Health inspection·December 2, 2024

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm 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) Residents Affected - Few 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 condition assessment. Residents involved in the medication error would be evaluated for adverse effects and their provider would be notified. Clinical record review revealed that Resident 1 had diagnoses that included diplopia (double vision), bilateral cataract, and diabetes mellitus with complications related to the eyes. A physician's order dated September 26, 2024, directed staff to administer Natural Balance Tears ophthalmic solution into both eyes every six hours as needed. A physician's order dated October 24, 2024, directed staff to administer Debrox Otic solution into both ears on Thursdays and Sundays. Review of facility documentation dated November 27, 2024, revealed that the resident reported that Debrox ear drops were administered into his eyes instead of eye drops. In an interview on December 2, 2024, at 10:58 a.m., Resident 1 stated that on November 26, 2024, he experienced a burning sensation when drops were administered into his eyes and LPN 1 acknowledged that Debrox ear drops were administered into his eyes instead of eye drops. There was a lack of evidence to support that LPN 1 reported the medication error to the DON or designee at the time it was discovered. In an interview on December 2, 2024, at 11:29 a.m., LPN 1 confirmed that on November 26, 2024, Debrox ear drops were incorrectly obtained from the medication cart and administered into Resident 1's eyes and that she recognized the medication error at that time. LPN 1 confirmed that she did not report the medication error to the DON or the resident's provider. In an interview on December 2, 2024, at 2:08 p.m., the DON confirmed that the medication error was not reported at the time it was identified and LPN 1 should have reported the medication error to the resident's provider. (continued on next page) 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 12/02/2024 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)