Pennsylvania Department of Health
 PATRIOT VILLAGE
Patient Care Inspection Results

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PATRIOT VILLAGE
Inspection Results For:

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PATRIOT VILLAGE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Based on a complaint survey completed on July 10, 2026, it was determined that Patriot Village was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
§483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
Observations:


Based on review of the Pennsylvania Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice, by failing to follow physician's orders to hold blood thinner and anticoagulant medications prior to a scheduled surgical procedure resulting in delayed surgery for one of seven residents reviewed (Resident 7).

Findings include:

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals.

A quarterly Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 7, dated June 4, 2026, indicated that the resident was cognitively intact, required set up assistance to supervision with most care needs, received an anticoagulant (medication that thins the blood) and antiplatelet (medication that prevents blood clots) medication and had a diagnosis of breast cancer.

Physician's orders for Resident 7, dated December 14, 2023, included orders for the resident to receive 5 milligrams (mg) of Eliquis (an anticoagulant medication) twice daily .

Physician's orders for Resident 7, dated May 2, 2025, included orders for the resident to receive 75 mg of Plavix (an antiplatelet medication) daily.

A surgical consult note for Resident 7, dated June 10, 2026, revealed that the resident was scheduled for a partial mastectomy (removes only the cancerous tumor and a surrounding margin of healthy tissue) on July 10, 2026.

A physician's note for Resident 7, dated June 11, 2026, revealed that the resident was seen by the physician for follow-up and pre-operative medical evaluation for a planned right breast surgical intervention in the setting of recently diagnosed invasive breast carcinoma (cancer). She was medically cleared to proceed with planned surgical intervention from a medical standpoint with orders to hold the resident's Eliquis and Plavix five days prior to the procedure.

A nursing note for Resident 7, dated July 8, 2026, at 6:30 p.m. a nurse practitioner called from cardiology called to confirm the resident was cleared for surgery on Friday. The nurse practitioner verified that he would be sending the surgical center the information as well with the clearance.

A nursing note for Resident 7, dated July 9, 2026, at 10:27 a.m. revealed that the resident was scheduled for breast surgery on July 14, 2026, and new orders were received to hold the resident's Plavix and Eliquis starting today.

Interview with Resident 7 on July 9, 2026, at 11:42 a.m. revealed that the resident was scheduled for surgery tomorrow for a lumpectomy for breast cancer. She indicated that she had waited six months for this appointment and it was canceled because they did not hold her Eliquis and Plavix. She indicated that the nurse gave her Eliquis this morning and she told the nurse she was not supposed to get the medication, and it was to be held due to her surgery that was scheduled on Friday, July 10, 2026. The nurse told her it was not listed on the Medication Administration Record (MAR) to hold the medications. She stated that now her surgery was rescheduled for next Tuesday, July 14, 2026. The resident stated , "I just want the cancer out of me and now I have to wait longer."

Interview with Licensed Practical Nurse 1 on July 9, 2026, at 12:34 p.m. confirmed that there were orders in her chart now to hold her Eliquis and Plavix and she held it this morning. She stated that the resident's surgery was changed, and she does not know why.

Review of the Resident 7's MAR for July 2026, revealed that the resident received her Eliquis and Plavix from July 1 through July 8, 2026. There was no documented evidence that the orders were transcribed to hold the resident's Eliquis and Plavix for the five days prior to the scheduled surgery on July 10, 2026.

Interview with the Director of Nursing on July 9, 2026, at 2:52 p.m. confirmed that Resident 7's Eliquis and Plavix should have been held five days prior to her scheduled surgery on July 10, 2026, as ordered by the physician on June 11, 2026, and they were not. She confirmed that the surgery had to be rescheduled due to the medications not being held.

28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.






 Plan of Correction - To be completed: 08/06/2026

1. R7 surgery completed 7/14/26.
2. Residents' surgical appointments reviewed to determine other residents at risk related to anticoagulant use and surgical procedure.
3.Education provided to Nurse Practitioner, Scheduler and Licensed Nursing staff regarding surgical procedures including orders to hold anticoagulants.
4. Surgical consults to be reviewed in morning meetings to identify upcoming procedures which require the holding of an anticoagulant.
5.Director of Nursing or designee to monitor three times per week for 1 month then weekly for 3 months to ensure orders are followed through. Results to be reviewed with the Quality Assurance and Improvement committee.

§ 201.14(d) LICENSURE Responsibility of licensee.:State only Deficiency.
[Reserved]
Observations:

Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to notify the Department of Health of an incident that had the potential for serious harm to a resident for one of 7 residents reviewed (Resident 1).

Findings include:

A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated July 7, 2026, revealed that the resident was cognitively impaired, was understood sometimes and could sometimes understand others, was dependent on staff for daily care, and used both a walker and a wheelchair.

A nursing note for Resident 1, dated May 25, 2026, at 8:10 a.m., revealed that the resident had an unwitnessed fall and neuro checks (a rapid, focused assessment used to evaluate brain function) were started.

A nursing note for Resident 1, dated May 26, 2026, at 10:40 a.m. revealed that there was a change in her mental status during her neuro check and new orders were received to send the resident to the Emergency Department for evaluation.

A nursing note for Resident 1, dated May 26, 2026, at 2:20 p.m. revealed that the resident had a brain bleed and was being transferred to a hospital in Pittsburgh.

There was no documented evidence to indicate that this incident was reported to the Department of Health.

Interview with the Director of Nursing on July 9, 2026, at 1:15 p.m. confirmed that this incident was not reported to the Department of Health and should have been.







 Plan of Correction - To be completed: 08/06/2026

1.R1 incident to be reported to the Department of Health via the Electronic Reporting System.
2.30 days of Incidents were reviewed to potentially identify similar concerns.
3.Chief Nursing Officer to educate Nursing Home Administrator, Director of Nursing and Assistant Director of Nursing regarding the requirements of reportable information to the Department of Health.
4.Nursing Home Administrator or designee to monitor incidents weekly for 3 months to ensure notifications are being reported.
5. A report of findings will be submitted to the Quality Assessment and Performance Improvement committee.

§ 211.12(f.1)(3) LICENSURE Nursing services. :State only Deficiency.
(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on review of nursing schedules, review of staffing information furnished by the facility, and staff interviews, it was determined that the facility failed to ensure a minimum of one nurse aide per 10 residents on the day shift for fourteen of 21 days, and failed to ensure a minimum of one nurse aide per 11 residents on the evening shift for twelve of 21 days, and failed to ensure a minimum one nurse aide per 15 residents on the night shift for twenty-one of 21 days reviewed for June 18, 2026 July 8, 2026.

Findings include:

On June 18, 2026, the facility census was 81 for day shift, which required 8.10 nurse aides to provide care. Review of the nursing time schedules revealed 7.94 nurse aides provided care on the day shift. The facility census was 82 for night shift, which required 5.47 nurse aides to provide care. Review of the nursing time schedules revealed 3.10 nurse aides provided care on evening shift.
On June 19, 2026, the facility census was 83 for evening shift, which required 7.55 nurse aides to provide care. Review of the nursing time schedules revealed that 7.46 nurse aides provided care for the evening shift. The facility census was 83 for the night shift which required 5.53 nurse aides to provide care. Review of the nursing time schedules revealed that 4.01 nurse aides provided care during the night shift.
On June 20, 2026, the facility census was 81 for the day shift, which required 8.10 nurse aides to provide care. Review of the nursing time schedules revealed that 6.67 nurse aides provided care during the day shift. The facility census was 81 for the evening shift which required 7.36 nurse aides to provide care. Review of the nursing time schedules revealed that 6.97 nurse aides provided care during the evening shift. The facility census was 81 for night shift which required 5.40 nurse aides to provide care. Review of the nursing time schedules revealed that 5.03 nurse aides provided care during the night shift.
On June 21, 2026, the facility census was 81 for the day shift, which required 8.10 nurse aides to provide care. Review of the nursing time schedules revealed that 7.88 nurse aides provided care during the day shift. Review of the nursing time schedules revealed that 7.88 nurse aides provided care during the day shift. The facility census was 81 for the evening shift which required 6.47 nurse aides to provide care. Review of the nursing time schedules revealed that 6.47 nurse aides provided care during the evening shift. The facility census was 81 during night shift which required 5.40 nurse aides to provide care. Review of the nursing time schedules revealed that 3.13 nurse aides provided care during the night shift.
On June 22, 2026, the facility census was 80 during the day shift which required 8.00 nurse aides to provide care. Review of the nursing time schedules revealed that 6.98 nurse aides provided care during the day shift. The facility census was 81 during the night shift which required 5.40 nurse aides to provide care. Review of the nursing time schedules revealed that 4.06 nurse aides provided care during the night shift.
On June 23, 2026, the facility census was 81 during the day shift which required 8.10 nurse aides to provide care. Review of the nursing time schedules revealed that 8.04 during the day shift. The facility census was 82 during the night shift which required 5.47 nurse aides to provide care. Review of the nursing time schedules revealed that 4.59 nurse aides provided care during the night shift.
On June 24, 2026, the facility census was 82 during the day shift which required 8.20 nurse aides to provide care. Review of the nursing time schedules revealed that 7.65 nurse aides provided care during the day shift. The facility census was 83 during the evening shift which required 7.55 nurse aides to provide care. Review of the nursing time schedules revealed that 7.02 nurse aides provided care during the evening shift. The facility census was 83 during the night shift which required 5.53 nurse aides to provide care. Review of the nursing time schedules revealed that 4.74 nurse aides provided care during the night shift.
On June 25, 2026, the facility census was 83 during the day shift which required 8.30 nurse aides to provide care. Review of the nursing time schedules revealed that 8.03 nurse aides provided care during the day shift. The facility census was 86 during the evening shift which required 7.82 nurse aides to provide care. Review of the nursing time schedules revealed that 6.47 nurse aides to provide care during the evening shift. The facility census was 86 during the night shift which required 7.73 nurse aides to provide care. Review of the nursing times schedules revealed that 4.07 nurse aides provided care during the night shift.
On June 26, 2026, the facility census was 87 during the evening shift which required 7.91 nurse aides to provide care. Review of the nursing time schedules revealed that 7.84 nurse aides provided care during the evening shift. The facility census was 87 during the night shift which required 5.80 nurse aides to provide care. Review of the nursing time schedules revealed that 4.74 nurse aides provided care during the night shift.
On June 27, 2026, the facility census was 85 during the evening shift which required 7.73 nurse aides to provide care. Review of the nursing time schedules revealed that 7.42 nurse aides provided care during the evening shift. The facility census was 85 during the night shift which required 5.67 nurse aides to provide care. Review of the nursing time schedules revealed that 4.54 nurse aides provided care during the night shift.
On June 28, 2026, the facility census was 85 during the evening shift which required 7.73 nurse aides to provide care. Review of the nursing time schedules revealed that 6.54 nurse aides provided care during the evening shift. The facility census was 85 during the night shift which required 5.67 nurse aides to provide care. Review of the nursing time schedules revealed that 4.01 nurse aides provided care during the night shift.
On June 29, 2026, the facility census was 85 during the day shift which required 8.50 nurse aides to provide care. Review of the nursing time schedules revealed that 8.36 nurse aides to provide care during the day shift. The facility census was 85 during the evening shift which required 7.73 nurse aides to provide care. Review of the nursing time schedules revealed that 7.21 nurse aides provided care during the evening shift. The facility census was 86 during the night shift. Review of the nursing time schedules revealed that 3.79 nurse aides provided care during the night shift.
On June 30, 2026, the facility census was 86 during the day shift which required 8.60 nurse aides to provide care. Review of the nursing time schedules revealed that 7.33 nurse aides provided care during the day shift. The facility census was 86 during the evening shift which required 7.82 nurse aides to provide care. Review of the nursing time schedules revealed that 7.70 nurse aides provided care during the evening shift. The facility census was 86 during the night shift which required 5.73 nurse aides provided care. Review of the nursing time schedules revealed that 4.02 nurse aides provided care during the night shift.
On July 1, 2026, the facility census was 86 during the day shift which required 8.60 nurse aides to provide care. Review of the nursing time schedules revealed that 7.99 nurse aides provided care during the day shift. The facility census was 86 during the night shift which required 5.73 nurse aides to provide care. Review of the nursing time schedules revealed that 4.05 nurse aides provided care during the night shift.
On July 2, 2026, the facility census was 85 during the day shift which required 8.50 nurse aides to provide care. Review of the nursing time schedules revealed that 6.03 nurse aides provided care during the day shift. The facility census was 87 during the night shift which required 5.80 nurse aides to provide care. Review of the nursing time schedules revealed that 3.50 nurse aides provided care during the night shift.
On July 3, 2026, the facility census was 86 during the day which required 8.60 nurse aides to provide care. Review of the nursing time schedules revealed that 8.04 nurse aides provided care during the day shift. The facility census was 87 during the night shift which required 5.80 nurse aides to provide care. Review of the nursing time schedules revealed that 5.75 nurse aides provided care during the night shift.
On July 4, 2026, the facility census was 87 during the night shift which required 5.80 nurse aides to provide care. Review of the nursing time schedules revealed that 4.43 nurse aides provided care during the night shift.
On July 5, 2026, the facility census was 86 during the day shift which required 8.60 nurse aides to provide care. Review of the nursing time schedules revealed that 8.05 nurse aides provided care during the day shift. The facility census was 86 during the night shift which required 5.73 nurse aides to provide care. Review of the nursing time schedules revealed that 4.11 nurse aides provided care during the night shift.
On July 6, 2026, the facility census was 90 during the day shift which required 9.00 nurse aides to provide care. Review of the nursing time schedules revealed that 7.91 nurse aides provided care during the day shift. The facility census was 90 during the evening shift which required 8.18 nurse aides to provide care. Review of the nursing time schedules revealed that 8.10 nurse aides provided care during the evening shift. The facility census was 90 during the night shift which required 6.00 nurse aides to provide care. Review of the nursing time schedules revealed that 3.70 nurse aides provided care during the night shift.
On July 7, 2026, the facility census was 85 during the night shift which required 6.57 nurse aides to provide care. Review of the nursing time schedules revealed that 3.46 nurse aides provided care during the night shift.
On July 8, 2026, the facility census was 89 during the evening shift which required 8.09 nurse aides to provide care. Review of the nursing time schedules revealed that 8.03 nurse aides provided care during the evening shift. The facility census was 89 during the night shift which required 5.93 nurse aides to provide care. Review of the nursing time schedules revealed that 4.03 nurse aides provided care during the night shift.
Interview with the Nursing Home Administrator via email on June 10, 2026, at 11:56 a.m. confirmed that the facility did not meet the required nurse aide-to-resident staffing ratios for the shifts listed above.






 Plan of Correction - To be completed: 08/06/2026

1.Unable to correct.
2.Education was provided to the Nursing, Nursing Home Administrator, scheduler and licensed nursing staff regarding the regulatory requirements for certified nursing assistant ratios.
3.Routine staffing meetings to review certified nursing assistant ratios. The Director of Nursing or designee to review ratios five times per week for one month, then three times per week for one month.
4.Nursing assistant ratios will be reviewed with the Quality Assurance and Performance Improvement committee.

§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:

Based on review of nursing schedules and staffing information furnished by the facility it was determined that the facility failed to ensure a minimum of one Licensed Practical Nurse (LPN) per 25 residents on the day shift for five of 21 days, and failed to ensure a minimum of one LPN per 40 residents on the night shift for three of 21 days from June 28, 2026 to July 8, 2026.

Findings include:

On June 18, 2026, review of facility census data indicated the census was 81 during the day shift which required 3.24 LPNs to provide care. Review of the nursing time schedules revealed that 2.26 LPNs provided care during the day shift.
On June 20, 2026, review of the facility census data indicated that the census was 81 during the day shift which required 3.24 LPNs to provide care. Review of the nursing time schedules revealed that 3.17 LPNs provided care during the day shift.
On June 22, 2026, review of the facility census data indicated that the census was 80 during the day shift which required 3.20 LPNs to provide care. Review of the nursing time schedules revealed that 3.10 LPNs provided care during the day shift.
On June 23, 2026, review of the facility census data indicated that the census was 82 during the night shift which required 2.05 LPNs to provide care. Review of the nursing time schedules revealed that 1.99 LPNs provided care during the night shift.
On July 1, 2026, review of the facility census data indicated that the census was 86 during the night shift which required 2.15 LPNs to provide care. Review of the nursing time schedules revealed that 1.45 LPNs provided care during the night shift.
On July 2, 2026, review of the facility census data indicated that the census was 85 during the day shift which required 3.40 LPNs to provide care. Review of the nursing time schedules revealed that 3.18 LPNs provided care during the day shift.
On July 5, 2026, review of the facility census data indicated that the census was 86 during the day shift which required 3.44 LPNs to provide care. Review of the nursing time schedules revealed that 2.90 LPNs provided care during the day shift.
On July 7, 2026, review of the facility census data indicated that the census was 85 during the night shift which required 2.13 LPNs to provide care. Review of the nursing time schedules revealed that 1.99 LPNs provided care during the night shift.

There were no additional excess higher-level staff available to compensate for these deficiencies.

Interview with the Administrator on July 10, 2026, at 11:05 a.m. confirmed that the facility did not meet the required LPN-to-resident staffing ratios for the days listed above.






 Plan of Correction - To be completed: 08/06/2026

1.Unable to correct.
2.Education was provided to the Nursing, Nursing Home Administrator, scheduler and licensed nursing staff regarding the regulatory requirements for Licensed Practical Nurse ratios.
3.Routine staffing meetings to review licensed practical nurse ratios. The Director of Nursing or designee to review ratios five times per week for one month, then three times per week for one month.
4.Licensed Practical Nurse ratios will be reviewed with the Quality Assurance and Performance Improvement committee.
§ 211.12(i)(2) LICENSURE Nursing services.:State only Deficiency.
(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:

Based on review of staffing information furnished by the facility and staff interviews, it was determined that the facility failed to provide 3.20 hours of direct resident care for each resident for 17 of 21 days (24-hour periods) reviewed.

Findings include:

Nursing time schedules provided by the facility for the days of June 18, 2026 to July 8, 2026, revealed that the facility provided only 3.11 hours of direct care on June 18, 2026, 3.19 hours of direct care on June 19, 2026, 2.98 hours of direct care on June 20, 2026, 3.13 hours of direct care on June 21, 2026, 3.02 hours of direct care on June 22, 2026, 3.08 hours of direct care on June 23, 2026, 3.19 hours of direct care on June 24, 2026, 2.90 hours of direct care on June 25, 2026, 3.19 hours of direct care on June 26, 2026, 3.10 hours of direct care on June 28, 2026, 3.04 hours of direct care on June 29, 2026, 3.01 hours of direct care on June 30, 2026, 2.93 hours of direct care on July 1, 2026, 3.00 hours of direct care on July 2, 2026, 2.97 hours of direct care on July 6, 2026, 2.97 hours of direct care on July 7, 2026, and 3.08 hours of direct care on July 8, 2026.

Interview with the Nursing Home Administrator on July 10, 2026, at 11:23 a.m. confirmed that the facility did not meet the required daily direct resident care hours on the days listed above.






 Plan of Correction - To be completed: 08/06/2026

1.Unable to correct.
2.Education regarding direct care hours will be provided to the scheduler, administrator and licensed nursing staff. The licensed nursing staff will update the scheduler of call offs in an effort to replace.
3.A daily staffing meeting is to be held to review direct resident care hours.
4.Director of Nursing or designee to review direct care hours five times per week for one month then three times per week for one month to ensure the direct care hours are met.
5.The direct care staffing hours will be reviewed and the Quality Assurance and Performance Improvement meeting.


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