Pennsylvania Department of Health
SANATOGA CENTER
Building Inspection Results

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SANATOGA CENTER
Inspection Results For:

There are  38 surveys for this facility. Please select a date to view the survey results.

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SANATOGA CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000


Based on an Emergency Preparedness Survey completed on August 20, 2024, at Sanatoga Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.




 Plan of Correction:


Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000


Facility ID #233702
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on August 20, 2024, it was determined that Sanatoga Center was not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a two-story, Type II (111), protected, non-combustible building, with an attic, that is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Building Construction Type and Height:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0161

Based upon observation and interview, it was determined the facility failed to maintain the building construction's fire resistive rating, affecting one of two levels.

Findings include:

Observation on August 20, 2024, revealed missing rated ceiling tiles, on the first floor, in Mechanical Room.

Exit interview with the Administrator and Maintenance Director on August 20, 2024, at 12:30 p.m., confirmed the missing bonnet protection.






 Plan of Correction - To be completed: 10/11/2024

Maintenance director installed missing rated ceiling tiles in the first floor mechanical room on 8/3/2024
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 replaced.
Audit results to be reviewed at the QA Committee to determine the need for further follow up/monitoring.

NFPA 101 STANDARD Emergency Lighting:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0291

Based on document review and interview, it was determined the facility failed to provide battery back up light testing, affecting one of two reports.
Findings include:
Document review on August 20, 2024, between 8:30 a.m. and 12:30 p.m., revealed the facility failed to provide documentation of the reports:
1.Battery back up lighting 90 minute test

Exit interview with the Administrator and Maintenance Director on August 20, 2024, at 12:30 p.m., confirmed the lack of documentation.




 Plan of Correction - To be completed: 10/11/2024

Battery backup lighting 90 minute test scheduled for monthly compliance and will be placed in the life safety binder

Maintenance director/designee will complete an initial audit to ensure the battery back up 90 minute test is completed.

Maintenance director will be reeducated on K0291 in regards to Battery backup lighting 90 minute test by the NHA/Designee.

Monthly audits of the Battery Backup lighting will be completed monthly X 4 to ensure lighting is functioning.

Maintenance Director/ designee will report findings of the audits to the QAPI committee

NFPA 101 STANDARD Cooking Facilities:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324

Based on observation, interview, and document review, it was determined the facility failed to ensure kitchen staff were trained on how to manually activate the kitchen cooktop fire suppression system, affecting one of two floors. Refer to NFPA 101 2012 Edition, Section 19.3.2.5.3(5b). It was determined the facility failed to provide semi annual exhaust hood/duct cleaning report, affecting one of two stories.

Findings include:

1. Observation made on August 20, 2024, at 11:15 a.m., revealed in the kitchen, a staff member did not know where the kitchen fire suppression system manual pull station was located when asked.

2. Document review on August 19, 2024, between 8:30 a.m. and 12:30 p.m., revealed the facility failed to provide documentation of the reports:
a. Kitchen exhaust hood/duct cleaning semi annual reports

Exit interview with the Administrator and Maintenance Director on August 20, 2024, at 12:30 p.m., confirmed kitchen staff personnel did not know the manual pull station location.









 Plan of Correction - To be completed: 10/11/2024

Kitchen exhaust hood/duct cleaned on August 7, 2024 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 location of fire suppression system manual pull station. Maintenance director will also be educated on continued cleaning schedule of the kitchen exhaust hood/duct. Education to be completed by the NHA/Designee.
Monthly audits X 4 to be completed to ensure kitchen exhaust hood/duct is clean.
Maintenance Director/ Designee will report findings of the inspection report to the QAPI meeting.

NFPA 101 STANDARD Alcohol Based Hand Rub Dispenser (ABHR):This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
Alcohol Based Hand Rub Dispenser (ABHR)
ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met:
* Corridor is at least 6 feet wide
* Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols
* Dispensers shall have a minimum of 4-foot horizontal spacing
* Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room
* Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30
* Dispensers are not installed within 1 inch of an ignition source
* Dispensers over carpeted floors are in sprinklered smoke compartments
* ABHR does not exceed 95 percent alcohol
* Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11)
* ABHR is protected against inappropriate access
18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0325

Based on observation and interview, it was determined the facility failed to protect Alcohol Based Hand Rub Dispenser (ABHR), affecting one of two levels.

Findings include:

Observation on August 20, 2024, at 11:25 a.m., revealed an ABHR was installed directly above a light switch and a duplex electrical outlet, in the laundry on the first floor.

Exit interview with the Administrator and Maintenance Director on August 20, 2024, at 12:30 p.m., confirmed the ABHR location.




 Plan of Correction - To be completed: 10/11/2024

The alcohol based hand rub ( ABHR) was removed from above the light switch and duplex electrical outlet in the laundry on the first floor.

Facility wide audit will be conducted to check placement of ABHR systems to ensure they are not located above light switches or electrical outlets.

Maintenance director was reeducated on K0325 with focus on proper and safe placement of ABHR. Education provided by NHA/Designee.

Compliance will be monitored by the Maintenance Director/Designee through random audits monthly x 6 months for location of ABHR

Results of the audit results to be reviewed at the QAA Committee to determine the need for further follow up/monitoring.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on document review and interview, it was determined the facility failed to maintain sprinkler system affecting entire facility.

Findings include:

Document review on August 20, 2024, between 8:30 a.m. and 12:30 p.m., revealed the facility failed to provide documentation of the following tests and inspections:
a. main drain annual test
b. annual control valves including PIV
c. Dry system trip test annual
e. internal valve and pipe 5 year

Exit interview with the Administrator and Maintenance Director on August 20, 2024, at 12:30 p.m., confirmed the lack of documentation.





 Plan of Correction - To be completed: 10/11/2024

Documentation was located for the water sprinkler system test and the water supply test Documents were placed in the life safety binder. A copy was sent to the surveyor.

Maintenance director will ensure sprinkler system is tested quarterly for compliance

3) Maintenance director was in-serviced by the NHA on K0353 with focus on ensuring documentation for sprinkler system testing is kept in life safety binder

NFPA 101 STANDARD HVAC:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0521

Based on document review and interview, it was determined the facility failed to maintain Heating, Ventilating and Air Conditioning (HVAC) equipment, affecting two of two levels.

Findings include:

Document review on August 20, 2024, at 9:00 a.m., revealed the June 30, 2023, fire damper inspection report listed 17 dampers deficient. Evidence of corrective action was not available at time of survey.

Exit interview with the Administrator and Maintenance Director on August 20, 2024, at 12:30 p.m., confirmed the missing documentation.




 Plan of Correction - To be completed: 10/11/2024

Vendor came to the facility on 9/4/2024 to service fire dampers.

An initial audit to be conducted of all fire dampers for valid inspection.

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

NFPA 101 STANDARD Fire Drills:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on document review and interview, it was determined the facility failed to provide quarterly fire drill reports, affecting 4 of 12 drills.
Findings include:

Document review on August 20, 2024, between 8:30 a.m. and 12:30 p.m., revealed the facility failed to provide documentation of the following drills:
1.Second quarter, first shift
2.Second quarter, second shift
3.Third quarter, second shift
4.Third quarter, third shift

Exit interview with the Administrator and Maintenance Director on August 20, 2024, at 12:45 p.m., confirmed the lack of documentation.




 Plan of Correction - To be completed: 10/11/2024

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 through monthly audit x 4 months 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.

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors: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.
Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0761
Based on document review and interview, it was determined the facility failed to provide annual fire door functional/visual test reports, affecting the entire facility.
Findings include:
Document review on August 20, 2024, between 8:30 a.m, revealed the facility failed to provide documentation of the following:
1.Fire door functional/visual annual test
Exit interview with the Administrator and Maintenance Director on August 20, 2024, at 12:30 p.m., confirmed the lack of documentation.


 Plan of Correction - To be completed: 10/11/2024

Annual fire door inspection was completed and placed in the Life Safety Binder)

Maintenance Director/designee will ensure annual fire door inspection is completed and documented by monitoring through the TELS online PM program.
Maintenance Director was reeducated by the NHA/Designee on K0761 with focus on fired door inspections
The Maintenance Director/designee will report the findings of door inspection to the QAPI committee annually.

NFPA 101 STANDARD Electrical Systems - Other:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 6 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0911

Based on observation and interview, it was determined facility failed to maintain protection of electrical wiring, affecting one of two floors.

Findings include:

Observation on August 20, 2024, at 11:20 a.m., revealed a 240v 30a receptacle was missing its protective cover, exposing the inner wiring, in the kitchen, on the first floor.

Exit interview with the Administrator and Maintenance Director on August 20, 2024, at 12:30 p.m., confirmed the exposed wiring.




 Plan of Correction - To be completed: 10/11/2024

Maintenance director replaced the 240V 30a receptacle protective cover

A facility wide audit will be conducted to ensure all receptacles have covers

Maintenance director will be reeducated by the NHA/Designee on K0911 with focus on ensuring all receptacles have protective covers

Monthly audits to be completed x 4 months to ensure receptacles have protective covers.
Results of the audits to be reviewed at the QAA committee monthly to determine the need for further follow up/monitoring

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918

Based on document review and interview, it was determined the facility failed maintain and inspect the emergency generator, affecting the entire facility.

Findings include:

Document Review on August 20, 2024, between 8:30 a.m. and 12:30 p.m., revealed the facility failed to provide documentation of the following tests and inspections:
a. weekly visual inspection
b. weekly battery electrolyte level or voltage
c. monthly battery electrolyte specific gravity or conductance testing
d. monthly 30 minute load
e. monthly operation of transfer switches

Exit interview with the Administrator and Maintenance Director on August 20, 2024, at 12:30 p.m., confirmed the lack of documentation.





 Plan of Correction - To be completed: 10/11/2024

Documentation of generator tests and inspections were located and placed in the life safety binder. A copy was sent to the surveyor. Vendor scheduled for replacement of broken guages on generator for 9/9/2024 to correct readings.

2)Maintenance director was reeducated by NHA/Designee on K0918 with focus on proper method and frequency to test generators with or without load

3) Maintenance director/ designee will monitor the monthly generator log monthly x 4 months to ensure compliance.

4) Results of the audits to be reviewed at the QAA committee to determine the need for further follow up/monitoring.


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