Health inspection·May 3, 2024

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm Based on review of facility documents and clinical records, and staff and family interviews, it was determined that the facility failed to fully inform and discuss the change of treatments for the medical management of a resident's clinical status and/or discuss alternate treatment options preferred by the resident's representative in advance of these changes for one of five residents reviewed for pharmacy recommendations (Resident R38). Residents Affected - Few Findings include: The facility's admission packet provided to residents/representatives on admission revealed: all residents have the right to equal access to quality care regardless of diagnosis, severity of condition, or payment source; have to right to be fully informed of your medical condition in a language you can understand, and to participate in your person-centered care planning and treatment; and the right to refuse and/or discontinue medications and treatments (but this could be harmful to your health). Resident R38's clinical record revealed an admission date of 10/26/17, with diagnoses including secondary hyperaldosteronism (hyperaldosteronism- is a condition in which one or both of your adrenal glands produce too much aldosterone [aldosterone is a hormone that helps regulate your blood pressure by controlling the levels of potassium and sodium in your blood]), kidney disease, heart disease, Alzheimer's Disease (progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), severe intellectual disabilities, and psychosis (collection of symptoms that affect the mind, where there has been some loss of contact with reality). Resident R38's clinical record included a pharmacy consultant Note to Attending Physician/Prescriber dated 10/24/23, that identified Resident R38 was receiving a combination of two medications (Valsartanantihypertensive, and Spironolactone- diuretic) that may increase his/her potassium levels, and included a recommendation that the facility monitor Resident R38's potassium levels, and a physician's response of Family declined dated 10/30/23. Further review of Resident R38's clinical record revealed a practitioner progress note dated 11/07/23, indicated no diagnostic tests. A court appointment of guardianship dated 9/25/23, indicated that Resident R38's brother was recognized as his/her legal guardian, and a POLST (Physician Order for Life Sustaining Treatment) dated 11/20/21, lacked evidence the Resident R38's legal guardian consented to withhold bloodwork and/or diagnostic testing. Page 1 of 19 395853 395853 05/03/2024 Crawford Care Center 20881 State Highway 198 Saegertown, PA 16433

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident R38's clinical record lacked evidence that his/her responsible party received education to make an informed consent (the process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention) to refuse diagnostic tests and lacked evidence of a physician's order declining bloodwork and/or diagnostic testing. Interview on 5/03/24, at 11:48 a.m. (via telephone) with Resident R38's legal guardian confirmed that he/she did not decline for the facility to obtain bloodwork and/or diagnostic testing. Interview on 5/03/24, at 12:58 a.m. with the facility's Clinical Consultant Employee E6 confirmed that there was no evidence of informed consent from the family to not obtain bloodwork, and the facility was unable to determine the source of the physician's response of 'Family declined to the pharmacy consultant Note to Attending Physician/Prescriber dated 10/24/23. Interview on 5/03/24, at 12:12 p.m. with the Director of Nursing confirmed Resident R38's clinical record lacked evidence of a physician's order or a practitioner's note to obtain consent from the family to withhold bloodwork and/or diagnostic testing. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(2)(3) Management 28 Pa. Code 201.29(a) Resident Rights 28 Pa. Code 211.12(d)(1)(5) Nursing services 395853 Page 2 of 19 395853 05/03/2024 Crawford Care Center 20881 State Highway 198 Saegertown, PA 16433

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documentation and staff interview, it was determined that the facility failed to issue the Notice of Medicare Non-Coverage liability and/or appeal notice, and Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN form - provides information to residents so they can decide if they wish to continue skilled services that may not be paid for by Medicare and assume financial responsibility) to the resident, or the resident's representative, following the end of Medicare covered services for two of two residents reviewed who remained in the facility for long-term care (Residents R6, R52) and one resident who was discharged from the facility (Closed Record Resident CR190). Residents Affected - Some Findings include: Resident R6's clinical record revealed an admission date of 1/25/24, with diagnoses including broken vertebrae, colon cancer, repeated falls, and bacterial skin infection of the left toe. Review of an admission Minimum Data Set (MDS- standardized assessment tool that measures health status in nursing home residents) dated 5/01/24, under Section C0500 indicated that Resident R6's Brief Interview of Mental Status (BIMS- mandatory tool used to screen and identify the cognitive condition of residents in a long-term care facility) was 15 (intact cognition). A Notice of Medicare Non-Coverage notice dated 4/22/24, revealed that Medicare provided services would end on 4/24/24, and that Resident R6 did not wish to continue Medicare covered treatment or appeal the decision. Review of a SNFABN form dated 4/22/24, also indicated that Resident R6 would be discharged from Medicare provided services and had benefit days remaining. The clinical record lacked evidence of acknowledgement that Resident R6 had received the Notice of Medicare Non-Coverage notice or the SNFABN. Resident R52's clinical record revealed an admission date of 3/12/24, with diagnoses including pulmonary embolism (sudden blockage in your pulmonary arteries, the blood vessels that send blood to your lungs), seizure disorder, general muscle weakness, and abnormal gait and mobility. Review of an admission MDS assessment dated [DATE], under Section C0500 indicated that Resident R52's BIMS was 12 (intact cognition). A Notice of Medicare Non-Coverage notice dated 4/10/24, revealed that Medicare provided services would end on 4/12/24, and that Resident R52 did not wish to continue Medicare covered treatment or appeal the decision. Review of a SNFABN form dated 4/10/24, also indicated that Resident R6 would be discharged from Medicare provided services and had benefit days remaining. The clinical record lacked evidence of acknowledgement that Resident R52 had received the Notice of Medicare Non-Coverage notice or the SNFABN. Resident CR190's closed clinical record revealed an admission date of 3/13/24, with diagnoses including urinary tract infection, dementia, history of falling, alcohol abuse, and long-term kidney disease. Review of an admission MDS dated [DATE], under Section C0500 indicated that Resident CR190's BIMS was 15. A Notice of Medicare Non-Coverage notice dated 3/19/24, revealed that Medicare provided services would end on 3/21/24, and that Resident CR190 did not wish to continue Medicare covered treatment or appeal the decision. Review of a SNFABN form dated 3/19/24, also indicated that Resident CR190 395853 Page 3 of 19 395853 05/03/2024 Crawford Care Center 20881 State Highway 198 Saegertown, PA 16433

F 0582 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some voluntarily discharged from Medicare provided services. The closed clinical record lacked evidence of acknowledgement that Resident CR190 had received the Notice of Medicare Non-Coverage notice or the SNFABN. During an interview on 5/03/24, at 1:09 p.m. the Director of Nursing and Clinical Consultant Employee E6 confirmed there was no evidence that Residents R6, R52, and Resident CR190 or their representatives received the Notice of Medicare Non-Coverage notices or the SNFABN upon being discharged from Medicare provided services. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(2)(3)(e)(1) Management 28 Pa. Code 201.29(a) Resident rights 395853 Page 4 of 19 395853 05/03/2024 Crawford Care Center 20881 State Highway 198 Saegertown, PA 16433

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and facility documentation, and staff interview, it was determined that the facility failed to complete the Minimum Data Set (MDS-periodic assessment of resident care needs) to accurately reflect the resident's status at the time of the assessment for two of 22 residents reviewed (Residents R14 and R57). Residents Affected - Few Findings include: Resident R14's clinical record revealed an admission date of 3/27/24, with diagnoses that included end stage renal disease (a diseases where the kidneys no longer work to meet the body's needs), hypokalemia (low potassium levels), and hypertension (high blood pressure). Resident R14's clinical record revealed that dialysis was ordered on 3/27/24, and Resident R14 received dialysis treatments on 3/30/24, and 4/2/24. The five day MDS dated [DATE], Section O0100 J. Special Treatments, Procedures, and Programs category, dialysis was marked No indicating Resident R14 was not receiving dialysis treatments. Resident R57's clinical record revealed an admission date of 1/15/24, with diagnoses that included hypertension (high blood pressure), anxiety, and type II diabetes. Resident R57's order summary revealed that a Trulicity injection (an antihyperglycemic injection used to help control blood sugar, which is not classified as an insulin) was ordered on 1/15/24. The Quarterly MDS dated [DATE], Medications Section N0350A indicated that Resident R57 received insulin one time. During an interview on 5/2/24, at 2:00 p.m. Registered Nurse Assessment Coordinator Employee E3 confirmed that Section O - Special Treatments, Procedures, and Programs category J1 Dialysis of the five day MDS dated [DATE], was incorrectly coded for Resident R14 and should have been marked yes and that Section N - Medications category N0350A Insulin of the Quarterly MDS dated [DATE] was incorrectly coded for Resident R57 and should have been zero days. 28 Pa. Code 211.5(f)(iv) Medical records 395853 Page 5 of 19 395853 05/03/2024 Crawford Care Center 20881 State Highway 198 Saegertown, PA 16433

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for eight of 22 residents reviewed (Residents R30, R14, R81, R3, R41, R69, R74, and R83). Findings include: A facility policy entitled, Care Plans - Baseline dated 2/12/24, revealed The resident and/or representative are provided a written summary of the baseline care plan (in a language that the resident/representative can understand) that includes, but is not limited to the following: a. The stated goals and objectives of the resident; b. A summary of the resident's medications and dietary instructions; c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility; and d. Any updated information based on the details of the comprehensive care plan, as necessary. Resident R30's clinical record revealed an admission date of 3/29/24, with diagnoses that included heart failure (a condition where the heart cannot supply the body with enough blood). Resident R30's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R30 and/or his/her representative. Resident R14's clinical record revealed an admission date of 3/27/24, with diagnoses that included end stage renal disease (a diseases where the kidneys no longer work to meet the body's needs). Resident R14's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R14 and/or his/her representative. Resident R81's clinical record revealed an admission date of 1/21/24, with diagnoses that included vitamin D deficiency, major depressive disorder, and pneumonia. Resident R81's clinical record lacked evidence that a written summary of the baseline care plan and 395853 Page 6 of 19 395853 05/03/2024 Crawford Care Center 20881 State Highway 198 Saegertown, PA 16433

F 0655 order summary was provided to Resident R81 and/or his/her representative. Level of Harm - Minimal harm or potential for actual harm Resident R3's clinical record revealed an admission date of 2/25/24, with diagnoses that included diabetes (a health condition related to the body's inability to produce enough insulin and elevated blood sugar levels). Residents Affected - Some Resident R3's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R3 and/or his/her representative. Resident R41's clinical record revealed an admission date of 3/29/24, with diagnoses that included dysphagia (difficulty swallowing), pain in left shoulder, and muscle weakness. Resident R41's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R41 and/or his/her representative. Resident R69 admission record revealed an admission date of 11/6/23, with diagnoses that included Chronic Obstructive Pulmonary disease (a disease that obstructs air flow from the lungs). Resident R69's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R69 and/or his/her representative. Resident R74's clinical record revealed an admission date of 3/13/24, with diagnoses that included muscle weakness, unsteadiness on feet, and dysphagia. Resident R74's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R74 and/or his/her representative. Resident R83's clinical record revealed an admission date of 3/16/24, with diagnoses that included retention of urine (a condition when the body is unable to empty all the urine from the bladder). Resident R83's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R83 and/or his/her representative. During an interview on 5/2/24, at 2:35 p.m. the Assistant Director of Nursing confirmed that the clinical record for all residents listed above lacked evidence that a written summary of the baseline care plan and order summary was provided to the residents and/or his/her representative. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(3) Nursing services 395853 Page 7 of 19 395853 05/03/2024 Crawford Care Center 20881 State Highway 198 Saegertown, PA 16433

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to develop comprehensive care plans for two of 22 residents reviewed (Residents R14 and R64 ). Residents Affected - Few Findings include: Review of facility policy entitled Care Plans, Comprehensive Person Centered dated 2/12/24, indicated The comprehensive person centered care plan is developed within seven days of the completion of the required MDS assessment, and no more than 21 days after admission. Review of Resident R14's clinical record revealed an admission date of 3/27/24, with diagnoses that included end stage renal disease (a diseases where the kidneys no longer work to meet the body's needs), hypokalemia (low potassium levels), and hypertension (high blood pressure). Review of Resident R14's physician orders revealed an order for dialysis every Tuesday and Saturday. Further review of Resident R14's person centered plans of care revealed only a plan of care for nutrition. Review of Resident R64' clinical record revealed an admission date of 4/10/24, with a diagnoses that included, urinary tract infection, Parkinson's Disease (involuntary muscle movements) and hypertension (high blood pressure). Review of Resident R64's clinical record revealed that the comprehensive plan of care included only one area of assessment which was a plan for nutrition. During an interview on 5/2/24, at 2:00 p.m. the Registered Nurse Assessment Coordinator confirmed that Residents R14 and R64's comprehensive plans of care were not completed within 21 days from admission. 28 Pa. Code 211.12(d)(1)(5) Nursing services 395853 Page 8 of 19 395853 05/03/2024 Crawford Care Center 20881 State Highway 198 Saegertown, PA 16433

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to review and revise comprehensive care plans to reflect the current care and services for nine of 22 residents reviewed (Residents R40, R14, R30, R37, R81, R41, R43, R74, and R83). Findings include: A facility policy entitled, Care Plans, comprehensive Person-Centered, dated 2/12/24, indicated that the interdisciplinary team reviews and updates the care plan: when there has been a significant change in the resident's condition; when the desired outcome is not met; when the resident has been readmitted to the facility from a hospital stay; and at least quarterly (every three months) in conjunction with the required quarterly MDS (Minimum Data Set- standardized assessment tool that measures health status in nursing home residents). Resident R81's clinical record revealed an admission date of 1/21/24, with diagnoses that included vitamin D deficiency, major depressive disorder, and pneumonia. Resident R81's care plan revealed a target date of 2/21/24, indicating that the care plan was not reviewed and revised to reflect the current care and services. Resident R41's clinical record revealed an admission date of 3/29/24, with diagnoses that included dysphagia (difficulty swallowing), pain in left shoulder, and muscle weakness. Resident R41's care plan revealed a target date of 4/18/24, indicating that the care plan was not reviewed and revised to reflect the current care and services. Resident R74's clinical record revealed an admission date of 3/13/24, with diagnoses that included muscle weakness, unsteadiness on feet, and dysphagia. Resident R74's care plan revealed a target date of 4/1/24, indicating that the care plan was not reviewed and revised to reflect the current care and services. Resident R37's clinical record revealed an admission date of 8/10/20, with diagnoses that included heart failure, dementia, Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). Resident R37's care plan revealed a target date of 2/22/24, indicating that the care plan was not reviewed and revised to reflect the current care and services. Resident R40's clinical record revealed an admission date of 7/09/20, with diagnoses that included Parkinsonism (a motor syndrome that manifests as rigidity, tremors, and difficulty walking). Resident R40's care plan revealed a target date of 3/22/24, indicating that the care plan was not reviewed and revised to reflect the current care and services. Resident R14's admission record revealed an admission date of 3/27/24, with diagnoses that included 395853 Page 9 of 19 395853 05/03/2024 Crawford Care Center 20881 State Highway 198 Saegertown, PA 16433

F 0657 end stage renal disease (a diseases where the kidneys no longer work to meet the body's needs). Level of Harm - Minimal harm or potential for actual harm Resident R14's care plan revealed a target date of 4/11/24, indicating that the care plan was not reviewed and revised to reflect the current care and services. Residents Affected - Some Review of Resident R43's clinical record revealed an admission date of 11/21/17, with diagnoses that included Dementia (a disease that affects short term memory and the ability to think logically). Resident R43's care plan revealed a target date of 4/21/24, indicating that the care plan was not reviewed and revised to reflect the current care and services. Review of Resident R30's clinical record revealed an admission date of 3/29/24, with diagnoses that included heart failure (a condition where the heart cannot supply the body with enough blood). Resident R30's care plan revealed a target date of 4/15/24, indicating that the care plan was not reviewed and revised to reflect the current care and services. Review of Resident R83's clinical record revealed an admission date of 3/16/24, with diagnoses that included retention of urine (a condition when the body is unable to empty all the urine from the bladder). Resident R83's care plan revealed a target date of 4/5/24, indicating that the care plan was not reviewed and revised to reflect the current care and services. During an interview on 5/2/24, at 2:00 p.m. the Registered Nurse Assessment Coordinator Employee E3 confirmed that the care plans for Residents R40, R14, R30, R37, R81, R41, R43, R74, and R83 were not reviewed and revised timely to reflect current resident care and services. 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services 395853 Page 10 of 19 395853 05/03/2024 Crawford Care Center 20881 State Highway 198 Saegertown, PA 16433

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observations, review of clinical records and facility policy and staff interviews, it was determined that the facility failed to promote cleanliness and help prevent the spread of infection regarding respiratory care equipment according to physician's orders for two of two residents reviewed for respiratory care (Residents R43 and R69) Residents Affected - Few Finding include: Review of facility policy entitled Oxygen Administration dated 2/12/24, indicated tubing is to be changed weekly and dated, and filters on concentrators to be cleaned weekly with tubing change. Review of Resident R43's clinical record revealed an admission date of 11/21/17, with diagnoses that included dementia (a disease that affects short term memory and the ability to think logically), chronic obstructive pulmonary disease (COPD-a disease that obstructs air flow from the lungs), and peripheral vascular disease (a disease where your veins have trouble sending blood from your limbs back to your heart). Review of Resident R43's physician orders revealed an order dated 11/1/23, for oxygen at two liters per minute as needed. Further review of Resident R43's physician orders revealed an order dated 1/15/24, for changing the humidification water bottle (a bottle filled with water to add moisture to the oxygenated air) every two days and one time weekly on Sundays when utilizing oxygen. Another order dated 1/15/24, revealed an order for changing oxygen tubing (a soft tube that delivers oxygen) and cleaning the filter on the oxygen concentrator weekly on Mondays. Review of Resident R43's treatment record for the month of March 2024, revealed that he/she received oxygen on 3/4/24, 3/5/24, 3/7/24, 3/12/24, and 3/18/24. Treatment record for the month of April 2024, revealed that he/she received oxygen on 4/5/24, 4/8/24, and 4/17/24. Observation on 4/30/24, at 12:30 p.m. in Resident R43's room revealed an oxygen concentrator with a humification water bottle connected to it dated 3/4/24, there was oxygen tubing connected to the humification water bottle which lacked a date. Review of Resident R69 clinical record revealed an admission date of 11/6/23, with diagnoses that included COPD, heart failure (a condition where the heart cannot supply the body with enough blood) and hypertension (high blood pressure). Review of Resident R69's physician orders revealed an order dated 11/8/23, for oxygen at two liters per minute every shift as needed and to change the humidification water bottle on the oxygen concentrator every two days. Further review of his/her physician orders reveal an order dated 11/12/23, to change oxygen tubing and clean filter every Sunday. Observation on 4/30/24, at 12:35 p.m. revealed an oxygen concentrator with a filter on the back of the concentrator with a large amount of a white substance covering the entire filter. Further observations revealed oxygen tubing connected to the humidification water bottle which both the oxygen tubing and humidification water bottle lacked dates. During an interview with License Practical Nurse (LPN) Employee E2 on 4/30/24, at 2:18 p.m. he/she revealed that if the resident needed oxygen, he/she would have used the concentrator, oxygen tubing 395853 Page 11 of 19 395853 05/03/2024 Crawford Care Center 20881 State Highway 198 Saegertown, PA 16433

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and the humidification water bottle that was connected to the oxygen concentrator that was in the resident's room. During an interview with LPN Employee E2 on 4/30/24, at 2:20 p.m. he/she confirmed that the humidification water bottle, and the oxygen tubing should be dated, and the filter should be cleaned as ordered by the physician. He/she also confirmed that the oxygen tubing and humidification water bottle should be discarded and the concentrator filter should be cleaned. 28 Pa. Code 211.12(d)(1)(5) Nursing services 395853 Page 12 of 19 395853 05/03/2024 Crawford Care Center 20881 State Highway 198 Saegertown, PA 16433

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on review of facility contract, clinical record, and staff interview, it was determined that the facility failed to maintain records relating to dialysis communication for one of one residents reviewed for dialysis (Resident R14). Residents Affected - Few Findings include: Review of dialysis contract dated 2/12/24, indicated Designated Resident Information, Facility shall ensure that all appropriate medical, social, administrative, and other information accompany all designated residents at the time of transfer to center. This information shall include . appropriate medical records . treatments being provided to designated resident, including medications and any changes in the patient's condition, change of medication, diet, or fluid intake . any other information that will facilitate the adequate coordination of care as reasonably determined by center. Review of facility's dialysis communication form entitled Dialysis/Observation Communication Form revealed that the top section was to be completed by the facility, which included treatments being provided to the resident, including medications and any changes in the patient's condition, change of medication, diet, or fluid intake and other information that will facilitate the adequate coordination of care. Review of Resident R14's clinical record revealed an admission date of 3/27/24, with diagnoses that included end stage renal disease (a disease where the kidneys no longer work to meet the body's needs), hypokalemia (low potassium levels), and hypertension (high blood pressure). Review of Resident R14's physician orders revealed an order for dialysis every Tuesday and Saturday with a time of 11:30 a.m. Review of Resident R14's nursing documentation dated 3/27/24, revealed that he/she would have dialysis on the following Saturday 3/30/24, and then his/her normal dialysis days would be on Tuesday, Thursday, and Saturdays. Review of Resident R14's clinical record lacked evidence of communication between the facility and dialysis clinic. Interview with Registered Nurse Employee E1 on 5/2/24, at 12:16 p.m. revealed that Resident R14 received dialysis every Tuesday and Saturday and a communication form should be completed and sent with the resident with each transfer to dialysis. During an interview on 5/2/24, at 2:35 p.m. the Assistant Director of Nursing confirmed there was no evidence of communication between the facility and dialysis clinic. He/she also confirmed that communication should be done with every dialysis treatment. 28 Pa. Code 211.5(f)(iv)(viii) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395853 Page 13 of 19 395853 05/03/2024 Crawford Care Center 20881 State Highway 198 Saegertown, PA 16433

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to provide a clinical rationale for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14-days and failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of a PRN psychotropic medication for four of 22 residents reviewed (Residents R81, R41, R43, and R2). Findings include: A facility policy entitled Psychotropic Medication Use dated 2/12/24, revealed that Non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible For psychotropic medications that are NOT antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration of the PRN order. Resident R81's clinical record revealed an admission date of 1/21/24, with diagnoses that included vitamin D deficiency, major depressive disorder, and pneumonia. A physician's order dated 3/4/24, identified to administer Lorazepam (anti-anxiety) 0.5 milligrams (mg) by mouth every 6 hours as needed for aggression and combativeness, and lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days. Review of the March 2024 and April 2024 medication administration record (MAR) for Resident R81 revealed that the PRN Lorazepam was used on 3/5/24, 3/7/24, 3/8/24, 3/9/24, 3/11/24, 3/12/24, 3/14/24, 3/16/24, 3/17/24, 3/19/24, 3/20/24, 3/22/24, 3/23/24, 3/24/24, 3/25/24, 3/26/24, 4/20/24, 4/23/24, 4/24/24, 4/25/24, 4/26/24, and 4/30/24. Review of the March and April 2024 MARs, and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions attempted prior to the administration of the PRN Lorazepam for the 16 administrations of Lorazepam in March 2024 and six administrations of Lorazepam in April 2024. Resident R41's clinical record revealed an admission date of 3/29/24, with diagnoses that included anxiety, dysphagia (difficulty swallowing), pain in left shoulder, and muscle weakness. A physician's order dated 3/29/24, identified to administer Lorazepam 0.5 mg by mouth as needed for anxiety, and lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days. Review of the March and April 2024 MARs for Resident R41 revealed that the PRN Lorazepam was used on 3/31/24, 4/5/24, 4/9/24, 4/13/24, 4/23/24, 4/24/24, 4/27/24, 4/29/24, and 4/30/24. Review of the March and April 2024 MARs, and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions attempted prior to the administration of the PRN Lorazepam for the one administration of Lorazepam in March 2024 and three of eight administrations of Lorazepam in April 2024 (4/13/24, 4/23/24, and 4/29/24). Review of Resident R43's clinical record revealed an admission date of 11/21/17, with diagnoses that included dementia, chronic obstructive pulmonary disease (a disease that obstructs air flow from 395853 Page 14 of 19 395853 05/03/2024 Crawford Care Center 20881 State Highway 198 Saegertown, PA 16433

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the lungs), and peripheral vascular disease (a disease where your veins have trouble sending blood from your limbs back to your heart). A physician's order dated 3/26/24 to administer Lorazepam, 0.5 mg by mouth every six hours as needed for anxiety and lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days. Review of Resident R2's clinical record revealed an admission date of 1/12/21, with diagnoses that included dementia, weakness, and anxiety. A physician's order dated 5/1/24, to administer Lorazepam, 0.5 mg by mouth every four hours as needed for anxiety and lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days. During an interview on 5/2/24, at 2:35 p.m. the Assistant Director of Nursing confirmed that all the residents listed above had Lorazepam orders that lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days and that R41's and R81's clinical record lacked evidence that non-pharmacological interventions were being attempted prior to administering Lorazepam. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395853 Page 15 of 19 395853 05/03/2024 Crawford Care Center 20881 State Highway 198 Saegertown, PA 16433

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 review of facility policy, observations, and staff interview, it was determined that the facility failed to prevent the opportunity for potential unauthorized access of medications for one of five medication carts (Primrose Lane- memory care unit), failed to label a multi-dose insulin pen (medication to treat elevated blood sugar levels) with the date it was opened in one of five medication carts (Maple Lane), and failed to ensure that medications subject to abuse were stored in separately locked, permanently affixed compartment in one of three medication refrigerators (Blue Unit). Findings include: Review of the facility policy entitled Administering Medications dated 2/12/24, indicated that the medication cart must be kept closed and locked when out of the nurse's view. Review of the facility policy entitled Medication Labeling and Storage dated 2/12/24, indicated that multi-dose vials/containers are dated when opened and discarded within 28 days unless the manufacturer specifies a shorter or longer date. Review of the facility policy entitled Controlled Substances dated 2/12/24, indicated that controlled substances are separately locked in permanently affixed compartments. Observation on 4/30/24, at 11:54 a.m. revealed the Primrose medication cart was in the central hallway by the nurse's station in the Memory Gardens unit unlocked and unattended, and at 11:59 a.m. Licensed Practical Nurse (LPN) Employee E2 entered the Memory Gardens unit. During an interview at 11:59 a.m. LPN Employee E2 confirmed that the medication cart should be secured when not in view. Observation on 5/02/24, at 12:53 p.m. revealed the Maple Lane medication cart contained an opened undated multi-dose insulin pen and the manufacturer's packaging was labeled to discard within 28 days of opening. During an interview at that time, LPN Employee E4 confirmed that multi-dose vials/containers of medication are to be dated upon opening to ensure that staff discard them in a timely manner. Observation on 5/02/24, at 1:00 p.m. revealed a locked refrigerator in the Blue Wing Medication Room that contained a locked clear plastic box intended to safely secure controlled medications and was affixed to the removable wire shelving and not permanently affixed. At the time of the observation, LPN Employee E5 confirmed that the clear plastic box intended to safely secure controlled medications was not permanently affixed and could be removed from the refrigerator. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(a)(1) Pharmacy services 395853 Page 16 of 19 395853 05/03/2024 Crawford Care Center 20881 State Highway 198 Saegertown, PA 16433

F 0761 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 395853 Page 17 of 19 395853 05/03/2024 Crawford Care Center 20881 State Highway 198 Saegertown, PA 16433

F 0851 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on facility requirements according to the Affordable Care Act (ACA), review of Payroll Based Journal (PBJ) Staffing Data Reports and staff interview, it was determined that the facility failed to electronically submit direct care staffing information for one of the last four quarters (Quarter Four of 2023). Findings include: Review of Section 6106 of the ACA requires facilities to electronically submit direct care staffing information (including agency and contract staff) based on payroll and other auditable data to the Centers for Medicare and Medicaid Services (CMS). Submission must be received by the end of the 45th calendar day (11:59 p.m. Eastern Standard Time) after the last day of each fiscal quarter to be considered timely. First quarter reporting includes data from October 1st through December 31st and is due by February 14th. Second quarter reporting includes data from January 1st through March 31st and is due by May 15th. Third quarter reporting includes data from April 1st through June 30th and is due by August 14th. Fourth quarter reporting includes July 1st through September 30th and is due by November 14th. Review of PBJ staffing data reports for fiscal year fourth quarter 2023 revealed the facility triggered for Failed to Submit Data for the Quarter. During an interview on 4/30/24, at 11:11 a.m. the Nursing Home Administrator confirmed that the PBJ report for Quarter Four for 2023 indicated failed for submission status and the facility did not meet the reporting requirement. 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.18(e)(1) Management 395853 Page 18 of 19 395853 05/03/2024 Crawford Care Center 20881 State Highway 198 Saegertown, PA 16433

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, facility records, and staff interview, it was determined that the facility failed to provide evidence of a Quality Assurance and Performance Improvement (QAPI) Committee meeting for one of four quarterly QAPI Committee meetings reviewed occurring in 2023 and 2024 (First Quarter of 2024). Residents Affected - Some Findings include: Review of facility policy entitled, Quality Assurance and Performance Improvement (QAPI) Program dated 2/27/2023 stated, The committee meets monthly to review reports, evaluate data and monitor QAPI-related activities and make adjustments to the plans. Review of the QAPI Committee Attendance Records revealed no evidence of a quarterly meeting for the First Quarter of 2024. During an interview on 5/01/24, at 11:30 a.m. the Nursing Home Administrator confirmed that there was no evidence of a QAPI Committee meeting regarding the First Quarter meetings of 2024. 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.18(e)(1) Management 395853 Page 19 of 19