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
- 20
- 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
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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