Pennsylvania Department of Health
PATRIOT, A CHOICE COMMUNITY THE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

PATRIOT, A CHOICE COMMUNITY THE
Inspection Results For:

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PATRIOT, A CHOICE COMMUNITY THE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and Civil Rights Compliance survey completed on February 29, 2024, it was determined that The Patriot, A Choice Community 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:

483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors:

This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.

The facility must ensure that its-
§483.45(f)(2) Residents are free of any significant medication errors.

Observations:

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide medication as ordered by the physician, resulting in significant medication errors for one of 37 residents reviewed (Resident 7).

Findings include:

The facility's policy regarding medication administration, dated January 1, 2024, indicated that residents were to receive all medications as per the physician's order meeting the requirements of the right dose, right route, at the right rate, at the right time, and for the right resident.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated December 19, 2023, indicated that the resident was alert and oriented, received insulin, and had diagnoses that included diabetes.

Physician's orders for Resident 7, dated December 14, 2023, included an order for the resident to receive 5 units of Insulin Lispro (fast acting insulin) subcutaneously (beneath the skin) twice a day for diabetes and to hold the insulin if the resident's blood sugar was less than 150 milligrams/deciliter (mg/dL).

Resident 7's Medication Administration Record (MAR) for December 2023 and January 2024 revealed that the resident's blood sugar at 11:30 a.m. on December 21 was 116 mg/dL, December 27 was 149 mg/dL, December 28 was 123 mg/dL, December 29 was 133 mg/dL, December 30 was 146 mg/dL, December 31 was 140 mg/dL, January 9 was 125 mg/dL, and January 19 was 145 mg/dL; and the resident's blood sugar at 4:45 p.m. on December 30 was 120 mg/dL, January 9 was 112 mg/dL, January 10 was 130 mg/dL, January 12 was 104 mg/dL, January 15 was 108 mg/dL, and January 25 was 131 mg/dL.

There was no documented evidence that Resident 7's insulin was held according to the physician-ordered parameters on the dates and times above.

Interview with the Director of Nursing on February 29, 2024, at 8:10 a.m. confirmed that the Insulin Lispro was not held as ordered on the dates and times above.

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

Plan of Correction - To be completed: 04/16/2024

This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because The Patriot, A Choice Community agrees with the allegations and citations listed on the statement of deficiencies. The Patriot, A Choice Community maintains that the alleged deficiencies do not, individually and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as The Patriot, A Choice Community written credible allegation of compliance.
By submitting this plan of correction, The Patriot, A Choice Community does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and The Patriot, A Choice Community all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding.

The identified concern for R7 cannot be corrected. The responsible party and primary care physician will be notified of the identified concern.

The director of nursing or designee will audit all current resident's insulin medication administration record (MAR) for accuracy of administration dosages in comparison to the physician order.

The Director of Nursing or Designee will re-educate all licensed professional (including agency nurses) on the facility policy and procedure for administration of medication (including Insulin) per physician order.

The Director of Nursing or Designee will audit insulin administration records for accuracy per physicians' order. The audits will be conducted weekly X4 and monthly X2. All Finding will be submitted to the Quality Assurance Committee.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Observations:

Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to store food in accordance with professional standards for food service safety by failing to store food under sanitary conditions, failing to ensure that dietary staff wore appropriate hair coverings, and failing to ensure that a microwave was clean and free of deterioration, for one of three microwaves reviewed (first-floor pantry)

Findings include:

The facility's policy regarding uniform dress code, dated January 31, 2024, revealed to restrain all facial hair with a beard net/restraint.

Observations in the outside walk-in freezer on February 26, 2024, at 8:53 a.m. and February 27, 2024, at 1:15 p.m. revealed that there was an accumulation of ice on the ceiling and floor, as well as on a plastic jug that contained water, a case of ham, and a case of roast beef that were stored on the shelves below the freezer condenser.

Interview with the Dietary Manager on February 27, 2024, at 1:15 p.m. confirmed that there was an accumulation of ice on the food products stored below the freezer condensers in the outside walk-in freezer.

Observations in the main kitchen during service for the lunch meal on February 28, 2024, at 11:25 p.m. revealed that Dietary Aide 5 was placing the silverware and obtaining coffee, as well as taking the residents' prepared plates from the cook and placing them into the cart to be delivered to the residents. Dietary Aide 5 had a beard that was not covered with a beard net/restraint.

Interview with the Registered Dietitian on February 28, 2024, at 12:00 p.m. confirmed that Dietary Aide (Fernando Hernandez) should have had his beard covered when working around food in the kitchen.

Observations of the microwave in the first-floor pantry February 28, 2024, at 2:41 p.m. revealed that there were food splatters on the top, sides, and back inside walls of the microwave. The paint was worn off and rusty to the frame area below the floor of the microwave.

Interview with the Registered Nurse 6 on February 28, 2024, at the time of the observation confirmed that the microwave needed to be cleaned.

28 Pa. Code 211.6(f) Dietary Services.

Plan of Correction - To be completed: 04/16/2024

his plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because The Patriot, A Choice Community agrees with the allegations and citations listed on the statement of deficiencies. The Patriot, A Choice Community maintains that the alleged deficiencies do not, individually and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as The Patriot, A Choice Community written credible allegation of compliance.
By submitting this plan of correction, The Patriot, A Choice Community does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and The Patriot, A Choice Community all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding.

The ice buildup was immediately removed per manufacturer guidelines.

The dietary aide was immediately re-educated on the facilities dress code policy for restrain all facial hair with a beard net.

The Dietary manager or designee will audit all walk in freezers for ice buildup.
The Dietary manager or designee will audit all current dietary aides for dress code policy for application of beard net.
The Dietary manager or designee will audit all resident microwaves for residual food buildup.

The Dietary manager or Designee will re-educate all dietary aides on proper monitoring and removal of ice buildup in the walk in freezers, and the facility dress policy for application of beard net.
The Environmental manager or designee will audit all resident microwaves for residual food buildup.

The Dietary manager or Designee will audit all dietary workers for the use of beard covering.
The Environmental manager or designee will audit all resident microwaves for residual food buildup.

The audits will be conducted weekly X4 and monthly X2. All Finding will be submitted to the Quality Assurance Committee.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Observations:

Based on review of manufacturer's instructions and clinical records, as well as observations and staff interviews, it was determined that the facility failed to store unopened (unused) multi-dose containers of insulin according to manufacturer's instructions for one of 37 residents reviewed (Resident 22), and failed to ensure that controlled refrigerated medications were stored in a separately-locked, permanently-affixed container in one of two medication refrigerators reviewed (third-floor east medication room refrigerator).

Findings include:

Manufacturer's directions for Insulin Lispro (Humalog - a fast-acting insulin used to lower blood sugar levels), dated July 2023, indicated to store unused pens in the refrigerator at 36 degrees Fahrenheit (F) to 46 degrees F. Unused pens may be used until the expiration date printed on the label if the pen has been kept in the refrigerator.

Physician's orders for Resident 22, dated January 30, 2024, included an order for the resident to receive Insulin Lispro as per a sliding scale (the amount of Insulin given was determined by the blood sugar level) three times per day.

Observations of the 3rd floor central 2 medication cart on February 29, 2024, at 8:42 a.m. revealed that Resident 29's Insulin Lispro Pen Injector was unopened and not in use in the top drawer of the medication cart. The medication label indicated that the Insulin Lispro Pen was dispensed by the pharmacy to the facility on February 26, 2024. Interview with Licensed Practical Nurse 3 at the time of observation confirmed that Resident 22's Insulin Lispro Pen was not opened, not in use, and should not have been in the medication cart but should have been stored in the refrigerator until ready for use.

Observations of the third-floor east medication room refrigerator on February 29, 2024, at 9:38 a.m. revealed that there was a clear plastic box attached to the shelf in the refrigerator that contained three boxes of Ativan Intensol (an antianxiety medication that is a controlled drug); however, the shelf that the clear plastic box was attached to could be removed from the refrigerator. Interview with Licensed Practical Nurse 4 at the time of observation confirmed that the clear plastic box containing the Ativan Intensol was not permanently affixed to the refrigerator and could be removed.

28 Pa. Code 211.9(a)(1) Pharmacy Services.

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

Plan of Correction - To be completed: 04/16/2024

This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because The Patriot, A Choice Community agrees with the allegations and citations listed on the statement of deficiencies. The Patriot, A Choice Community maintains that the alleged deficiencies do not, individually and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as The Patriot, A Choice Community written credible allegation of compliance.
By submitting this plan of correction, The Patriot, A Choice Community does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and The Patriot, A Choice Community all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding.
The identified concern for R22 was immediately corrected by disposing of the Insulin Lispro and facility contacting pharmacy to replace at the expense to the facility.

The third floor medication refrigerator shelf was immediately permanently attached to the refrigerator.

The director of nursing or designee will audit all current residents with insulin pens for proper storage of unopened insulin pens.

The director of nursing or designee will audit all medication storage rooms for the required medication security including non-removable locked storage containers for the refrigerator.

The Director of Nursing or Designee will re-educate all licensed professional (including agency nurses) on the facility policy and procedure for storage of unopened insulin pens.

The Director of Nursing or Designee will re-educate all licensed professional (including agency nurses) on the need for all controlled medication to have double locks, and all refrigerated controlled medications must be in a non-removable container when stored in the medication room.

The Director of Nursing or Designee will audit 25% per unit of all insulin pen orders substances for accurate storage of insulin pens.

The Director of Nursing or Designee will audit each medication room refrigerator to ensure the refrigerator box is secure and non-removable.

The audits will be conducted weekly X4 and monthly X2. All Finding will be submitted to the Quality Assurance Committee.

483.20(g) REQUIREMENT Accuracy of Assessments:

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.

§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

Observations:

Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate comprehensive Minimum Data Set assessments for two of 45 residents reviewed (Residents 30, 72).

Findings include:

The RAI User's Manual, dated October, 2023, indicated that Sections P0100A-P0100H were to capture physical restraint use, Section E0100A-H was to be coded (0) when restraints are not used, (1) when a restraint was used less than daily, and (2) when a restraint was used daily.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) (for Resident 30, dated November 24, 2023, revealed that section P0100F (limb restraint) was coded (1) used less than daily.

Observations of Resident 30 in the dining room on February 26, 2024, at 12:29 p.m. revealed the resident was sitting in her broda chair with no restraints.

Interview with Licenced Practical Nurse 1 on February 28, 2024, at 1:55 p.m. revealed that Resident 30 does not have a limb restraint.

Interview with Licenced Practical Nurse 2, who assisted with the MDS assessment, on February 29, 2024, at 10:25 a.m. indicated that Resident 30 does not have a limb restraint and that the assessment was inaccurate.

The RAI User's Manual, dated October 2023, indicated that Section E0200A was to capture physical behavioral symptoms directed towards others, Section E0200B was to capture verbal behavioral symptoms directed towards others, and Section E0200C was to capture other behavioral symptoms not directed towards others. The sections were to be coded zero (0) behavior not exhibited, one (1) behaviors of this type occurred one to three days, two (2) behaviors of this type occurred four to six days, but less than daily, and (3) behavior of this type occurred daily.

A nursing note, dated February 17, 2024, at 11:50 p.m., revealed that Resident 72 was standing in his doorway, wet with urine, and when the nurse aide went to help him change socks, the resident kicked her right knee. He then started swearing "mother f***ing leave me alone." He refused to have his socks changed and was agitated with staff.

A nursing note, dated February 18, 2024, at 3:26 p.m., revealed that Resident 72 walked into another resident's room and the resident in the room did not want him in there. Resident 72 exited the room with staff and then attempted to enter the room again. He was told by staff "the lady in that room does not want you in there." The resident was told again he could not go into the room and the resident stated, "I don't care," and grabbed the nurse by the arms and brought them up to her chest and shook them, and said, "F**k you, I don't care."

A nursing note, dated February 19, 2024, at 10:15 p.m., revealed that Resident 72 was combative and aggressive with care at times and swatted his hands at staff three times.

A nursing note, dated February 21, 2024, at 8:16 a.m., revealed that Resident 72 walked up to the licensed practical nurse (LPN) and grabbed her shirt and breast. He told the nurse to "get the f**k away from him." When the LPN stepped back from him he followed her as she quickly walked away. Resident 72 reapproached her again and told her to get away from him. The LPN quickly walked away; however, the resident increased his pace to a jog to keep up with her and had clenched fists and bared his teeth during the incident.

A nursing note, dated February 21, 2024, at 8:45 a.m., revealed that Resident 72 attempted to go out the exit door and told staff to" keep the f**k away from me." The resident entered another resident's room and then left the room, then walked towards staff with clenched fists and grabbed a staff member's arm and would not let go.

An admission MDS assessment for Resident 72, dated February 23, 2024, revealed that Sections E0200A, E0200B, and E0200C were coded as zero (0), indicating that the resident did not display any behaviors during the seven-day assessment period.

Interview with the Social Service Director (who was responsible for the completion of Section E) on February 29, 2024, at 10:45 a.m. confirmed that the above MDS assessment for Resident 72 was not accurate.

28 Pa. Code 211.5(f) Clinical Records.

Plan of Correction - To be completed: 04/16/2024

This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because The Patriot, A Choice Community agrees with the allegations and citations listed on the statement of deficiencies. The Patriot, A Choice Community maintains that the alleged deficiencies do not, individually and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as The Patriot, A Choice Community written credible allegation of compliance.
By submitting this plan of correction, The Patriot, A Choice Community does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and The Patriot, A Choice Community all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding.

The Minimum Data Set, MDS, for R30 and R72 have been corrected and re-submitted to Internet Quality Improvement & Evaluation System, IQUIES.

The Director of Nursing or Designee will audit the last Minimum Data Set, MDS, for each resident to determine accuracy of assessment. All issues identified will be corrected per the Resident Assessment Instrument, RAI, manual and resubmitted if warranted.

The Director of Nursing or designee will re-educate interdisciplinary team on the The Resident Assessment Instrument Manual, RAI, guidance for MDS accuracy and coding criteria.

The Director of nursing or designee will audit 5% of all newly completed MDS's for accuracy. The audits will be conducted weekly X4 and monthly X2. All Finding will be submitted to the Quality Assurance Committee.

483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan:

§483.21 Comprehensive Person-Centered Care Planning
§483.21(a) Baseline Care Plans
§483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

§483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

§483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.

Observations:

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that baseline care plans included the information and instructions needed to provide person-centered care for one of 37 residents reviewed (Resident 80).

Findings include:

The facility's policy regarding baseline care plans, dated January 31, 2024, indicated that within 24-48 hours of admission the facility was to coordinate the gathering, assessment, and evaluation of information from all sources (hospital, facility assessments and notes, resident/resident representative interview) and initiate the resident's care plan. No later than 48 hours after admission the Registered Nurse Assessment Coordinator (RNAC- a registered nurse who is often involved in the development of residents' care plans) or designated person would ensure that the baseline care plan was in place and all required items were addressed.

Admission information for Resident 80 revealed that he was admitted to the facility on February 24, 2024, with diagnoses that included dementia and psychotic disturbances, and a colostomy (an opening for the colon, or large intestine, through the abdomen). Physician's orders, dated February 24, 2024, included orders for the resident to receive 15 milligrams (mg) of aripiprazole (an antipsychotic medication) in the morning and colostomy care every shift and the removal and replacment of the face plate and bag every seven days.

Resident 80's baseline care plan (developed within 48 hours of a resident's admission and must include the minimum healthcare information necessary to properly care for each resident immediately upon their admission), dated February 24, 2024, did not include information regarding the care or services the resident required for the treatment with an an antipsychotic medication or regarding the care and services required for the use of a colostomy.

Interview with Director of Nursing on February 28, 2024, at 11:25 a.m. confirmed that she could not find any information on Resident 80's baseline care plan regarding the treatment with an anti-psychotic medication or the use of a colostomy.

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

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:

§483.21(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Observations:

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that residents' care plans were reviewed and revised to reflect their current care needs for two of 37 residents reviewed (Residents 35, 42).

Findings include:

A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 35, dated December 18, 2023, revealed that the resident was cognitively intact and required extensive assistance for daily care tasks. The resident's care plan, dated November 14, 2023, revealed that the resident was medicated with an anticoagulant (blood thinner); however, the resident's anticoagulant was discontinued on December 13, 2023.

There was no documented evidence that Resident 35's care plan was updated to reflect the discontinuation of the anticoagulant.

Interview with the Director of Nursing on February 28, 2024, at 3:42 p.m. confirmed that Resident 35's care plan should have been updated to reflect the discontinuation of the anticoagulant and it was not.

A significant change MDS assessment for Resident 42, dated December 15, 2023, revealed that the resident was cognitively intact, required extensive assistance for bed mobility, was dependent on staff for transfers and toileting, and had diabetic foot ulcer and a fall with a fracture. The resident's care plan regarding skin integrity, dated September 28, 2023, revealed that the resident had a pressure-reducing mattress.

Physician's order for Resident 42, dated January 20, 2024, revealed that the resident was ordered a bariatric alternating air mattress, at comfort level three.

Observations of Resident 42 on February 26, 2024, at 11:29 a.m. and February 28, 2024, at 2:26 p.m. revealed that she was lying in bed on an air mattress.

Interview with the Registered Nurse Assessment Coordinator (RNAC - the nurse responsible for completing the mandated assessment) on February 28, 2024, at 12:01 p.m. confirmed that a pressure-reducing mattress would meet the needs of the care plan, but the care plan was not individualized to reflect Resident 42's care needs.

28 Pa. Code 201.24(e)(4) Admission Policy.

Plan of Correction - To be completed: 04/16/2024

This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because The Patriot, A Choice Community agrees with the allegations and citations listed on the statement of deficiencies. The Patriot, A Choice Community maintains that the alleged deficiencies do not, individually and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as The Patriot, A Choice Community written credible allegation of compliance.
By submitting this plan of correction, The Patriot, A Choice Community does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and The Patriot, A Choice Community all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding.

The plan of care for R35 and R42 will be reviewed and corrected.

The director of nursing or designee will audit the last comprehensive care plan completed for all current residents. The comprehensive care plan will be updated with all issues identified.

The Director of Nursing or designee will re-educate the interdisciplinary team on the comprehensive care plan requirements for completion and accuracy in accordance with the Resident Assessment Instrument, RAI, manual and federal regulation.

The director of nursing or designee will audit of all newly completed comprehensive care plans for accuracy. The audits will be conducted weekly X4 and monthly X2. All Finding will be submitted to the Quality Assurance Committee.

483.25 REQUIREMENT Quality of Care:

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:

Based on clinical record reviews and staff interviews, it was determined that the facility failed to complete treatments as ordered by the physician for one of 37 residents reviewed (Resident 78).

Findings include:

An admission skin assessment, dated February 24, 2024, revealed that Resident 78 had scabs on his second, fourth, and fifth toes of the left foot. Physician's orders, dated February 25, 2024, included an order to apply skin prep (protective film) to the second, fourth, and fifth toe of the left foot every day shift.

A comprehensive admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated June 26, 2021, revealed that the resident was able to make himself understood and could understand others, required supervision with daily care activities, had a surgical wound that required treatments, and had diagnoses that included a wound infection. Physician's orders, dated June 20, 2021, included an order to clean the resident's abdominal wounds with normal saline solution (medical grade salt water) and pack the openings with wet-to-dry dressings each day and evening shift. The resident's care plan, dated June 21, 2021, included that staff were to provide treatments according to physician's orders.

Review of Resident 78's Treatment Administration Records (TAR's) for February 2024 revealed that there was no documented evidence that skin prep was applied to Resident 78's second, fourth, and fifth toe as ordered from February 25 to 28, 2024.

Interview with the Director of Nursing on September 29, 2024, at 8:10 a.m. confirmed that there was no documented evidence that skin prep was applied to Resident 78's second, fourth, and fifth toe as ordered from February 25 to 28, 2024.

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

Plan of Correction - To be completed: 04/16/2024

This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because The Patriot, A Choice Community agrees with the allegations and citations listed on the statement of deficiencies. The Patriot, A Choice Community maintains that the alleged deficiencies do not, individually and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as The Patriot, A Choice Community written credible allegation of compliance.
By submitting this plan of correction, The Patriot, A Choice Community does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and The Patriot, A Choice Community all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding.

The identified issue for R78 cannot be corrected.

The Director of Nursing or designee will audit all current treatment orders for completion per physician order. The primary care provider and responsible party will be notified of all identified concerns.

The Director of Nursing or Designee will re-educate all licensed professional (including agency nurses) on the professional standards for following, completing, and documenting care and services as directed in the physician order.

The Director of Nursing or Designee will audit 25% per unit of all treatment orders for completion and documentation per the physician's order. The audits will be conducted weekly X4 and monthly X2. All Finding will be submitted to the Quality Assurance Committee.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:

§483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

§483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

§483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

§483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

§483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

Observations:

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 37 residents reviewed (Residents 42).

Findings include:

The facility's policy regarding controlled substances, dated January 31, 2024, indicated that accurate accountability of the inventory of all controlled drugs is maintained at all times. When a controlled substance was administered, the licensed nurse administering the medication was to immediately enter the following information on the accountability record and Medication Administration Record (MAR): date and time of administration, amount administered, remaining quantity, and the initials of the nurse administering the dose, completed after the medication is actually administered.

A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 42, dated December 15, 2023, revealed that the resident was cognitively intact, required extensive assistance for bed mobility, was dependent on staff for transfers and toileting, had a fall with a major injury, and received opiod medication. Current physician's orders for Resident 42 included an order for the resident to receive 5-325 mg of Norco (narcotic pain reliever) every four hours as needed for moderate to severe pain.

The resident's controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for October, November and December 2023 indicated that one dose of Norco was signed-out for administration to the resident on October 28 at 6:00 p.m., November 23 at 9:00 p.m., December 14 at 7:30 a.m., and December 19 at 8:00 a.m. However, the resident's clinical record, including the Medication Administration Records (MAR's) and nursing notes, contained no documented evidence that the signed-out doses of Norco were actually administered to the resident on these dates and times.

Interview with the Director of Nursing on February 29, 2024, at 10:02 a.m. confirmed that there was no documented evidence that staff administered signed-out doses of Norco to Resident 42 on the above dates and times.

28 Pa. Code 211.9(a)(h) Pharmacy Services.

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

Plan of Correction - To be completed: 04/16/2024

This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because The Patriot, A Choice Community agrees with the allegations and citations listed on the statement of deficiencies. The Patriot, A Choice Community maintains that the alleged deficiencies do not, individually and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as The Patriot, A Choice Community written credible allegation of compliance.
By submitting this plan of correction, The Patriot, A Choice Community does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and The Patriot, A Choice Community all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding.

The identified concern for R42 cannot be corrected.

The director of nursing or designee will audit all current resident's controlled substance accountability records for accuracy of administration times in comparison to the medication administration records.

The Director of Nursing or Designee will re-educate all licensed professional (including agency nurses) on the facility policy and procedure for administration and documentation of controlled substances.

The Director of Nursing or Designee will audit 25% per unit of all administered controlled substances for accurate documentation at the time of administration. The audits will be conducted weekly X4 and monthly X2. All Finding will be submitted to the Quality Assurance Committee.

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use:

§483.45(e) Psychotropic Drugs.
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

§483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

§483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

§483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Observations:

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that non-pharmacological (non-medication) interventions were attempted prior to the administration of anti-anxiety medications for one of 37 residents reviewed (Resident 53).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 53, dated January 30, 2024, indicated that the resident was cognitively impaired and had diagnoses that included anxiety.

Physician's orders for Resident 53, dated January 28, 2024, included an order for the resident to receive 0.5 milligrams (mg) of Ativan (an antianxiety medication) every six hours as needed for anxiety. Resident 53's care plan, dated January 28, 2024, revealed that the resident used an antianxiety medication related to anxiety.

Resident 53's Medication Administration Records (MAR's) for February 2024 revealed that staff administered "as needed" Ativan to the resident on February 1 at 12:41 a.m. and 9:30 p.m., February 2 at 5:21 a.m., February 5 at 9:00 p.m., February 6 at 7:27 a.m., February 8 at 7:50 p.m., and February 9, 2024 at 7:19 p.m.

There was no documented evidence in Resident 53's clinical record regarding any non-medication interventions that were attempted prior to the administration of Ativan on the above days.

Interview with the Director of Nursing on February 27, 2024, at 2:30 p.m. confirmed that there was no documention of any non-medication interventions prior to the administration of Ativan, and staff were to document the attempts at non-medication interventions.

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

Plan of Correction - To be completed: 04/16/2024

This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because The Patriot, A Choice Community agrees with the allegations and citations listed on the statement of deficiencies. The Patriot, A Choice Community maintains that the alleged deficiencies do not, individually and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as The Patriot, A Choice Community written credible allegation of compliance.
By submitting this plan of correction, The Patriot, A Choice Community does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and The Patriot, A Choice Community all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding.

The facility is unable to correct the identified concern for R53

The Director of Nursing or designee will audit residents with current orders for as needed psychotropic orders for the supporting documentation of non-pharmacological interventions prior to medication administration.

The Director of Nursing or Designee will re-educate all licensed professional (including agency nurses) on the facilities expectation for the use of at least three non-pharmacological interventions prior to administration of psychotropic medications.

The Director of Nursing or Designee will audit new as needed psychotropic medications provided for the supporting documentation of three non-pharmacological interventions prior to administration of psychotropic medications The audits will be conducted weekly X4 and monthly X2. All Finding will be submitted to the Quality Assurance Committee.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:

§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

§483.70(i) Medical records.
§483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

§483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

§483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

§483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

§483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.

Observations:

Based on clinical records reviews, observations, and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for two of 37 residents reviewed (Residents 7, 42).

Findings include:

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated December 19, 2024, revealed that the resident was cognitively intact, had pressure ulcers (skin impairment caused by pressure), and received pressure ulcer care. Physician's orders, dated December 18, 2023, included an order for collagen (promotes wound healing, silver alginate (prevents infection) and a bordered foam covering be applied to the left heel every day shift.

A wound note, dated February 20, 2024, revealed the resident had a Stage 3 pressure ulcer (a full thickness tissue loss where subcutaneous fat may be visible) on the left heel that measured 1.3 x 0.6 x 0.3 centimeters (cm).

Resident 7's Treatment Administration Records (TAR's) for February 2024 revealed that there was no documented evidence that a treatment was applied to the resident's left heel on February 8, 12, 14, 18, and 23, 2024.

Interview with the Director of Nursing on February 29, 2024, at 8:10 a.m. confirmed that staff did not document when they completed the resident's treatment to the left heel as ordered.

A significant change MDS assessment for Resident 42, dated December 15, 2023, revealed that the resident was cognitively intact and required extensive assistance for bed mobility and dependent on staff for transfers and toileting, had a fall with a major injury, and was received opiod medication. Physician's orders for Resident 42, dated January 20, 2024, included an order for the resident to have boot on the right ankle, to be kept in place and removed for hygiene and wound treatment.

An orthopedic consult for Resident 42, dated February 2, 2024, indicated that the benefits of any type of immobilization outweighs the risk so offloading the heel was recommended.

Observations of Resident 42 on February 26, 2024, at 11:29 a.m. revealed that she was lying in bed on an air mattress with no boot. Interview with Resident 42 on February 28, 2024, at 2:26 p.m. revealed that her husband got rid of it at the doctor's appointment. He said if it is not going to work then throw it away.

Review of Resident 42's Treatment Administration Record (TAR) for February 26, 2024, revealed that staff documented that the resident had the boot in place.

Interview with the Director of Nursing on February 29, 2024, at 11:42 a.m. confirmed that documentation was incorrect.

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

Plan of Correction - To be completed: 04/16/2024

This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because The Patriot, A Choice Community agrees with the allegations and citations listed on the statement of deficiencies. The Patriot, A Choice Community maintains that the alleged deficiencies do not, individually and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as The Patriot, A Choice Community written credible allegation of compliance.
By submitting this plan of correction, The Patriot, A Choice Community does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and The Patriot, A Choice Community all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding.

The identified concern for R7 and R42 cannot be corrected.

The director of nursing or designee will audit all current resident's orthopedic boot orders for accuracy of application and documentation in comparison to the order.

The director of nursing or designed will audit all current resident's treatment orders for accuracy of completion and documentation in comparison to the TAR (treatment administration record)

The Director of Nursing or Designee will re-educate all nursing staff in regards to accuracy of application of orthopedic boots and documentation in comparison to the order.
The Director of Nursing or Designee will re-educate all licensed professional (including agency nurses) on the facility policy and procedure for administration and documentation of treatments.

The Director of Nursing or Designee will audit all orthopedic boot orders for accuracy of application of orthopedic boots and documentation in comparison to the order.
The Director of Nursing or Designee will audit 25% per unit of all administration and documentation of treatments. The audits will be conducted weekly X4 and monthly X2. All Finding will be submitted to the Quality Assurance Committee.

483.75(c)(d)(e)(g)(2)(i)(ii) REQUIREMENT QAPI/QAA Improvement Activities:

§483.75(c) Program feedback, data systems and monitoring.
A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following:

§483.75(c)(1) Facility maintenance of effective systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement.

§483.75(c)(2) Facility maintenance of effective systems to identify, collect, and use data and information from all departments, including but not limited to the facility assessment required at §483.70(e) and including how such information will be used to develop and monitor performance indicators.

§483.75(c)(3) Facility development, monitoring, and evaluation of performance indicators, including the methodology and frequency for such development, monitoring, and evaluation.

§483.75(c)(4) Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events.

§483.75(d) Program systematic analysis and systemic action.

§483.75(d)(1) The facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained.

§483.75(d)(2) The facility will develop and implement policies addressing:
(i) How they will use a systematic approach to determine underlying causes of problems impacting larger systems;
(ii) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and
(iii) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained.

§483.75(e) Program activities.

§483.75(e)(1) The facility must set priorities for its performance improvement activities that focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care.

§483.75(e)(2) Performance improvement activities must track medical errors and adverse resident events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the facility.

§483.75(e)(3) As part of their performance improvement activities, the facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the facility's services and available resources, as reflected in the facility assessment required at §483.70(e). Improvement projects must include at least annually a project that focuses on high risk or problem-prone areas identified through the data collection and analysis described in paragraphs (c) and (d) of this section.

§483.75(g) Quality assessment and assurance.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:

(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
(iii) Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements.

Observations:

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.

Findings include:

The facility's deficiencies and plans of correction for the State Survey and Certification (Department of Health) survey ending March 2, 2023, revealed that the facility developed plans of corrections that included quality assurance systems to ensure that the facility-maintained compliance with cited nursing home regulations. The results of the current survey, ending February 29, 2024, identified repeated deficiencies related to a failure to complete Minimum Data Set (MDS) assessments (mandated assessments of residents' abilities and care needs) accurately, revision of care plans, following physician's orders, to prepare and store food under sanitary conditions, and to maintain complete and accurate clinical records.

The facility's plan of correction for a deficiency regarding completing accurate MDS assessments, cited during the survey ending March 2, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F641, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding completing accurate MDS assessments.

The facility's plan of correction for a deficiency regarding revising care plans, cited during the survey ending March 2, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F657, revealed that the QAPI committee was ineffective in correcting deficient practices related to revising care plans.

The facility's plan of correction for a deficiency regarding following physician's orders, cited during the survey ending March 2, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the QAPI committee was ineffective in correcting deficient practices related to following physician's orders.

The facility's plan of correction for a deficiency regarding labeling and storing food under sanitary conditions, cited during the survey ending March 2, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F812, revealed that the QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding preparing and storing food under sanitary conditions.

The facility's plan of correction for a deficiency regarding clinical records that were not complete and accurate, cited during the survey ending March 2, 2023, indicated that audits of documentation would be completed, and the results of the audits would be presented at the QAPI committee. The results of the current survey, cited under F842, revealed that the QAPI committee was ineffective in correcting deficient practices related to ensuring that residents' clinical records were complete and accurately documented.

Refer to F641, F657, F684, F812, F842.

28 Pa. Code 201.14(a) Responsibility of Licensee.

28 Pa. Code 201.18(e)(1) Management.

Plan of Correction - To be completed: 04/16/2024

This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because The Patriot, A Choice Community agrees with the allegations and citations listed on the statement of deficiencies. The Patriot, A Choice Community maintains that the alleged deficiencies do not, individually and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as The Patriot, A Choice Community written credible allegation of compliance.
By submitting this plan of correction, The Patriot, A Choice Community does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and The Patriot, A Choice Community all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding.

All areas identified during this annual survey have submitted plans of correction. All identified resident concerns that are correctable will be corrected.

Audits will be completed for all federal regulations identified as not in compliance to ensure any additional residents have been identified and corrective measures have been implemented.

All submitted plans of correction have specific education/ re-education listed for all appropriate disciplines that will be provided by the listed facility employees.

The Vice president of Operations will re-educate the QAPI committee of the facility expectations and role of the committee per the federal regulation.

Audits for each citation will be submitted to the quality assurance committee for review. The Nursing Home Administrator or designee will audit the QAPI minutes Monthly X3 to ensure all audits have been submitted and all identified areas have been addressed.

§ 201.22(b) LICENSURE Prevention, control and surveillance of tuber:

(b) Recommendations of the Centers for Disease Control and Prevention (CDC), United States Department of Health and Human Services (HHS) shall be followed in screening, testing and surveillance for TB and in treating and managing persons with confirmed or suspected TB.

Observations:

Based on a review of policies and employee files, as well as staff interviews, it was determined that the facility failed to follow CDC (Centers for Disease Control) guidelines for the administration of tuberculin skin testing for four of five employees reviewed (Registered Nurse 7, Nurse Aide 8, Nurse Aide 9, Nurse Aide 10).

Findings include:

According to current CDC guidelines (TB Screening and Testing of Health Care Personnel, last updated August 30, 2022) revealed that if the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used. This is because some people with latent TB infection have a negative reaction when tested years after being infected. The first TST may stimulate or boost a reaction. Positive reactions to subsequent TSTs could be misinterpreted as a recent infection. Administer first TST following proper protocol. Administer second TST one to three weeks after first test.

The facility's policy regarding TB, dated January 31, 2024, revealed that the facility will follow the CDC guidelines and utilize an approved method of management, screening, surveillance, testing and in treating and managing persons with confirmed or suspected TB. If an employee is able to provide documentation of any prior administration of a negative 2-step PPD (Purified Protein Derivative), this will be utilized as the first step PPD and the employee will be given a one-step PPD prior to beginning employment. If no record of previous administration of a negative 2-step PPD is available, the employee will be required to have TB testing.

Review of the personnel file for Registered Nurse 7 revealed that the employee received the first step TB skin test on December 27, 2023, and it was read on December 29, 2023. However, there was no documented evidence that Registered Nurse 7 had completed the second step.

Review of the personnel file for Nurse Aide 8 revealed that the employee received the first step TB skin test on December 15, 2023, and it was read on December 17, 2023. However, there was no documented evidence that Nurse Aide 8 had completed the second step.

Review of the personnel file for Nurse Aide 9 revealed that the employee received the first step TB skin test on January 18, 2024, and it was read on January 20, 2024. However, there was no documented evidence that Nurse Aide 9 had completed the second step.

Review of the personnel file for Nurse Aide 10 revealed that the employee received the first step TB skin test on February 6, 2024, and it was read on February 8, 2024. However, there was no documented evidence that Nurse Aide 10 had completed the second step.

Interview with the Director of Nursing on February 28, 2024, at 1:43 p.m. confirmed that there was no documented evidence that the second step was completed on the above employees.

Plan of Correction - To be completed: 04/16/2024

This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because The Patriot, A Choice Community agrees with the allegations and citations listed on the statement of deficiencies. The Patriot, A Choice Community maintains that the alleged deficiencies do not, individually and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as The Patriot, A Choice Community written credible allegation of compliance.
By submitting this plan of correction, The Patriot, A Choice Community does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and The Patriot, A Choice Community all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding.

There were no residents affected in regards to this tag.

There were no residents affected in regards to this tag.

The Director of Nursing or designee will audit all current staff members for compliance of the 2nd step Purified Protein Derivative, PPD. The PPD will be provided to all identified employees via the Mantoux technique.

The director of nursing or designee will audit 100% of all current staff members for accuracy of administration 2nd step PPD. The audits will be conducted weekly X4 and monthly X2. All Finding will be submitted to the Quality Assurance Committee.

The Administrator of designee will review all new personnel files to ensure the employee has the appropriate documentation of the 2step PPD, Tuberculosis (TB) blood test, or rule out chest x-ray in accordance with the facility policy.

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