Crawford Care Center

Inspectors wroteBased on review of facility policies, clinical records, facility documents, observations, and staff interview, it was determined that the facility failed to implement sufficient monitoring and supervision to prevent elopement (when a resident leaves a safe care setting without staff knowledge) and failed to adequately implement search procedures related to an elopement. This failure placed residents at the facility in an Immediate Jeopardy situation for one of one residents reviewed (Resident R1).

Inspectors wroteBased on review of facility records and job descriptions, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to implement sufficient monitoring and supervision to prevent an elopement.

Inspectors wroteBased on review of facility policies, clinical records, and staff interview it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day), and failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital for five of five residents reviewed (Residents R2, R3, R5, R7, and R56).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to ensure that the attending physician documented required visits by writing, signing, and dating a physician progress note for each visit for 12 of 24 residents reviewed (Residents R2, R3, R5, R11, R13, R14, R25, R39, R42, R58, R60, and R94).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to ensure the physician alternated required resident visits with the nurse practitioner or physician's assistant for 16 of 24 residents reviewed (Residents R2, R3, R5, R7, R9, R11, R12, R13, R14, R39, R42, R55, R58, R60, R61, and R94).

Inspectors wroteBased on review of a facility policy, observations, and staff interview, it was determined that the facility failed to maintain sanitary operations in the main kitchen and failed to ensure that food was stored in accordance with standards for food safety in the main kitchen and three resident pantries reviewed (Units 100/200, 200/300, and 400/500).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to ensure physician's orders and residents Physician Order for Life Sustaining Treatment (POLST- a legal document specifying the resident/responsible party choices regarding life-sustaining treatments) were consistent for one of 24 residents reviewed (Resident R123).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide evidence that pharmacist medication regimen reviews were reviewed and signed by a physician prior to the administration of an as needed (PRN) psychotropic (mind altering) medication for one of one residents reviewed (Resident R109).

Inspectors wroteBased on review of facility policy, 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 two of 12 residents reviewed (Residents R12 and R7).

Inspectors wroteBased on review of facility policy and clinical record and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of 24 residents reviewed (Resident R11).

Inspectors wroteBased on review of facility policies and clinical record and staff interview, it was determined that the facility failed to review and/or revise resident care plans for one of 24 residents reviewed (Resident R11).

Inspectors wroteBased on review of facility policies, clinical records, and staff interview, it was determined that the facility failed to follow physician's orders related to a medication gradual dose reduction (GDR-lowering a high-risk medication to determine if a person can function safely on a lower dose) and failed to administer pain medication timely resulting in a delay in treatment for two of 24 residents reviewed (Residents R3 and R5).

Inspectors wroteBased on review of facility policy, facility documents, and facility meal schedule, observations, and resident and staff interviews, it was determined that the facility failed to ensure that alternate meals were served comparable to normal mealtime in accordance with resident preference and request for two of 24 residents (Residents R55 and R123).

Inspectors wroteBased on review of facility policy, clinical records, observations, and staff interview, it was determined that the facility failed to provide appropriate urinary catheter (tubing inserted into the bladder to drain urine into a bag) care to help prevent urinary tract infections for one resident reviewed for catheter care (Resident R12).

Inspectors wroteBased on review of clinical records and Minimum Data Set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care), and staff interviews it was determined that the facility failed to ensure that MDS assessments accurately reflected the status of three of 27 residents reviewed (Residents R7, R11, and R120).

Inspectors wroteBased on observations, review of facility policies and International Plumbing Code, and staff interviews it was determined that the facility failed to safely store food containers, and prepare, serve and store food in a safe and sanitary manner in the main kitchen; failed to prevent the potential for cross contamination (transfer of harmful substances or disease-causing organisms to food from unclean hands or objects) during food preparation; and failed to maintain safe storage of ice for residents for one of one ice machines located in the kitchen.

Inspectors wroteBased 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 five of 13 residents reviewed (Residents R3, R18, R30, R64, and Closed Record CR110).

Inspectors wroteBased on review of facility policy and clinical records, observations, and staff interviews, it was determined that the facility failed to provide oxygen according to physician's orders and failed to promote cleanliness and help prevent the spread of infection for four of 25 residents reviewed for respiratory services (Residents R30, R44, R48, and R64).

Inspectors wroteBased on review of clinical records and resident and staff interviews, it was determined that the facility failed to ensure that physician visits were conducted at least once every 60 days for three of three residents reviewed (R15, R19, and R26).

Inspectors wroteBased on review of facility policy, observation and staff interview, it was determined that the facility failed to ensure that waste was properly contained in dumpsters or compactors with lids or otherwise covered, and the garbage storage area was maintained in a sanitary condition to prevent the potential of harborage and feeding of pests for one of one garbage storage areas.

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to ensure a physician's order and POLST (Pennsylvania Orders for Life-Sustaining Treatment) were identical to indicate the correct code status as Full Code (CPR/Attempt Resuscitation) or Do Not Resuscitate (DNR/Do Not Attempt Resuscitation-Allow Natural Death) for one of 18 residents reviewed (Resident R18).

Inspectors wroteBased on observations, review of facility policies and documents, and staff interviews, it was determined that the facility failed to provide housekeeping services necessary to maintain a clean environment for one of one resident equipment observed (Resident R64).

Inspectors wroteBased on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to develop a respiratory care plan for two of 25 residents reviewed (Residents R30 and R64).

Inspectors wroteBased on review of clinical records, observations and staff interviews it was determined that the facility failed to follow the plan of care for one of 25 residents reviewed (Resident R48).

Inspectors wroteBased on review of facility policy and manufacturer's guidelines, observations and staff interviews, it was determined that the facility failed to appropriately discard outdated medications for one of three medication carts reviewed and one of two medication rooms reviewed (500 and 100 hall medication carts and 500/600 medication room).

Inspectors wroteBased on review of facility policies and clinical records, and staff interviews, it was determined that the facility failed to ensure the resident and/or resident representative was offered the opportunity to participate in the development, review, and/or revision of their person-centered care plan for three of three residents reviewed (Residents R1, R2, and R3).

Inspectors wroteBased on a review of facility policy, facility written menus, observations, and staff interviews, it was determined that the facility failed to follow their planned menu.

Inspectors wroteBased on a review of facility policy, facility meal schedules, observations, and staff interviews, it was determined the facility failed to follow their schedule for frequency of resident meals.

Inspectors wroteBased on review of facility policy, and facility provided documentation, and staff interviews, it was determined that the facility failed to ensure that resident financial records were made available through quarterly statements for two of two residents reviewed (Residents R1 and R3).

Inspectors wroteBased on review of facility policies and clinical records, and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of one residents reviewed regarding an elopement (Resident R30).

Inspectors wroteBased on review of facility policy and documentation and clinical records, and staff interview, it was determined that the facility failed to thoroughly investigate an elopement (unauthorized leave from a safe area) for one of one residents reviewed for elopements (Resident R30).

Inspectors wroteBased on observations, review of facility policies and documentation, and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program by failing to follow infection control guidelines from the Pennsylvania Department of Health (PA DOH) to reduce the spread of infections and prevent cross-contamination during the COVID-19 pandemic. This failure placed the facility in an Immediate Jeopardy situation for 20 of 20 residents reviewed (Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, and R20).

Inspectors wroteBased on observations, review of facility records, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to make certain that proper infection control procedures were followed to protect residents from cross-contamination, infections, viruses and disease in the facility.

Inspectors wroteBased on observations, review of clinical records and facility documents, and staff interviews, it was determined that the facility failed to ensure the Infection Preventionist (IP) performed the duties of the position to adequately implement an infection control program to detect and prevent the spread of COVID-19.

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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 ).

Inspectors wroteBased 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)

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased on review of facility documents, and resident and staff interview, it was determined that the facility failed to promote and facilitate resident self-determination through support of resident choice and make choices about aspects of his or her life in the facility that are significant to the resident for 11 of 11 residents reviewed for availability of food preferences (Residents R1-R11).