Deficiencies (last 5 years)
Deficiencies (over 5 years)
16.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
257% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
54% occupied
Based on a April 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 41
Capacity: 76
Deficiencies: 0
Apr 2, 2025
Visit Reason
The inspection was conducted as a complaint investigation at Patriot Senior Living on 04/02/2025.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Report Facts
Residents Served: 41
License Capacity: 76
Current Hospice Residents: 3
Residents Age 60 or Older: 40
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 13
Inspection Report
Routine
Deficiencies: 17
Jan 9, 2025
Visit Reason
The inspection was a routine regulatory survey to assess compliance with nursing home regulations, including resident rights, care planning, medication administration, infection control, dietary services, and quality assurance.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity, incomplete advance directive documentation, unsafe and unclean environment, inadequate notification of hospital transfers, inaccurate resident assessments, incomplete care plan revisions, failure to clarify physician orders, medication administration errors, improper pressure ulcer care, inadequate restorative nursing care, improper catheter care, oxygen therapy not administered as ordered, medication accountability issues, food quality concerns, failure to provide adaptive eating utensils, improper food storage and thawing, and ineffective quality assurance processes.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 16
Deficiencies (17)
| Description | Severity |
|---|---|
| Failure to maintain dignity for a resident with an indwelling urinary catheter by not covering the catheter bag and improper positioning. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure residents and/or representatives had opportunity to develop advance directives. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide a homelike environment due to heavily shredded and torn recliner chairs. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide timely notification to residents, representatives, and ombudsman before hospital transfers. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to complete accurate Minimum Data Set assessments for residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to update and revise resident care plans to reflect current care needs. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to clarify physician orders for residents receiving dialysis and other treatments. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide care and treatment according to physician orders, including medication administration and bowel protocols. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate pressure ulcer care and preventive measures as ordered. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide proper care for residents with indwelling urinary catheters, including improper positioning of catheter bag and tubing. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide oxygen therapy as ordered by the physician, including incorrect oxygen flow rate and lack of documentation. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain accountability for controlled medications, including failure to document administration and improper signing out of narcotics. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure food served was palatable, attractive, and at a safe and appetizing temperature. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide adaptive eating equipment as ordered for residents requiring assistance. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to store, prepare, and serve food in accordance with professional standards, including improper thawing of frozen foods and improper ice scoop storage. | Level of Harm - Minimal harm or potential for actual harm |
| Failure of the Quality Assurance Performance Improvement (QAPI) committee to effectively address and correct recurring deficiencies related to assessments, care planning, quality of care, medication accountability, medication storage and labeling, and food service. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to implement an infection prevention and control program consistent with CMS and CDC guidelines, including lack of signage for Enhanced Barrier Precautions for a resident with an indwelling catheter and surgical wound. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 31
Medication administration opportunities: 36
Medication administration errors: 2
Medication administration error rate: 6.25
Residents affected: 1
Residents affected: 2
Residents affected: 3
Residents affected: 2
Residents affected: 2
Residents affected: 5
Residents affected: 2
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Medication vials undated: 1
Expired IV fluid bags: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 1 | Confirmed lack of dignity cover on catheter bag | |
| Director of Nursing | Confirmed multiple deficiencies including dignity cover, hospital transfer notification, inaccurate MDS coding, care plan revisions, oxygen flow rate, medication accountability, infection control signage | |
| Licensed Practical Nurse 2 | Confirmed dialysis access and insulin administration observations | |
| Registered Nurse Assessment Coordinator | RNAC | Confirmed care plan not revised after catheter placement |
| Licensed Practical Nurse 6 | Confirmed undated medication vial and expired IV fluids | |
| Nursing Home Administrator | Confirmed recliner condition, missed wound treatments, medication accountability issues, food service issues, expired supplies | |
| Registered Nurse Supervisor 3 | Confirmed unclear physician orders and oxygen flow rate issues | |
| Certified Clinical Hemodialysis Technician-A | CCHTA | Confirmed Midodrine administration should be at facility |
| Licensed Practical Nurse 7 | Admitted failure to obtain vital signs prior to medication administration | |
| Nurse Aide 9 | Confirmed resident lacked adaptive eating utensils | |
| Food Service Director | Discussed food preparation and taste issues | |
| Cook | Discussed food preparation and taste issues |
Inspection Report
Renewal
Census: 40
Capacity: 76
Deficiencies: 6
Dec 17, 2024
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.
Findings
The inspection found several deficiencies including incomplete criminal background checks for staff, lack of annual fire safety training and fire drills conducted by a fire safety expert, evacuation times exceeding specified limits, and incomplete medical evaluations for a resident. All deficiencies had plans of correction submitted and were determined to be fully implemented.
Deficiencies (6)
| Description |
|---|
| Staff person A hired did not have a completed criminal background check. |
| Staff person A did not receive annual fire safety training by a fire safety expert in training year 2024. |
| Staff person B did not receive annual fire safety training by a fire safety expert in training year 2024. |
| The last safety inspection and fire drill observed by a fire safety expert was conducted on October 4, 2023, which is outside the required annual timeframe. |
| The home does not have a maximum safe evacuation time specified in writing within the past year by a fire safety expert. The home exceeded an evacuation time of 2 minutes 30 seconds during drills on November 13, 2024 and December 11, 2024. |
| Resident #1's medical evaluation did not include the resident's blood pressure, pulse rate or temperature. |
Report Facts
License Capacity: 76
Residents Served: 40
Current Hospice Residents: 5
Residents 60 Years or Older: 38
Residents Diagnosed with Mental Illness: 3
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 9
Residents with Physical Disability: 1
Total Daily Staff: 49
Waking Staff: 37
Inspection Report
Original Licensing
Census: 41
Capacity: 76
Deficiencies: 0
Jul 29, 2024
Visit Reason
The inspection was conducted as part of the licensing process for Patriot Senior Living, a newly licensed personal care home, to ensure compliance with 55 Pa. Code Chapter 2600 regulations.
Findings
The facility was found to be in substantial compliance with applicable regulations, and no regulatory citations or deficiencies were identified during the inspection.
Report Facts
Residents Served: 41
License Capacity: 76
Current Residents: 1
Residents Age 60 or Older: 40
Residents with Mental Illness: 3
Residents with Mobility Need: 8
Residents with Physical Disability: 1
Residents Receiving Supplemental Security Income: 5
Total Daily Staff: 49
Waking Staff: 37
Inspection Report
Census: 41
Capacity: 76
Deficiencies: 0
Mar 14, 2024
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident at the facility on 03/14/2024.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Residents Served: 41
License Capacity: 76
Total Daily Staff: 52
Waking Staff: 39
Residents Age 60 or Older: 40
Residents with Mobility Need: 11
Residents Diagnosed with Mental Illness: 2
Residents Receiving Supplemental Security Income: 5
Residents with Physical Disability: 1
Inspection Report
Routine
Deficiencies: 11
Feb 29, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including accurate resident assessments, care planning, treatment administration, medication management, food safety, and clinical record maintenance.
Findings
The facility was found deficient in completing accurate Minimum Data Set assessments, revising care plans to reflect current needs, following physician's orders for treatments and medications, maintaining accountability for controlled substances, implementing non-pharmacological interventions prior to psychotropic medication use, ensuring medication administration accuracy, proper storage and labeling of medications, food safety and sanitation, and maintaining complete and accurate clinical records. The Quality Assurance Performance Improvement (QAPI) committee was ineffective in correcting recurring deficiencies.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 11
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to complete accurate comprehensive Minimum Data Set assessments for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure baseline care plans included necessary information for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to review and revise care plans to reflect current care needs for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete treatments as ordered by the physician for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain accountability for controlled medications for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure non-pharmacological interventions were attempted prior to administration of anti-anxiety medications for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide medication as ordered by the physician, resulting in significant medication errors for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to store unopened multi-dose insulin pens according to manufacturer's instructions and failed to store controlled refrigerated medications in a separately-locked, permanently-affixed container. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to store food under sanitary conditions, ensure dietary staff wore appropriate hair coverings, and maintain a clean microwave. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain complete and accurate clinical records for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Quality Assurance Performance Improvement (QAPI) committee failed to correct recurring quality deficiencies and ensure effective corrective plans. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 45
Residents reviewed: 37
Dates of medication non-administration: 4
Dates of missing treatment documentation: 5
Medication administration dates: 8
Medication administration dates: 6
Medication doses signed out but not administered: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed multiple deficiencies including inaccurate assessments, incomplete care plans, missed treatments, medication errors, and inaccurate clinical documentation. | |
| Licensed Practical Nurse 1 | Interviewed regarding Resident 30's restraint status. | |
| Licensed Practical Nurse 2 | Assisted with MDS assessment and confirmed inaccuracies for Resident 30. | |
| Social Service Director | Confirmed inaccurate MDS assessment for Resident 72. | |
| Registered Nurse Assessment Coordinator | Confirmed care plan deficiencies for Resident 42. | |
| Licensed Practical Nurse 3 | Confirmed improper storage of unopened insulin pen. | |
| Licensed Practical Nurse 4 | Confirmed controlled medications were not stored in a permanently affixed locked container. | |
| Dietary Manager | Confirmed ice accumulation on food products in walk-in freezer. | |
| Dietary Aide 5 | Observed with uncovered beard while handling food. | |
| Registered Dietitian | Confirmed dietary aide should have had beard covered. | |
| Registered Nurse 6 | Confirmed microwave needed cleaning. |
Inspection Report
Renewal
Census: 43
Capacity: 76
Deficiencies: 9
Jan 10, 2024
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements at THE PATRIOT A CHOICE COMMUNITY.
Findings
The inspection identified multiple deficiencies including missing resident-home contracts, unsigned contracts, lack of signed resident statements acknowledging receipt of rights, incomplete direct care staff training documentation, lint accumulation in dryers, medication documentation errors, and failure to follow prescriber's orders. Plans of correction were accepted and implemented for all deficiencies.
Deficiencies (9)
| Description |
|---|
| Resident #4 lacked a resident-home contract on file. |
| Resident-home contracts for resident #1 and resident #2 lacked signatures by the residents. |
| Resident #4's record did not contain a signed statement acknowledging receipt of resident rights and complaint procedures. |
| Direct care staff person A lacked verification of completing the Department-approved direct care training course before providing unsupervised ADL services. |
| Approximately 1/2 inch accumulation of lint in the lint trap of the home's 3 commercial dryers. |
| Glucometer readings for residents #2 and #3 were not properly documented on the Medication Administration Record (MAR). |
| Prescribed medications for resident #3 were not documented on the MAR as being administered. |
| Resident #2 did not receive a blood sugar measurement as prescribed. |
| Resident #4 was not educated on the right to refuse medication if a medication error is suspected. |
Report Facts
License Capacity: 76
Residents Served: 43
Total Daily Staff: 52
Waking Staff: 39
Residents with Supplemental Security Income: 5
Residents 60 Years or Older: 41
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 9
Residents with Physical Disability: 0
Inspection Report
Complaint Investigation
Deficiencies: 3
Nov 8, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to honor a power of attorney's rights and allegations of physical and mental abuse of residents at the facility.
Findings
The facility failed to honor a power of attorney's right to make informed treatment decisions for one resident and failed to protect residents from physical and mental abuse by staff, resulting in Immediate Jeopardy to resident health and safety. The facility also failed to complete required Nurse Aide Registry verification for one staff member and failed to ensure timely reporting of abuse incidents.
Complaint Details
The complaint investigation revealed substantiated findings of abuse involving Nurse Aide 2 physically and verbally abusing Residents 1 and 2. Nurse Aide 3 witnessed abuse but failed to report it timely. Nurse Aide 5 also delayed reporting witnessed abuse. The facility failed to immediately report the abuse and failed to verify Nurse Aide 2's registry status prior to hire.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Level of Harm - Immediate jeopardy to resident health or safety: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to honor a power of attorney's right to make informed choices and participate in treatment decisions for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to protect residents from physical and mental abuse by staff, resulting in Immediate Jeopardy to resident health and safety. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to complete Nurse Aide Registry verification for one nurse aide upon hire and failed to report physical abuse in a timely manner. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Residents reviewed: 4
Residents affected: 2
Date of survey completed: Nov 8, 2023
Date of Immediate Jeopardy lifted: Nov 8, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide 2 | Nurse Aide | Perpetrator of physical and verbal abuse toward Residents 1 and 2; employment terminated |
| Nurse Aide 3 | Nurse Aide | Witnessed abuse of Resident 1 but failed to report timely; terminated |
| Nurse Aide 5 | Nurse Aide | Witnessed abuse of Resident 2 but delayed reporting; suspended and placed on probation |
| Registered Nurse 4 | Registered Nurse | Received abuse reports from staff and involved in investigation |
| Licensed Practical Nurse 7 | Licensed Practical Nurse | Received report of abuse from Nurse Aide 5 |
| Nursing Home Administrator | Administrator | Confirmed findings and corrective actions; involved in Immediate Jeopardy process |
Inspection Report
Complaint Investigation
Deficiencies: 4
Oct 20, 2023
Visit Reason
The inspection was conducted due to complaints and concerns regarding the facility's failure to develop and implement comprehensive care plans, ensure adequate supervision to prevent residents from giving or receiving food outside of prescribed diets, and to prevent unsafe behaviors such as pushing other residents in wheelchairs without leg rests.
Findings
The facility failed to develop and implement individualized care plans for residents with specific needs, failed to prevent Resident 1 from giving food to other residents on restricted diets, which led to Resident 2 choking to death on food outside his diet. The facility also failed to prevent Resident 1 from pushing other residents in wheelchairs without leg rests. Immediate Jeopardy was identified and later lifted after corrective actions including increased supervision and education were implemented.
Complaint Details
The complaint investigation revealed substantiated findings that the facility failed to prevent Resident 1 from giving food to Resident 2, who was on a restricted diet, leading to Resident 2's accidental choking and death. The facility also failed to prevent Resident 1 from pushing other residents in wheelchairs without leg rests, creating immediate jeopardy to resident safety.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Level of Harm - Immediate jeopardy to resident health or safety: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to develop and implement a comprehensive person-centered care plan for residents with individualized interventions. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure supervision and adequate interventions to prevent residents from giving or receiving food outside of ordered diet restrictions, resulting in Resident 2's accidental choking death. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to ensure supervision and adequate interventions to prevent Resident 1 from assisting other residents in wheelchairs without leg rests. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure of Nursing Home Administrator and Director of Nursing to effectively manage the facility to ensure residents' environment remained free of accident hazards and that residents received food prepared to meet individual needs. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Resident review count: 6
Date of survey completion: Oct 20, 2023
Date Immediate Jeopardy lifted: Oct 20, 2023
Dates of care plan development: Oct 6, 2023
Dates of care plan development: Oct 13, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 1 | Observed and educated Resident 1 about unsafe food sharing | |
| Licensed Practical Nurse 2 | Educated Resident 1 about pushing other residents | |
| Licensed Practical Nurse 3 | Observed Resident 1 pushing residents in wheelchairs | |
| Director of Nursing | Director of Nursing | Observed Resident 1 pushing Resident 4 in wheelchair and confirmed lack of interventions |
| Nurse Aide 5 | Witnessed Resident 2 not breathing and presence of cracker crumbs | |
| Nurse Aide 6 | Witnessed Resident 2 not breathing and presence of cracker crumbs | |
| Registered Nurse 4 | Witnessed Resident 2 not breathing and presence of cracker crumbs | |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed regarding lack of interventions and Resident 1's behavior |
| Speech Language Pathologist | Provided evaluation and diet recommendations for Resident 2 | |
| Dietician | Provided input on mechanical soft diet foods |
Inspection Report
Deficiencies: 2
Mar 22, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, specifically focusing on nutrition and laboratory testing services for residents.
Findings
The facility failed to ensure timely notification and intervention for significant weight loss in one resident and failed to obtain ordered laboratory tests for the same resident. Documentation showed inadequate response to weight loss and meal refusals, and lack of evidence that urine specimens were collected as ordered.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure timely notification and/or intervention for significant weight loss for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to obtain laboratory studies as ordered by the physician for one resident. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Resident weight: 102.5
Resident weight: 101
Resident weight: 89.6
Resident weight: 87.8
Meal intake percentage: 25
Meal intake percentage: 0
Number of meals refused: 8
Date of diagnosis record: Aug 5, 2023
Date of physician order: Jan 25, 2023
Number of shifts with no urinary output: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | Interviewed on March 22 and March 23, 2023 confirming lack of documentation for dietician notification and urine specimen collection |
Inspection Report
Routine
Deficiencies: 18
Mar 2, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey of the nursing home facility to assess compliance with state and federal regulations regarding resident care, safety, and facility operations.
Findings
The facility was found to have multiple deficiencies including failure to maintain resident dignity during dining, failure to act promptly on Resident Council grievances, failure to notify physicians of changes in resident conditions, failure to maintain a clean and homelike environment, incomplete criminal background checks for staff, inaccurate resident assessments, failure to update care plans, failure to clarify physician orders and assess residents after condition changes, failure to follow physician orders for treatment, improper catheter care, incomplete provider progress notes, failure to follow planned menus and notify residents of substitutions, serving food at improper temperatures, unsafe food handling practices, incomplete clinical records, failure to obtain and maintain hospice documentation, and ineffective Quality Assurance Performance Improvement (QAPI) committee oversight.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 17
Deficiencies (18)
| Description | Severity |
|---|---|
| Failed to maintain dignity during dining for Resident 28; food served uncovered and at improper temperatures. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to act promptly on Resident Council grievances regarding lack of evening snacks. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to notify physician regarding condition of Resident 35's tight cast resulting in pressure sore. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide a clean and homelike environment; recliners damaged and resident room walls unclean. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete criminal background checks within 30 days for Licensed Practical Nurse 2 and Nurse Aide 3. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete accurate Minimum Data Set assessments for Residents 4 and 95. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to update care plans to reflect current care needs for Residents 37 and 72. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to clarify physician's orders for Residents 9 and 86 and failed to assess Resident 69 after change in condition. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow physician's orders for weighing Resident 61 and medication administration for Resident 75. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate catheter care and prevent urinary tract infections for Residents 61 and 76. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure provider wrote progress notes at each required visit for Resident 69. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow planned menus and notify residents of food substitutions; served baked white potato instead of sweet potato. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to serve food and drink at safe and appetizing temperatures; food items served lukewarm or warm when they should have been hot or cold. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow food handling policy; staff touched food with bare hands during meal service. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain complete and accurate clinical records for Residents 37 and 78, including lack of nurse assessment and failure to notify family of falls. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to obtain and maintain current hospice documentation including physician recertification and hospice plan of care for Resident 11. | Level of Harm - Minimal harm or potential for actual harm |
| Quality Assurance Performance Improvement (QAPI) committee failed to effectively address recurring deficiencies in multiple areas including notification of changes, environment, assessments, catheter care, and clinical records. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure nurse aides received required 12 hours of annual in-service training for Nurse Aides 7 and 8. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 47
Food substitutions: 8
Resident 69 hip mass size: 15.2
Resident 69 hip mass size: 12.5
Resident 69 hip mass size: 4.3
Resident 61 weight record missing days: 3
Nurse Aide 2 hire date: Mar 30, 2022
Nurse Aide 3 hire date: Oct 31, 2022
Food temperatures: 108.6
Food temperatures: 128
Food temperatures: 116
Breakfast meal temperatures: 45.9
Breakfast meal temperatures: 52
Breakfast meal temperatures: 145
Breakfast meal temperatures: 128.8
Breakfast meal temperatures: 117.9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide 1 | Nurse Aide | Named in finding related to feeding Resident 28 |
| Licensed Practical Nurse 2 | Licensed Practical Nurse | Named in finding related to missing criminal background check |
| Nurse Aide 3 | Nurse Aide | Named in finding related to missing criminal background check |
| Registered Nurse 6 | Registered Nurse | Named in finding related to unsafe food handling practices |
| Director of Nursing | Director of Nursing | Interviewed multiple times confirming findings and deficiencies |
| Dietary Consultant | Dietary Consultant | Interviewed regarding food temperature and serving practices |
| Dietary Manager | Dietary Manager | Interviewed regarding food substitutions and meal temperatures |
| Licensed Practical Nurse 4 | Licensed Practical Nurse | Interviewed regarding catheter tubing touching floor |
| Licensed Practical Nurse 5 | Licensed Practical Nurse | Interviewed regarding catheter size discrepancy |
Inspection Report
Renewal
Census: 33
Capacity: 76
Deficiencies: 14
Oct 12, 2022
Visit Reason
The inspection was conducted as a renewal and complaint investigation visit to assess compliance with licensing requirements and address complaints.
Findings
The inspection identified multiple deficiencies including expired boiler certification, staff qualification issues, missing emergency phone numbers, food contamination risks, incomplete fire drill documentation, medication administration errors, and incomplete resident records. Plans of correction were accepted and fully implemented by December 5, 2022.
Complaint Details
The inspection included a complaint investigation component as indicated by the reason for visit and follow-up on plan of correction submissions.
Deficiencies (14)
| Description |
|---|
| Boiler certificate expired on 6/2/22 and required inspection and re-certification. |
| Direct care staff person lacked a high school diploma, GED, or active nurse aide registry status. |
| No emergency telephone numbers posted by the telephone in the nurse's station across from Room #226. |
| Food on a wheeled cart going to resident rooms was uncovered, risking contamination. |
| No documentation of written notification to the local fire department regarding home address, bedroom locations, and evacuation assistance. |
| Fire drill record for 9/20/22 did not include the minutes and seconds of the drill length. |
| Only 11 of 36 residents evacuated to a designated meeting place during the 9/20/22 fire drill. |
| Medication administration record missing staff initials for clonazepam given on 10/8/22 at 4:00 pm. |
| Resident #1 missed multiple doses of clonazepam on 10/8, 10/9, and 10/10/22 due to medication unavailability. |
| Staff Person B administered medication without completing required medication administration observation and review since May 2021. |
| Staff Person A administered insulin without completing required medication administration and diabetes education courses within required timeframes. |
| Resident #5's assessment did not document ability to self-administer medications. |
| Resident #5's support plan was not signed and lacked notation of refusal or inability to sign. |
| Resident #4's record did not include the official death certificate after death in the home. |
Report Facts
License Capacity: 76
Residents Served: 33
Total Daily Staff: 41
Waking Staff: 31
Residents with Mobility Need: 8
Residents 60 Years or Older: 33
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Physical Disability: 1
Residents Receiving Supplemental Security Income: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person A | Named in findings related to lack of required medication administration and diabetes education. | |
| Staff Person B | Named in findings related to insufficient medication administration observation and review. | |
| Maintenance Director | Responsible for boiler certificate monitoring and maintenance. | |
| Personal Care Home Administrator | Named in multiple findings related to education, audits, and corrective actions. | |
| Licensed Practical Nurse | Involved in audits and education related to emergency phone numbers and resident support plans. | |
| HR Director | Educated on monitoring diploma or GED prior to hire. |
Inspection Report
Routine
Deficiencies: 0
Dec 1, 2021
Visit Reason
The inspection was conducted as a routine licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Notice
Capacity: 76
Deficiencies: 0
Sep 7, 2021
Visit Reason
This document serves as a renewal notice and license issuance for The Patriot, A Choice Community Personal Care Home, confirming receipt of the renewal application and advising of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document; it is an administrative notice confirming license renewal and outlining future inspection requirements.
Report Facts
Maximum licensed capacity: 76
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notice letter. |
Inspection Report
Renewal
Deficiencies: 0
May 4, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
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