Pennsylvania Department of Health
SANATOGA CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

SANATOGA CENTER
Inspection Results For:

There are 131 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


SANATOGA CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey and an Abbreviated survey in response to a complaint, completed August 16, 2024, it was determined that Sanatoga Center, was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey.

Plan of Correction:

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

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

§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Observations:

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. There were two boxes of opened hamburger buns with ice on top of them. In the food preparation area, the can opener piercer had thick dried food debris on it.

In the Bistro 1 unit kitchen, the three drawers under the steam table had multiple areas of dried, sticky food debris on the front and edge. In the refrigerator, there was a package of turkey lunch meat and a pan of meat salad that were not dated. The freezer had dried food particles along the bottom. The outside of the refrigerator had multiple areas of dried food debris and several areas of rust along the door edges.

In an interview on August 13, 2024, at 10:30 a.m., DM1 confirmed the previously mentioned food items should have been dated.

Observation of the 1st floor unit pantry on August 14, 2024, at 1:06 p.m., revealed in the freezer, there were five bottles of water with no name or date on them. In the refrigerator, there was a salad with a use-by date of August 8, 2024, four opened bottles of tea, lemonade, two sports drinks, a bottle of juice, and a cup of ice tea. These items were not labeled with a resident's name or date. There were two cartons of chocolate milk with an expiration date of August 9, 2024. There were two dished containers of strawberries and pasta salad that were not dated. In the refrigerator drawer, there were two containers of a dished food with red sauce that were not labeled with a resident's name or date.

In an interview on August 14, 2024, at 1:10 p.m., Registered Nurse (RN) 1, confirmed the unit pantry refrigerator was to be used for resident food items.

28 Pa. Code 201.14(a) Responsibility of licensee.

28 Pa. Code 201.18(e)(2.1) Management.

Plan of Correction - To be completed: 10/02/2024

Following survey findings on Aug 16, 2024, DM discarded all items opened and outdated following the policy.

A sanitation audit was conducted by the Food Service Director/designee to ensure the dietary department is maintaining a sanitary environment. Any deficient areas identified were cleaned.

An audit of all food storage areas was completed by the Food Service Director/designee to ensure all food items were dated and labeled according to facility policy. Any discrepancies found were corrected.

The Food Service Director or designee will monitor compliance by conducting weekly audits x 4 weeks, monthly x 2 that food items are labeled and dated as per policy and the kitchen and bistro areas are maintained in a sanitary condition.

All dietary employees will be re-inserviced by the Food Service Director/designee on proper cleaning procedures to ensure the kitchen and bistro areas are maintained in sanitary conditions.

DM/Designee to in-service staff on labeling and dating opened containers, food/drinks being placed in refrigerator, and discarding food after seven days.

Tracking and trending of outcomes will be presented by the Food Service Director/designee and reported to the monthly Quality Improvement Committee.

483.25 REQUIREMENT Quality of Care:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:

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 administered when the SBP was less than 110 mmHg per physician's order.

Clinical record review revealed Resident 111 was admitted to the facility on July 24, 2024, with diagnoses that included epilepsy. On July 24, 2024, the physician ordered for the resident to receive phenobarbital (an anticonvulsant medication) 64.8 milligrams at bedtime. There was no documented evidence that Resident 111 received the phenobarbital on July 25, 2024.

In an interview on August 16, 2024, at 10:40 a.m., the Director of Nursing confirmed that Resident 111 did not receive the medication on July 25, 2024.

CFR 483.25 Quality of Care
Previously cited 8/18/23 and 5/28/24

28 Pa. Code 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 10/02/2024

Resident 111 was discharged from the facility at the time of survey. Immediate action to correct the alleged deficient practice included MD notification and clarification obtained for resident #23 blood pressure parameters.

A comprehensive review of current residents on blood pressure medications to be completed to ensure parameters are being followed per MD orders. A comprehensive review of current residents on anticonvulsants medications to be completed to ensure medications are given as ordered weekly x 4, monthly x 2

Licensed nursing staff will be re-in-serviced by DON/ADON/Designee on FTag 684 with focus on physician order and medication order policy. The medication administration record will be reviewed by the clinical team and reviewed daily to ensure compliance.

The daily medication administration record form will be monitored by DON/ADON/Designee to ensure medication administration compliance and any identified areas have been addressed

The DON/ADON/Designee will report findings in QAPI x 6 months

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on a review of nursing time schedules, it was determined that the facility failed to meet the minimum nurse aide (NA) to resident ratios for 11 of 14 days reviewed.

Findings include:

Review of nursing schedules for 14 days from July 5 through 11, and August 9 through 15, 2024, revealed the following:

The facility failed to meet the minimum NA to resident ratio of one NA for ten residents on day shift (7:00 a.m. to 3:00 p.m.) on July 6, 7, 9, and 11, and August 10, 14, and 15, 2024.

The facility failed to meet the minimum NA to resident ratio of one NA for 15 residents on night shift (11:00 p.m. to 7:00 a.m.) on July 8 and 10, and August 11, 13, and 15, 2024.

Plan of Correction - To be completed: 10/02/2024

1. All residents received care in accordance with their plan of care and attending physician orders.

2. 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.

3. 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.

4. 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.

§ 211.12(i)(1) LICENSURE Nursing services.:

(1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.

Observations:

Based on a review of nursing time schedules, it was determined that the facility failed to provide a minimum of 2.87 hours of direct care for each resident for one of seven days reviewed.

Findings include:

Review of nursing schedules for seven days from June 7 through 13, 2024, revealed the following total nursing care hours below minimum requirements:

June 9, 2024: 2.7 care hours per resident.

Plan of Correction - To be completed: 10/02/2024

1. All residents received care in accordance with their plan of care and attending physician orders.

2. 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.

3. All Nursing Staff have been educated on the 7/1/2023 and 7/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted.

4. 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.

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

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