Sanatoga Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to assess a resident's capability to self-administer medications for two of 24 sampled residents. (Residents 54 and 118) Findings include: Review of the facility policy entitled, Medications: Self-Administration, last reviewed May 15, 2026, revealed that a resident may exercise the right to self-administer medications when determined that this practice was safe. It was the responsibility of the Interdisciplinary Team to determine the following issues with regards to resident self-administration of medications: resident safety to self-administer medications, location of medication administration, determine who would be responsible for storage, and documentation of medication administration. If the resident indicated a desire to self-administer his or her medications, the Interdisciplinary Team would complete the Self-Administration of Medications UDA (User Defined Assessment) to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and staff interview, it was determined that the facility failed to implement physicians' orders for two of 24 sampled residents. (Residents 3, 82) Findings include: Clinical record review revealed that Resident 3 had diagnoses that included chronic heart failure and diabetes. A physician's order dated June 6, 2026, directed staff to administer a blood pressure medication (midodrine hydrochloride) three times a day for orthostatic hypotension. Staff were not to give the medication if Resident 3's systolic blood pressure (the first measurement of blood pressure when the heart beats and the pressure is at its highest) was greater than 120 millimeters of mercury (mm Hg). A physician's order dated June 20, 2026, directed staff to weigh Resident 3 daily and to notify the physician if there was a weight gain greater than five pounds in one week or two pounds in one day. Review of Resident 3's June 2026 Medication Administration Record (MAR) and Task Administration Record revealed that staff administered the midodrine hydrochloride three times when the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment on two of two nursing units. (First and Second floors)Findings include:Observations on July 22, 2025, from 9:30 a.m. through at 2:30 p.m. and July 25, 2025, from 8:00 a.m. through 12:00 p.m. revealed the following:The wall between the door and dresser in room [ROOM NUMBER] was damaged. The wall beside the resident's bed was streaked with dried liquid in room [ROOM NUMBER]-A.room [ROOM NUMBER]-A had scuffed and peeling wallpaper, and a broken handle on the resident's dresser.The wall beside the resident's bed was streaked with dried liquid in room [ROOM NUMBER]-A.The wall beneath the towel rack in the bathroom in room [ROOM NUMBER] was damaged.The wall was damaged at the baseboard at the closet in room [ROOM NUMBER].room [ROOM NUMBER] A and B bedside tables had chipped wood on the tops. The second floor bathing room shower stall on the right side of the room had a thick black substance on the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and staff interview, it was determined that the facility failed to implement physicians' orders for four of 22 sampled residents. (Residents 5, 8, 9, and 10)Findings include: Clinical record review revealed that Resident 5 had diagnoses that included diabetes mellitus and dysphagia (difficulty swallowing.) A physician's order dated July 11, 2025, directed staff to weigh Resident 5 two times per week, on Tuesdays and Fridays, for four weeks. Review of Resident 5's medication administration record (MAR) revealed that staff failed to weigh the resident as ordered on July 11, 18, and 22, 2025.Clinical record review revealed that Resident 8 had diagnoses that included post traumatic seizures, chronic systolic (congestive) heart failure, and diabetes mellitus. A physician's order dated January 31, 2025, directed staff to weigh the resident every Monday, Wednesday, and Friday. Review of Resident 8's MARs revealed that staff failed to weigh the resident as ordered five times in April 2025, once in May 2025, and once in June 2025.Clinical record review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interview, it was determined that the facility failed to ensure that medications with the potential for abuse (controlled substances) were secured in a locked, permanently affixed compartment at all times in one of two medication rooms. (Second Floor medication room) Findings include: Observation on July 25, 2025, at 11:50 a.m., revealed that the Second Floor medication room refrigerator contained four two-milligram vials of a Schedule IV anti-anxiety medication (lorazepam). The vials of medication were in a locked box, but the box was easily removable and not permanently affixed to the refrigerator. The refrigerator was not locked. In an interview on July 25, 2025, at 2:20 p.m., the Director of Nursing stated that the controlled medication storage box should have been permanently affixed to the refrigerator. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, policy review, review of facility documentation, and resident and staff interview, it was determined that the facility failed to ensure that a licensed practical nurse (LPN) maintained professional standards of quality care in following the established policies and procedures of the facility set forth in the Pennsylvania Code Title 49 Professional and Vocational standards for one of five residents sampled for medication administration. (Resident 1) Findings include: Review of Pennsylvania Code Title 49, Chapter 21, Subchapter B. Practical Nurses, revealed guidelines which included that an LPN shall follow the written, established policies and procedures of the facility. Review of the facility policy entitled, Medication Errors, last reviewed, July 1, 2024, revealed that medication errors that occurred at the center would be immediately reported to the Director of Nursing (DON) or designee and would be investigated. The nurse who discovered the medication error would enter the incident into the Risk Management portal and would initiate a change in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview and observation, it was determined that the facility failed to properly store food and maintain sanitary conditions in the dietary department, on one of two unit kitchens (Bistro 1), and on one of two unit pantries (1st Floor). Findings include: In an interview on August 13, 2024, at 9:50 a.m., Dietary Manager (DM) 1 stated that all opened food items were to be labeled with a date. In an interview on August 16, 2024, at 10:35 a.m., the Administrator stated that refrigerated foods were to be discarded after seven days and that foods in the unit pantry were to have the resident's name and date written on them by staff. Observations of the main kitchen on August 13, 2024, at 9:50 a.m., revealed the following: In dry storage, there was a bottle of syrup removed from the original packaging that was not dated. In the walk-in cooler, there was an opened package of lunch meat that was not dated. In the snack reach-in cooler, there was a box of raw pork that was dated August 1, 2024. In the freezer truck, there were three opened garden burgers that were not dated.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for two of 25 sampled residents. (Residents 23, 111) Findings include: Clinical record review revealed that Resident 23 had diagnoses that included hypertension (high blood pressure). A physician's order dated December 25, 2023, directed staff to administer a medication (carvedilol) two times a day for hypertension. Staff were not to administer the medication if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at its highest) was less than 110 millimeters of mercury (mmHg). Review of Resident 23's medication administration records revealed that staff administered the medication four times in July 2024 and three times in August 2024 outside of the ordered parameters. In an interview on August 16, 2024, at 10:30 a.m., the Director of Nursing confirmed the medication should not have been…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to notify the resident's physician and responsible party of changes in condition for one of nine sampled residents. (Resident CL1) Findings include: A review of the facility policy entitled, Notification of Change in Condition, revealed that staff were to notify the physician and resident representative immediately if there was a change in condition. Clinical record review revealed that Resident CL1 was admitted to the facility on [DATE], with diagnoses that included metabolic encephalopathy (brain dysfunction) and repeated falls. On May 28, 2024, a nurse noted a reddened moisture associated skin dermatitis to Resident CL1's sacrum. There was no documented evidence that Resident CL1's physician and resident representative were made aware of the change in condition. In an on June 8, 2024, at 1:41 p.m., the Registered Nurse Supervisor (RN 1) confirmed there was no evidence that Resident CL1's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to follow physician orders for one of six sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and had diagnoses that included hepatorenal syndrome (progressive kidney failure caused by severe liver damage), and cirrhosis of the liver (severe scarring of the liver). Review of Resident 1's hospital discharge instructions dated May 9, 2024, revealed R1 was to receive Rifaximin (an antibiotic used to lower the risk of a decline in brain function in adults with liver failure) two times a day. On May 10, 2024, the physician ordered for Resident 1 to receive Rifaximin two times a day. There was no documented evidence that Resident 1 had received the Rifaximin as ordered by the physician until May 18, 2024, when the medication was brought in by family. In an interview on May 28, 2024 at 1:54 p.m., the Nursing Home Administrator confirmed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and resident interview, it was determined that the facility failed to provide services to enhance each resident's quality of life by offering showers as scheduled to two of five sampled residents. (Residents 2, 3) Findings include: Clinical record review revealed that Resident 2 had diagnoses that included congestive heart failure. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was oriented and required substantial assistance from staff for bathing. The resident was to receive a shower twice per week on Monday and Thursday. During an interview on January 23, 2024, at 1:00 p.m., the resident reported that she preferred to take a shower twice a week and was not offered the opportunity to do so. Resident 1 stated that she would not refuse the opportunity to shower. Review of documentation in the clinical record revealed that the resident was not offered a shower five of seven scheduled times in the past 30 days. Clinical record review revealed that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on resident interview, observation, facility documentation, and staff interview, it was determined that the facility failed to follow the pre-approved menus on two of two nursing units. Findings include: During interviews on November 5, 2023, from 12:30 p.m., through 1:45 p.m., Residents 5, 6, 7, 8, 9, 10, and 11 stated that menu items are frequently substituted without notification or not received. Residents 5, 6, 7, and 8 stated that bacon was on the menu for breakfast that morning and they did not receive it. Review of the facility menus revealed the breakfast meal on November 5, 2023, was to include oatmeal, French toast, bacon, milk and fruit juice. The lunch menu on November 5, 2023, was to include maple sage turkey, seasoned peas, cornbread dressing, pumpkin pie with whipped topping, milk, assorted beverage, and a dinner roll. Observation of Resident 9's lunch meal on November 5, 2023, at 12:45 p.m., revealed that staff served maple sage turkey, collard greens, pumpkin pie without the whipped topping, and cranberry juice. Review of Resident 9's meal ticket at that time…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.