Inspection Reports for Sanatoga Court
227 Evergreen Rd, Pottstown, PA 19464, PA, 19464
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Inspection Report
Follow-Up
Census: 50
Capacity: 85
Deficiencies: 9
Apr 10, 2025
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to review the submitted plan of correction for the facility.
Findings
The facility was found to have multiple deficiencies related to resident treatment, staffing levels, medication storage and administration, and resident rights. The submitted plan of correction was determined to be fully implemented as of the inspection date.
Deficiencies (9)
| Description |
|---|
| Resident was treated without dignity and respect; caregiver was rude and rushed the resident. |
| Insufficient direct care staffing hours provided for residents with mobility needs; required 66 hours but only 61.5-62 hours were provided. |
| Less than 75% of personal care service hours were provided during waking hours; only 70-71% provided. |
| No staff trained to administer medications during overnight shift; insufficient staffing for emergencies. |
| Expired medication blister card found in medication cart. |
| Shift change narcotic counts were not consistently conducted; missing one pill unaccounted for. |
| Medication administration records missing initials of staff who administered medications at specified times. |
| Resident was not educated on the right to refuse medication if a medication error is suspected. |
| Resident-home contract and signed statements were missing required resident signatures. |
Report Facts
Residents served: 50
License capacity: 85
Secured Dementia Care Unit capacity: 10
Secured Dementia Care Unit residents served: 10
Residents with mobility needs: 16
Residents 60 years or older: 49
Residents diagnosed with mental illness: 2
Residents diagnosed with intellectual disability: 1
Residents with physical disability: 3
Total daily staff: 66
Waking staff: 50
Direct care hours required: 66
Direct care hours provided: 61.5
Percentage of direct care hours during waking hours: 70
Inspection Report
Renewal
Census: 64
Capacity: 85
Deficiencies: 23
Nov 15, 2023
Visit Reason
The inspection was conducted as a renewal review of the facility's compliance with applicable regulations and licensing requirements.
Findings
The inspection identified multiple deficiencies including missing influenza posters, issues with resident refunds after death, expired hospice licenses, missing resident rights and telephone number postings, equipment hazards, sanitary condition problems, emergency procedure omissions, fire safety documentation gaps, and medication documentation errors. Plans of correction were accepted and implemented with ongoing monitoring.
Deficiencies (23)
| Description |
|---|
| No influenza poster posted in a conspicuous and public place throughout the home. |
| Failure to submit refunds for residents who passed away in a timely manner. |
| Hospice services provided by a vendor with an expired license. |
| Resident rights poster not posted in a conspicuous and public place in the Memory Care Unit or 2nd floor. |
| Telephone numbers for key agencies not posted in conspicuous places in Memory Care Unit and 2nd floor. |
| Bed enablers without covers in multiple resident rooms. |
| Rugs stained and strong cat odor in resident rooms. |
| Elevators lacked certificate of operation from 3/31/2023 until 11/15/2023. |
| Old broken pallets, black rug, and wet cardboard outside facility dumpsters. |
| No toilet paper accessible in bathroom 138 in Memory Care Unit. |
| Unlabeled and undated leftover food item found in main kitchen freezer. |
| Three dented cans of mandarin oranges found in emergency food storage. |
| Large accumulation of lint in lint trap of main laundry dryer. |
| Emergency procedures did not include contact information for each resident’s designated person. |
| No documentation of written notification to local fire department regarding home address, bedroom locations, and evacuation assistance. |
| Fire drill evacuation time exceeded the maximum safe evacuation time specified by fire safety expert. |
| Smoking area contained wood chairs and table, not meeting fire safety guidelines. |
| Menus for certain weeks not posted in a conspicuous and public place in the home or Memory Care Unit. |
| Glucometer reading for resident 7 was incorrectly documented. |
| Resident 8 participated in support plan development but did not sign the plan. |
| No notation of resident 8's refusal or inability to sign the support plan. |
| No objection statements documented for residents admitted to Secure Dementia Care Unit. |
| Directions for operating key-locking devices not conspicuously posted near Secure Dementia Care Unit exits. |
Report Facts
License Capacity: 85
Residents Served: 64
Memory Care Unit Capacity: 15
Memory Care Unit Residents Served: 14
Current Hospice Residents: 6
Residents Age 60 or Older: 62
Residents with Mobility Need: 20
Residents with Physical Disability: 3
Staff Total Daily: 84
Staff Waking: 63
Deficient Resident Refunds: 2
Dented Cans: 3
Evacuation Time: 563
Maximum Safe Evacuation Time: 435
Inspection Report
Complaint Investigation
Census: 67
Capacity: 85
Deficiencies: 0
Mar 22, 2023
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 03/22/2023.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies were found and the follow-up type was noted as not required.
Report Facts
Total Daily Staff: 80
Waking Staff: 60
License Capacity: 85
Residents Served: 67
Secured Dementia Care Unit Capacity: 28
Secured Dementia Care Unit Residents Served: 13
Hospice Current Residents: 3
Residents Age 60 or Older: 63
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 13
Residents with Physical Disability: 1
Inspection Report
Census: 67
Capacity: 85
Deficiencies: 0
Oct 6, 2022
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 85
Residents Served: 67
Secured Dementia Care Unit Capacity: 28
Secured Dementia Care Unit Residents Served: 13
Hospice Residents: 4
Residents Age 60 or Older: 64
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 13
Inspection Report
Renewal
Census: 69
Capacity: 85
Deficiencies: 9
Jun 27, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.
Findings
The inspection identified multiple deficiencies including failure to post current license documents, missing emergency telephone numbers, unlabeled and outdated food items, failure to evacuate residents to a designated meeting place during a fire drill, unsecured medications in resident rooms, incorrect medication labeling, illegible record entries, and lack of thermometer in the freezer. Plans of correction were accepted or directed with education and audits planned.
Deficiencies (9)
| Description |
|---|
| The home's current license inspection summary and related documents were not posted in a conspicuous and public place. |
| No emergency telephone numbers including nearest hospital and fire department were posted by telephones in hallway Gen 2 and resident room 109. |
| Unlabeled and undated cup of juice found in the homestead ridge refrigerator. |
| Outdated food items including turkey dated 6/4/22-6/27/22 and dinner rolls expired 6/20/22 found in refrigerator. |
| During fire drill on 1/15/22, residents did not evacuate to a designated meeting place away from the building or within the fire-safe area. |
| Resident #2 self-administers medications but does not lock medications or room door when leaving the room. |
| Medication label for Resident #1 incorrectly states dosage as 'give 2 tablets by mouth every day' instead of twice a day. |
| Correction fluid was used on resident #3's documentation (DME), making entries illegible. |
| No thermometer was present in the freezer in the Carrington kitchen. |
Report Facts
License Capacity: 85
Residents Served: 69
Staffing Hours: 83
Waking Staff: 62
Secured Dementia Care Unit Capacity: 28
Secured Dementia Care Unit Residents Served: 14
Hospice Residents: 7
Residents 60 Years or Older: 67
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 14
Inspection Report
Renewal
Census: 59
Capacity: 72
Deficiencies: 13
Jul 12, 2021
Visit Reason
The inspection was a renewal inspection conducted on 07/12/2021 and 07/13/2021 to review the facility's compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including delays in resident refund processing, incomplete criminal background checks, inadequate staff orientation on fire safety and resident rights, unsecured poisonous materials, ventilation issues in a bathroom, lack of operable bedside lighting, stained bathroom surfaces, improper food storage, incorrect refrigerator/freezer temperatures, obstructed egress routes, medication administration record errors, and delayed admission support plans. Plans of correction were accepted and are in progress or implemented.
Deficiencies (13)
| Description |
|---|
| Resident 1 was discharged but the home did not send the refund check within the required 30 days. |
| Criminal background check for staff person A was not documented on the PA State Police Request for Criminal Record Check form or via the e-patch system. |
| Staff person B did not receive orientation on fire safety topics including evacuation procedures, fire drills, designated meeting place, smoking safety, fire extinguisher use, smoke detectors, fire alarms, and emergency notification. |
| Staff person B did not complete training within 40 scheduled hours on resident rights, emergency medical plan, mandatory abuse reporting, and reporting of incidents. |
| Poisonous material (toothpaste) was unlocked and accessible to resident 2 who was not assessed capable of safely using poisons. |
| Bathroom in resident room 130 lacked operable window or ventilation fan; ventilation fan was inoperable. |
| Resident 3 did not have access to a source of light that can be turned on/off at bedside. |
| Shower floor in bedroom 130 had a yellow stain from coating; ceiling had a brown water stain. |
| Boxes of water and juice were stored on the floor in basement storage. |
| Freezer temperature was 14°F, above the required 0°F for frozen food. |
| Two decorative plants blocked the 2nd floor exit from the home. |
| Medication administration record for resident 5's glucometer check was not signed by the staff person who performed the check. |
| Resident 4's initial support plan was completed late after admission to the Secure Dementia Care Unit. |
Report Facts
License Capacity: 72
Residents Served: 59
Memory Care Capacity: 14
Memory Care Residents Served: 13
Hospice Residents: 8
Residents Age 60 or Older: 57
Residents with Mental Illness: 2
Residents with Mobility Need: 14
Residents with Physical Disability: 1
Total Daily Staff: 73
Waking Staff: 55
Notice
Capacity: 85
Deficiencies: 0
Jun 15, 2021
Visit Reason
The document serves as a license renewal approval for the Personal Care Home 'Sanatoga Court' following receipt of the renewal application dated March 4, 2021, and advises that an onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document; it confirms issuance of a regular license and notifies the facility of the upcoming annual inspection requirement.
Report Facts
Maximum licensed capacity: 85
Secure Dementia Care Unit capacity: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal approval letter |
Inspection Report
Follow-Up
Census: 60
Capacity: 85
Deficiencies: 2
May 12, 2021
Visit Reason
The inspection was a follow-up visit to verify the implementation of a previously submitted plan of correction related to an incident involving an allegation of abuse by a staff person.
Findings
The submitted plan of correction was determined to be fully implemented. The facility demonstrated compliance with requirements to suspend the staff person involved in the alleged abuse and to submit a plan of supervision to the Department.
Complaint Details
The visit was related to an incident where resident #1 alleged that staff person A assaulted them on 05/07/2021. The facility initially failed to suspend the staff person or submit a plan of supervision but subsequently implemented corrective actions.
Deficiencies (2)
| Description |
|---|
| Failure to immediately suspend staff person A or develop and implement a plan of supervision approved by the Department following an allegation of abuse by resident #1. |
| Failure to immediately submit to the Department’s regional office a plan of supervision or notice of suspension of the affected staff person. |
Report Facts
License Capacity: 85
Residents Served: 60
Secured Dementia Care Unit Capacity: 14
Residents Served in Secured Dementia Care Unit: 13
Residents Age 60 or Older: 57
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 17
Residents with Physical Disability: 1
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