Health inspection·August 16, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **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) Residents Affected - Few 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 [DATE], 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. Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395904 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sanatoga Center 225 Evergreen Road Pottstown, PA 19464 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)