with an expiration date of August 9, 2024. RN 1 confirmed that the unit pantry refrigerator was intended for resident food items.
Failure to Implement Physician's Orders for Two Residents
Penalty
Summary
The facility failed to implement physician's orders for two residents, leading to deficiencies in care. Resident 23, diagnosed with hypertension, had a physician's order to receive carvedilol twice daily, with the stipulation that it should not be administered if the systolic blood pressure (SBP) was below 110 mmHg. Despite this, the medication was administered outside of these parameters four times in July 2024 and three times in August 2024. The Director of Nursing confirmed that the medication should not have been given under these conditions. Resident 111, who was admitted with a diagnosis of epilepsy, had a physician's order to receive phenobarbital at bedtime. However, there was no documented evidence that the resident received the medication on July 25, 2024. The Director of Nursing confirmed the omission of the medication administration on that date.
Failure to Notify Physician and Representative of Change in Condition
Penalty
Summary
The facility failed to notify a resident's physician and responsible party of a change in condition, as required by their policy. The policy mandates immediate notification of the physician and resident representative if there is a change in condition. A clinical record review revealed that a resident, admitted with diagnoses including metabolic encephalopathy and repeated falls, developed a reddened moisture-associated skin dermatitis on the sacrum. However, there was no documented evidence that the resident's physician and representative were informed of this change. This was confirmed by a Registered Nurse Supervisor during an interview, who acknowledged the lack of notification documentation.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to follow physician orders for a resident who was admitted with diagnoses including hepatorenal syndrome and cirrhosis of the liver. The resident was discharged from the hospital with instructions to receive Rifaximin, an antibiotic, twice daily to manage their condition. Despite a physician's order on May 10, 2024, to administer Rifaximin twice daily, there was no documented evidence that the resident received the medication until May 18, 2024, when it was provided by the family. This lapse in medication administration was confirmed by the Nursing Home Administrator during an interview on May 28, 2024.
Latest citations in Pennsylvania
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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