Health inspection·August 2, 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 review of clinical records and facility policy, and resident and staff interviews, it was determined that the facility failed to allow residents the right to make choices about aspects of his or her life in the facility that are significant to the resident for one of 22 residents reviewed (Resident R22). Findings include: A facility policy entitled, Discharge Summary and Plan, revised 10/2022, indicated when a resident's discharge is anticipated, a post-discharge plan is developed to assist the resident with discharge, every resident is evaluated for his/her discharge needs and has an individualized post-discharge plan, and includes: where the resident plans to reside; arrangements that have been made for follow-up care and services; description of the resident's stated discharge goals; degree of caregiver/support person availability, capacity and capability to perform required care; how the interdisciplinary team will support the resident in the transition to post-discharge care; what factors may make the resident vulnerable to preventable readmission; and how those factors will be addressed. If it is determined that returning to the community is not feasible, it will be documented why this is the case and who made the determination. Resident R22's clinical record revealed an admission date of 4/09/24, with diagnoses including respiratory failure, Type 2 Diabetes (condition that affects how the body uses glucose [sugar] for energy), adjustment disorder, high blood pressure, and chronic obstructive pulmonary disease (COPD- a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe). The clinical record also revealed a physician's order dated 5/30/24, that indicated Resident R22 had a discharge plan with home health. Resident R22's most recent Quarterly Minimum Data Set (MDS-a standardized assessment tool that measures health status in nursing home residents), with a reference date of 6/07/24, Section C0500 (Cognitive Status) revealed that Resident R22's Brief Interview for Mental Status (BIMS-15-point cognitive screening measure that evaluates memory and orientation and includes free and cued recall items) was a 15 (cognitively intact, able to make daily decisions). Further review of Resident R22's clinical record revealed: a Social Service admission Assessment that indicated Resident R22 expected to be discharged to the community and wanted to talk to someone about the possibility of leaving the facility; a Discharge Plan that indicated Resident R22 wanted to return home after treatment; a Care Conference Record dated 6/13/24, revealed Resident R22 wanted to return to his/her home, and that he/she is refusing to work with therapy. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 12 Event ID: 395853 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 08/02/2024 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)