Health inspection·April 12, 2024

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Based on observations, review of clinical records, and resident and staff interviews, it was determined that the facility failed to provide a bath/shower as resident preference for four of 26 residents reviewed (Residents R1, R4, R5, R6). Findings include: No policy was provided on baths/showers. Resident's R1's clinical record revealed an admission date of 9/03/21, with diagnoses that included polyosteoarthritis (joint pain and stiffness), dysuria (discomfort, pain, or burning when urinating), hypothyroidism (a condition when the thyroid gland doesn't produce enough thyroid hormone), and presence of artificial eye. During an interview with Resident R1 on 4/01/24, at 1:25 p.m. he/she indicated their bath/shower was scheduled for Wednesday and Saturday evenings, but he/she has not received the scheduled bath/shower in at least the past 10 days. Resident R1 verbalized, I told several people that I would like my bath on the dayshift, due to more reliable staff work those hours. It all depends on who and how many are working if you get a bath or not. Resident was observed with greasy hair. Review of Resident R1's bath/shower documentation for 3/01/24 through 4/03/24 revealed he/she was scheduled for a bath/shower on Wednesday/Saturday 3-11 p.m., however, no bath/shower was provided on 3/06/24, 3/20/24, and 3/30/24. Resident's R4's clinical record revealed an admission date of 3/06/24, with diagnoses that included heart failure, high blood pressure, chronic pulmonary obstructive disease (a chronic disease of the respiratory system that affects breathing), and hypothyroidism. Review of Resident R4's bath/shower documentation for 3/06/24 through 4/03/24 revealed he/she was scheduled for a bath/shower on Tuesday/Friday 3-11 p.m., however, no bath/shower was provided for the month of March 2024. Resident's R5's clinical record revealed an admission date of 3/19/24, with diagnoses that included heart failure, cardiac pacemaker (a small device used to keep the heart from beating too fast and/or too slow), lumbago with sciatica (low back that shoots down legs), and anxiety. Review of Resident R5's bath/shower documentation for 3/19/24 through 4/03/24 revealed he/she was scheduled for a bath/shower on Monday/Thursday 7-3 p.m., however, no bath/shower was provided on Page 1 of 6 395853 395853 04/12/2024 Crawford Care Center 20881 State Highway 198 Saegertown, PA 16433

F 0561 3/21/24, 3/25/24, and 4/01/24. Level of Harm - Minimal harm or potential for actual harm Resident's R6's clinical record revealed an admission date of 3/03/24, with diagnoses that included cerebral infarction due to occlusion (stroke where blood circulation in the brain is disrupted), urinary tract infection, high blood pressure, and heart failure. Residents Affected - Few Review of Resident R6's bath/shower documentation for 3/03/24 through 4/03/24 revealed he/she was scheduled for a bath/shower on Monday/Thursday 3-11 p.m., however, no bath/shower was provided on 3/04/24, 3/07/24, 3/11/24, 3/14/24, 3/18/24, and 3/21/24. During an interview on 4/03/24, at 3:55 p.m. the Nursing Home Administrator confirmed that the frequency of Baths/Showers are based on resident preference. An interview with the Director of Nursing on 4/04/24, at 12:20 p.m. confirmed that baths/showers were not provided according to residents'' scheduled days and preference for the period of 3/01/24 through 4/03/24 for the above noted residents. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services 395853 Page 2 of 6 395853 04/12/2024 Crawford Care Center 20881 State Highway 198 Saegertown, PA 16433

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on review of clinical records, and staff and resident interviews, it was determined that the facility failed to follow physician orders for three of six residents reviewed (Residents R1, R2, and R3). Residents Affected - Few Findings include: Resident's R1's clinical record revealed an admission date of 9/03/21, with diagnoses that included polyosteoarthritis (joint pain and stiffness), dysuria (discomfort, pain, or burning when urinating), hypothyroidism (a condition when the thyroid gland doesn't produce enough thyroid hormone), and presence of artificial eye. Review of Resident R1's Medication Administration Record (MAR) revealed a physician order with start date of 2/25/22, Levothyroxine Sodium 100 micrograms (mcg) give one tablet by mouth one time a day for hypothyroidism. Resident R1's MAR further revealed for the month of March 2024 that his/her Levothyroxine Sodium 100 mcg was not administered per physician order on 3/03/24, 3/04/24, 3/06/24, 3/09/24, 3/11/24, 3/12/24, and 3/13/24. During an interview on 4/01/24, at 1:25 p.m. Resident R1 indicated he/she has not received his/her medication for hypothyroidism as the physician ordered. Resident's R2's clinical record revealed an admission date of 3/13/24, with diagnoses that included urinary tract infection, muscle weakness, need for assistance with personal care, and unsteadiness on feet. Review of Resident R2's MAR revealed a physician order with start date of 3/14/24, and end date of 3/18/24, Nubega Oral Tablet 300 milligrams (mg) (Darolutamide) give 2 tablets by mouth two times a day related to Urinary Tract Infection. Resident R2's MAR further revealed for the month of March 2024 that his/her Nubega 300 mg 2 tablets was not administered per physician order on 3/15/24, at 8:00 a.m. and 9:00 p.m., 3/17/24, at 8:00 a.m., and 3/18/24, at 8:00 a.m. Resident R2's MAR further revealed a successive physician order with start date of 3/18/24, and end date of 4/03/24, Nubega Oral Tablet 300 mg (Darolutamide) give 2 tablets by mouth two times a day related to Urinary Tract Infection. Resident R2's MAR further revealed for the month of March 2024 that his/her Nubega 300 mg 2 tablets was not administered per physician order on 3/19/24, at 8:00 a.m and 3/30/24, at 8:00 a.m. Resident's R3's clinical record revealed an admission date of 1/15/24, with diagnoses that included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side (stroke with paralysis and weakness to left side of body), high blood pressure, gastro-esophageal reflux disease (a digestive disease in which the stomach acid or bile irritates the food pipe lining), and rheumatoid arthritis (a chronic inflammatory painful disorder affecting typically affecting small joints in the hands and feet). Review of Resident R3's MAR revealed a physician order with start date of 3/03/24, Norco Oral Tablet 7.5-325 mg (Hydrocodone-Acetaminophen) give 1 tablet by mouth every 12 hours for Pain Total dose = 7.5-487.5 mg Not to exceed 3000 mg acetaminophen every 24 hours. Resident R3's MAR further revealed for the month of March 2024 that his/her Norco Oral Tablet 7.5-325 mg (Hydrocodone-Acetaminophen) 395853 Page 3 of 6 395853 04/12/2024 Crawford Care Center 20881 State Highway 198 Saegertown, PA 16433

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was not administered per physician order on 3/04/24, at 6:00 a.m., 3/14/24, at 6:00 a.m. and 6:00 p.m., 3/15/24, at 6:00 a.m. and 6:00 p.m., 3/16/24, at 6:00 a.m. and 6:00 p.m., 3/17/24, at 6:00 a.m. and 6:00 p.m., 3/18/24, at 6:00 a.m. and 6:00 p.m., and 3/19/24, at 6:00 a.m. and 6:00 p.m. During an interview on 4/04/24, at 12:20 p.m. the Director of Nursing confirmed the medications noted above were not administered per physician orders for Residents R1, R2, and R3 during the month of March 2024. 28 Pa. Code 211.12(d)(1)(5) Nursing services 395853 Page 4 of 6 395853 04/12/2024 Crawford Care Center 20881 State Highway 198 Saegertown, PA 16433

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on review of facility policy and planned written menus, observations, and resident and staff interviews, it was determined the facility failed to provide each resident with a nourishing, well-balanced diet that meets his/her daily nutritional needs for one of one meal observed (lunch meal 4/01/24) and three of three meals reviewed (lunch, dinner meal 4/01/24 and breakfast meal 4/02/24). Findings include: Review of a facility policy entitled, Resident Food Preferences, dated 2/12/24, revealed Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident's or representative's consent. The food services department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night. Review of the facility menu for cycle week 3 for the lunch meal on 4/01/24, revealed Chicken Pot Pie w/Biscuit, Alternate- Hamburger on a Bun-Lettuce & Tomato-Ketchup-Pickle Spear, Tossed Salad w/Dressing, Broccoli Florets, Tater Tots-Ketchup Deluxe Fruit Salad. Review of the facility menu for cycle week 3 for the dinner meal on 4/01/24, revealed Butter Crumb Tilapia Fillet, Alternate-Glazed Baked Pork Chop, [NAME] Peas, Sliced Carrots, Baked Potato-Sour Cream-Margarine, Parsley Rice, Dinner Roll/Bread, Blondie. Review of the facility menu for cycle week 3 for the breakfast meal on 4/02/24, revealed Scrambled Eggs w/Cheese, Biscuit-Margarine-Jelly. Observations of the lunch meal service on 4/01/24, revealed noodles were provided instead of the chicken pot pie and biscuit. Also, no hamburger buns and tomato were available for the alternate. Facility resident census was 93 on 4/01/24. Observations of one of two unit pantries on 4/01/24 at 1:38 p.m. revealed only 13 sugar free cookies, no juice, and no other snacks available. Observations of the kitchen on 4/01/24 at 2:00 p.m. revealed the only snacks available were one case of cream pies, a half case of graham crackers, half box of peanut butter crackers and 8 sugar free cookies, the only ice cream available was 18 individual cups of vanilla and 10 individual cups of chocolate, alternate menu for hamburgers revealed only seven hamburgers and zero hamburgers in the freezer, zero buns, the only milk was one gallon of 1%, three gallons of whole milk, 41 individual serve cartons of 1% milk, and 19 individual cartons of chocolate milk, the juice station revealed three juice concentration boxes hooked up to the juice station which two of the boxes were empty and one was observed with a small amount of juice. Further observations revealed 16 black tea bags, one and a half standard size boxes of green tea bags, zero fresh fruit, one small container of shredded lettuce in water, zero tomatoes, zero pickles, zero biscuits, and zero peas. Residents' R1, R7, R8, R9 indicated during interviews on 4/01/24, that the facility food supply consistently runs out before the next delivery; they have been out of coffee for days, can have green tea, but not black tea due to nobody enjoys green tea and the stock of it stays the same and is then 395853 Page 5 of 6 395853 04/12/2024 Crawford Care Center 20881 State Highway 198 Saegertown, PA 16433

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some available. Residents further indicated recently there has been no creamer, fresh lettuce, hamburgers, buns for hamburgers (and other sandwiches), tomatoes, salad, fresh fruit, juice, milk - typically only 1%, and snacks are very limited. Resident R8 indicated, menus are not followed, and residents never know what they are going to get for a meal, until they open the cover when the meal arrives. Residents then request an alternate food and find out that it is not available as well. The residents further indicated that they were not notified of any menu changes on 4/01/24, and/or prior to 4/01/24. During an interview on 4/01/24, at 3:18 p.m. the Dietary Manager confirmed that noodles and not chicken pot pie with biscuits were served for the lunch meal on 4/01/24, and the residents were not notified of the change on the menu. The Dietary Manager further confirmed the facility had no coffee for breakfast and he/she had to run out to a local store to retrieve some on 4/01/24, and there were no peas for dinner on 4/01/24 -serving green beans with no notification to residents, no biscuit for breakfast for 4/02/24 -serving English muffins with no notification to residents of the changes. He/she confirmed the facility only had seven hamburgers for the alternate menu for 4/01/24, and the facility had zero in the freezer, and the facility had no buns for the hamburgers or tomatoes. He/she further confirmed the only snack available to offer diabetic residents was sugar free cookies, due to the facility had no fresh fruit salad and the juice station containers were empty with all juice poured into containers for later use during dinner and breakfast the next day. No extra juice was observed to offer the residents except for the two later meals. The Dietary Manager confirmed that the food supply truck was not expected to make a delivery until after 12:00 p.m. on 4/02/24. The facility failed to ensure that the dietary department was effectively managed to ensure the appropriate ordering and acquisition of food items was completed to fulfill the residents' nutritional needs for each meal and provide a variety of food at each scheduled meal. 28 Pa. Code 201.18 (b)(3) Management 28 Pa. Code 211.6 (a) Dietary services 395853 Page 6 of 6