Health inspection·June 15, 2023

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, and facility documentation and resident and staff interviews, it was determined that the facility failed to provide necessary precautionary measures to maintain resident safety and prevent injury during transport in a wheelchair resulting in actual harm of a fractured tibia for one of 18 residents reviewed (Resident R9). Findings include: Review of facility policy entitled Assistive Devices and Equipment dated 1/18/23, indicated, Residents, family, and visitors are trained, as indicated, on the safe use of equipment and devices and Staff practices-staff are required to demonstrate competency on the use of devices and equipment and are available to assist and supervise residents as needed. Review of the clinical record revealed that Resident R9 was admitted to the facility on [DATE], with diagnoses that included avulsion of the left and right eye (loss of eyesight), history of pulmonary embolism (blood clot in the lung), gout (pain and swelling in joints), hypertension (high blood pressure), and abnormalities of gait and mobility. Review of the Minimum Data Set (MDS-a federally mandated standardized assessment process conducted to plan resident care) assessment dated [DATE], revealed a BIMS (Brief Interview for Mental Status-a tool used to assess cognitive function) with score of 15, that indicates intact cognition. Review of the past 30 days of Resident R9's tasks which is used by the Nursing Assistants (NA) to provide care and document on residents indicated that from 5/16/23-6/14/23, Resident R9's Ambulation/Locomotion task was non-ambulatory. Uses wheelchair with pressure relief cushion, back cushion, calf pad, leg rests always on for transport. Review of the initial facility incident report dated 5/17/23, revealed a staff description that Resident was being pushed down the hallway by aide and resident's left foot was pulled under wheelchair. Resident R9's description of the event was that staff pushed her knee up against something and believes her knee was twisted. Facility incident report also included staff statements at the time of the incident which all revealed that the leg rests were not on the wheelchair at the time of the incident. Review of nursing progress notes revealed on 5/18/23, at 11:08 a.m. a STAT (immediate) x-ray of the left lower extremity, from the hip to foot and pelvis was ordered. The results were called in to the Certified Nurse Practitioner on 5/18/23, at 4:08 p.m. which indicated that Resident R9 had a left acute non-displaced proximal fracture, new orders were received at this time. Interview with Resident R9 on 6/13/23, at approximately 11:30 a.m. revealed that he/she was being pushed in his/her wheelchair without the leg rests on to get a shower. He/she expressed that he/she always wants the leg rests on the wheelchair because he/she is blind. Resident R9 expressed that his/her left leg was run into something and got caught, which broke his/her shin. He/she revealed that when this happened, he/she hollered out in pain and asked to be placed back into bed. During an interview on 6/14/23, at 1:00 p.m. the Director of Nursing (DON) confirmed the wheelchair (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395853 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crawford Care Center 20881 State Highway 198 Saegertown, PA 16433 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 0689 Level of Harm - Actual harm leg rests are always to be on the resident's wheelchair during transport. The DON confirmed that during the Resident R9's transport on 5/17/23, wheelchair leg rests were not in place and the resident sustained a fractured left tibia. The DON confirmed that Resident R9 always insists that the leg rest are always in place. Residents Affected - Few 28 Pa. Code 211.12 (d)(3)(5) Nursing services 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.14(a) Responsibility of licensee FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395853 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crawford Care Center 20881 State Highway 198 Saegertown, PA 16433 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on review of clinical records and facility policies, and staff interviews, it was determined that the facility failed to consistently obtain weights to thoroughly monitor and address the nutritional status for one of 18 residents reviewed (Resident R49). Residents Affected - Few Findings include: Review of a facility policy entitled, Quick Reference Guide dated 1/18/23, indicated residents: are weighed upon admission, weekly for four weeks, and then monthly unless their treatment plan dictates differently; weights are obtained by the seventh of the month; weight changes will be verified and addressed in the weekly interdisciplinary team meeting; weekly weights will be implemented on residents experiencing a weight change of three or more pounds in a week; and will remain on weekly weights until weight is stable. Review of Resident R49's clinical record revealed an admission date of 1/30/23, with diagnoses including Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), Type 2 Diabetes (condition that affects how the body uses glucose [sugar]), kidney disease, and intellectual disability. Further review of Resident R49's clinical record revealed the following recorded weights: 3/07/23- 200 lbs., 3/14/23- 195 lbs., 4/04/23- 183 lbs. (confirmed 4/06/23- identified significant weight loss), 5/02/23- 183 lbs., and 6/15/23- 177 lbs. (identified significant weight loss). The clinical record lacked evidence that the facility consistently monitored his/her weekly weights and nutritional status after the identified significant weight loss on 4/06/23, and failed to obtain his/her weight prior by the seventh of June and identify a significant weight loss in a timely manner. During an interview on 6/15/23, at 1:05 p.m. the Assistant Director of Nursing confirmed that weekly weights should have been done on Resident R49 when the significant weight loss was identified on 4/06/23. 28 Pa. Code 211.6 (d) Dietary services 28 Pa. Code 211.10 (c) Resident care policies 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395853 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crawford Care Center 20881 State Highway 198 Saegertown, PA 16433 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, review of facility policy, and staff interviews, it was determined that the facility failed to store controlled medications in a separately locked permanently affixed compartment and separate from non-controlled medications in two of two medication rooms (Memory Support Unit and Units 5 and 6 medication rooms), and utilize a system to identify residents prescribed specific over-the-counter stock (multi-dose containers of medications utilized for more than one resident) medications on one of two medication carts (300 hall). Findings include: Review of a facility policy entitled Medication Labeling and Storage, with a revision date of February 2023, indicated: Controlled substances (listed as Schedule II - IV of the Comprehensive Drug Abuse Prevention and Control Act of 1976) and other drugs subject to abuse are separately locked in permanently affixed compartments. Observation on 6/14/23, at 10:40 a.m. revealed that the medication room refrigerator on the 500 and 600 unit contained controlled medications stored in a separately locked compartment, and that the locked compartment was not permanently affixed to the refrigerator. During an interview at that time Licensed Practical Nurse Employee E1 confirmed that the controlled medication locked compartment was not permanently affixed to the refrigerator and that it should be permanently affixed to the refrigerator. Observation on 6/14/23, at 10:55 a.m. revealed that the 300 hall medication cart located in the Memory Care Unit contained one opened multi-dose stock bottle of Tylenol, Milk of Magnesia, and Pepto Bismol, and there was no system to identify which residents were prescribed to take these medications. Observation on 6/14/23, at 10:55 a.m. revealed that the medication room refrigerator on the Memory Care Unit contained two multi-dose vials of Ativan (antianxiety controlled medication) stored in a plastic bag with non-controlled medications and lacked a permanently affixed locked compartment. During an interview at that time, the Director of Nursing confirmed there was no system to properly identify which residents were prescibed to receive the stock Tylenol, Milk of Magnesia, and Pepto Bismol, and that the medication room refrigerator lacked a permanently affixed locked compartment to safely and securely store controlled medications. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395853 If continuation sheet Page 5 of 5