Patriot, A Choice Community The

F-F641, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding the accuracy of assessments.

The facility's plan of correction for a deficiency regarding care plan timing and revision, cited during the survey ending February 29, 2024, 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

F-F657, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding care plan timing and revision.

The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending February 29, 2024, 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

F-F684, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding quality of care.

The facility's plan of correction for a deficiency regarding the failure to account for controlled medications, cited during the survey ending February 29, 2024, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under

F-F755, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to the accountability of controlled medications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 30 395840 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395840 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Patriot Village 495 West Patriot Street Somerset, PA 15501

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 The facility's plans of correction for deficiencies regarding storage and labeling of medications, cited during

the survey ending February 29, 2024, revealed that the facility developed plans of correction that included Level of Harm - Minimal harm or completing audits and reporting the results of the audits to the QAPI committee for review. The results of the potential for actual harm current survey, cited under

F-F761, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding storage and labeling of medications. Residents Affected - Few

The facility's plan of correction for a deficiency regarding appropriate food preparation and serving, cited

during the survey ending February 29, 2024, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under

F-F812.

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

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 30 395840 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395840 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Patriot Village 495 West Patriot Street Somerset, PA 15501

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 48941 potential for actual harm Based on review of established infection control guidelines, facility policy, and residents' clinical records, as Residents Affected - Few well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for one of 31 residents reviewed (Resident 50).

Findings include:

CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and control guidance effective April 1, 2024. The recommendations now include the use of EBP

during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply.

The facility's policy regarding EBP, dated August 28, 2024, revealed that EBP's are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. Wounds generally include chronic wounds (such as pressure ulcers, diabetic foot ulcers, venous stasis ulcers, and unhealed surgical wounds). Indwelling medical devices include central lines, urinary catheters feeding tubes, and tracheostomies. Signs are posted in the door or on the wall outside of the resident's room indicating the type of precautions and PPE required. PPE is available inside of

the residents' rooms.

An admission MDS assessment for Resident 50, dated December 9, 2024, revealed that the resident had mild cognitive impairment, was understood and able to understand others, required substantial assist with bed mobility, was dependent for transfers, was not ambulatory, had an indwelling catheter (a thin, flexible tube inserted into the bladder to drain urine from the bladder), was frequently incontinent of bowel, had two Stage 2 pressure ulcers (pressure wound with skin loss) on admission, had a surgical wound and wound infection, had a pressure-relieving device to bed and chair, and received pressure ulcer care and surgical wound care. A care plan for Resident 50, dated December 3, 2024, revealed that the resident had a sacral surgical wound with EBP and a care plan, dated December 3, 2024, for an indwelling catheter with EBP.

A physician's order for Resident 50, dated December 2, 2024, included an order for an indwelling catheter, 16 French (size) with a 10 cubic centimeters (cc) balloon (located on the bladder end of the catheter and filled with sterile water to hold the tube in place).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 30 395840 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395840 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Patriot Village 495 West Patriot Street Somerset, PA 15501

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Physician's orders for Resident 50, dated December 3, 2024, included an order to cleanse the right and left buttocks with warm soap and water, pat dry, apply zinc oxide (topical medication to treat skin irritations) and Level of Harm - Minimal harm or cover with comfort foam twice daily. Physician's orders for Resident 50, dated December 3, 2024, included potential for actual harm an order to apply betadine (an solution used to treat and prevent infection) to the intergluteal cleft and buttocks flap closure with sutures and cover with comfort foam twice daily. Residents Affected - Few

Observations during the facility tour on January 7, 2025, at 2:20 p.m. revealed no signage on Resident 50's door or on the wall outside the resident's room to indicate that the resident was on EBP. Observations on January 8, 2025, at 9:02 a.m. revealed that the resident sitting in her wheelchair in her room with an indwelling catheter bag hanging under wheelchair and no signage on the resident's door or on the wall outside the resident's room to indicate that the resident was on EBP.

Interview with the Director of Nursing on January 8, 2025, at 2:18 p.m. confirmed that Resident 50 had an unhealed surgical wound and an indwelling catheter and that signage should have been visibly posted on the resident's door or outside the resident's room to indicate that the resident was on EBP.

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

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

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

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