Crawford County Care Center

F-F880.

28 Pa. Code 201.14(a) Responsibility of Licensee

28 Pa. Code 201.18(a) Management

28 Pa. Code 201.18(b)(1)(3) Management

28 Pa. Code 201.18(e)(1) Management

28 Pa. Code 211.12(c) Nursing Services

28 Pa. Code 211.12(d)(1)(5) Nursing Services

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 11 395853 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395853 B. Wing 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)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Immediate **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40832 jeopardy to resident health or safety Based 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 Residents Affected - Some 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 Resident R1, Resident R2, Resident R3, Resident R4, Resident R5, Resident R6, Resident R7, Resident R8, Resident R9, Resident R10, Resident R11, Resident R12, Resident R13, Resident R14, Resident R15, Resident R16, Resident R17, Resident R18, Resident R19, and Resident R20).

Findings include:

Review of the Pennsylvania Department of Health COVID-19 Infection Control and Outbreak Response Toolkit for Long-Term Care Version 1.1 dated February 2024, and expanded from infection prevention and control guidance from the Centers for Disease Control and Prevention (CDC) for nursing homes and Long-Term Care Facilities revealed the following:

During the Outbreak: COVID-19 Outbreak Management and Control Measures included:

1.Identify and Isolate First Case.

a. Isolate with transmission-based precautions (TBP) on COVID-19 Care Unit in accordance with most up-to-date isolation guidance or provide source control to positive resident and isolate in room (ideally residents should be placed in a single-person room).

b. Place TBP signs on the door to indicate to those entering the COVID-19 Care Unit/room of the personal protective equipment (PPE) requirements when providing care to residents with COVID-19.

c. Ensure all required PPE is available including N95 or higher-level respirator, gowns, gloves, and eye protection and is worn.

d. Reinforce core infection prevention practices among residents, visitors, and healthcare personnel (HCP) including hand hygiene, appropriate use of PPE, environmental cleaning, and disinfection.

2.Identify Additional Cases and Exposures.

a. Exposed asymptomatic residents and HCP should be tested with a series of up to three viral tests.

b. Determine approach (contact-tracing, unit-based, facility-based).

c. Identify exposures because of close contact.

d. Test exposures immediately (but not within 24 hours of exposure) and if negative, another test at 48 hours, and if negative another test 48 hours later.

Evaluation and Monitoring of Residents included:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 11 395853 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395853 B. Wing 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)

F 0880 Older adults with COVID-19 may not show common symptoms such as fever or respiratory symptoms, and it is important to assess for other symptoms such as: Level of Harm - Immediate jeopardy to resident health or 1. Fever or chills safety 2. Cough Residents Affected - Some 3. Shortness of breath

4. Fatigue

5. Muscle or body aches

6. Headache

7. New loss of taste or smell

8. Sore throat

9. Congestion or runny nose

10. Nausea or vomiting

11. Diarrhea

With identification of any COVID-19 symptoms, implement prompt isolation and further evaluation for COVID-19 infection.

During an interview on 7/31/24, at 11:50 a.m. the Infection Preventionist (IP) confirmed that the facility does not COVID-19 test residents unless they present with a fever, and that the facility follows, PAHAN 741, New Respiratory Virus Guidance (General Guidance for Community Settings) dated 3/15/24, which indicated to refer to CDC guidance and that fever is listed at the top of the symptom list, and that residents must have a fever before any other symptoms are considered to testing.

During an interview on 8/01/24, at 1:37 p.m. the Director of Nursing (DON) and Assistant Director of Nursing (ADON), confirmed the facility only tests for COVID when the resident presents a fever, and that residents are isolated and watched, and that the facility follows CDC guidance by testing for COVID-19 when a resident presents with a fever.

Review of facility policy provided to the surveyor on 8/01/24, entitled, [NAME] Care Center COVID-19 (revised 11/01/23), included:

1.Residents with suspected COVID-19:

a. Place the resident in a single-person room, or cohort with other simultaneously identified known COVID-19, exposures or symptoms and remain in their current location pending test results.

b. Initiate TBP per CDC.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 11 395853 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395853 B. Wing 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)

F 0880 c. PPE-N95 or higher respirator, eye protection, gown, and gloves.

Level of Harm - Immediate d. Roommates of residents confirmed COVID-19 are considered to have close contact. jeopardy to resident health or safety 2.Residents who have close contact to someone with COVID-19 will have a series of three viral test, immediately (but not earlier than 24 hours after exposure), and, if negative, again in 48 hours after the first Residents Affected - Some negative test, if negative, again in 48 hours after the second negative test.

3.Residents with confirmed COVID-19 infection

a. Place resident in a single person room, door should remain closed if safe, or cohort with other residents with the same respiratory pathogen.

b. Initiate TBP (N95 or higher respirator, eye protection, gown, and gloves).

c. Resident will remain in their room during this time.

4.Symptomatic testing of residents who have signs or symptoms of COVID-19 as soon as possible and placed on TBP pending test results.

Review of clinical records and facility documents revealed:

Resident Resident R1 was readmitted from the hospital on 7/26/24, with COVID-19, and remained with roommate Resident Resident R2 who tested positive on 7/28/24, and experienced a fever and cough.

Resident Resident R3 tested positive on 7/28/24, and experienced cough, lethargy, increased confusion, and nausea, and remained with roommate Resident Resident R4 who was not tested and discharged to home on 7/30/24.

Resident Resident R5 tested positive on 7/28/24, and experienced a fever, cough, lethargy, nausea and vomiting, and remained with roommate Resident Resident R6 who tested positive on 8/01/24, and experienced fatigue.

Resident Resident R7 experienced difficulty breathing, and lethargy on 7/20/24, and requested to be sent to the hospital where he/she tested positive, and his/her roommate (Resident Resident R8) was tested on [DATE REDACTED], and was negative.

Resident Resident R9 tested positive on 7/30/24, and experienced a fever, increased confusion, rambling speech, and remained with roommate Resident Resident R10 who tested negative on 8/02/24, and who was asymptomatic.

Resident Resident R11 experienced low oxygen saturations, was difficult to arouse, productive cough on 7/24/24, and family requested to be sent to the hospital where he/she tested positive, and his/her roommate (Resident Resident R12) was tested on [DATE REDACTED], and was negative and asymptomatic.

Resident Resident R13 tested positive on 7/28/24, and experienced a fever, cough, lethargy, and increased confusion, and remained with roommate Resident Resident R14 who tested negative on 7/28/24, and experienced a fever, cough, lethargy, and nausea, and tested negative again on 8/01/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 11 395853 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395853 B. Wing 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)

F 0880 Resident Resident R15 experienced lethargy, disorientation, confusion, on 7/19/24, and on 7/26/24, and was sent to

the hospital and diagnosed with COVID-19, his/her roommate (Resident Resident R16) tested positive on 7/28/24, and Level of Harm - Immediate experienced a fever, cough, lethargy, and nausea. jeopardy to resident health or safety Further review of clinical records revealed:

Residents Affected - Some On 7/27/24, Resident Resident R17 experienced lethargy, cough, cyanosis (bluish color), wheezing, and fever and was not tested for COVID-19.

On 7/25/24, Resident Resident R18 experienced abnormal lung sounds and cough, and continued to exhibit respiratory symptoms and lethargy and was not tested for COVID-19.

On 7/16/24, Resident Resident R19 experienced lethargy, headache, nasal congestion, sore throat, harsh cough, and continued through 7/23/24, and was not tested for COVID-19.

On 7/17/24, Resident Resident R20 experienced headache, sore throat, cough, and continued through 7/23/24, and was not tested for COVID-19.

Observations on 8/01/24, between 12:10 p.m. and 12:25 p.m. revealed COVID positive resident Rooms 201, 202, 203, 104, 110, 108, 109, and 107 lacked signage indicating the presence of a respiratory infection and

the necessary precautions and lacked provision of appropriate PPE upon entry into COVID positive resident rooms.

During an interview on 8/01/24, at approximately 12:30 p.m. Registered Nurse Employee E1 confirmed the lack of signage and provision of PPE at COVID positive resident rooms, and that not all staff wear N95's when entering COVID positive resident rooms.

During an interview on 8/01/24, at 2:45 p.m. the ADON confirmed that COVID positive resident rooms lacked signage, and the provision of PPE.

The DON and ADON were made aware that an Immediate Jeopardy (IJ) existed for 12 of 12 residents in the facility on 8/01/24, at 4:32 p.m. and a corrective action plan was requested and the IJ Template was provided.

On 8/01/24, at 6:43 p.m. an acceptable corrective action plan was approved which included the following interventions:

1. Appropriate signage and PPE were immediately placed by the entry of the COVID-19 positive rooms.

2. Roommates of all residents that tested positive for COVID-19 will be immediately tested if they have not yet been tested .

3. Residents will be moved to the appropriate rooms with COVID-19 positive residents separate from residents that are not COVID-19 positive.

4. The facility will then test all residents for COVID-19 to ensure we are cohorting the residents as appropriate.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 11 395853 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395853 B. Wing 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)

F 0880 5. Upon plan approval all staff will be educated on proper PPE and signage for rooms that have COVID-19 residents. The nursing staff will be educated on the infection control policy. Level of Harm - Immediate jeopardy to resident health or 6. Upon plan approval the staff that are currently in the facility will immediately be educated on these safety policies. Any employees not currently in the facility will be educated prior to the start of their next scheduled shift. Residents Affected - Some 7. Monitoring will continue for all residents with signs and symptoms of COVID-19. Testing will be performed immediately when signs and symptoms are identified. Roommates will be tested as well. Appropriate signage and PPE will be placed immediately.

8. The DON or designee to audit

a. all residents who are symptomatic each day during morning clinical meeting.

b. all newly diagnosed residents for proper signage and PPE upon diagnosis.

c. facility staff compliance with isolation and PPE directives three times a week on random shifts during the outbreak.

9. the facility will hold ad hoc QAPI to address COVID-19 outbreak in facility to ensure proper adherence to state guidelines and directives.

10. The facility will provide education to all management staff including the facility infection preventionist regarding proper signage, PPE, and measures to be implemented during COVID-19 outbreak in the facility.

The corrective action plan was verified as implemented and the Immediate Jeopardy was removed on 8/02/24, at 2:16 p.m.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(1)(3) Management

28 Pa. Code 201.18(e)(1) Management

28 Pa. Code 211.12(d)(1)(5) Nursing services

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 11 395853 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395853 B. Wing 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)

F 0882 Designate a qualified infection preventionist to be responsible for the infection prevent and control program in

the nursing home. Level of Harm - Minimal harm or potential for actual harm 40832

Residents Affected - Some Based 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.

Findings include:

The job description for the IP revealed that the purpose of this position is to implement, coordinate, and ensure that the facility's infection prevention and control program is effective and in compliance with all state and federal regulations.

Pennsylvania Department of Health COVID-19 Infection Control and Outbreak Response Toolkit for Long-Term Care Version 1.1 dated February 2024, and expanded from infection prevention and control guidance from the Centers for Disease Control and Prevention (CDC) for nursing homes and Long-Term Care Facilities.

During the Outbreak: COVID-19 Outbreak Management and Control Measures included:

1.Identify and Isolate First Case.

a. Isolate with transmission-based precautions (TBP) on COVID-19 Care Unit in accordance with most up-to-date isolation guidance or provide source control to positive resident and isolate in room (ideally residents should be placed in a single-person room).

b. Place TBP signs on the door to indicate to those entering the COVID-19 Care Unit/room of the personal protective equipment (PPE) requirements when providing care to residents with COVID-19.

c. Ensure all required PPE is available including N95 or higher-level respirator, gowns, gloves, and eye protection and is worn.

d. Reinforce core infection prevention practices among residents, visitors, and healthcare personnel (HCP) including hand hygiene, appropriate use of PPE, environmental cleaning, and disinfection.

2.Identify Additional Cases and Exposures.

a. Exposed asymptomatic residents and HCP should be tested with a series of up to three viral tests.

b. Determine approach (contact-tracing, unit-based, facility-based).

c. Identify exposures because of close contact.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 11 395853 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395853 B. Wing 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)

F 0882 d. Test exposures immediately (but not within 24 hours of exposure) and if negative, another test at 48 hours, and if negative another test 48 hours later. Level of Harm - Minimal harm or potential for actual harm Evaluation and Monitoring of Residents included:

Residents Affected - Some Older adults with COVID-19 may not show common symptoms such as fever or respiratory symptoms, and it is important to assess for other symptoms such as:

1. Fever or chills

2. Cough

3. Shortness of breath

4. Fatigue

5. Muscle or body aches

6. Headache

7. New loss of taste or smell

8. Sore throat

9. Congestion or runny nose

10. Nausea or vomiting

11. Diarrhea

With identification of any COVID-19 symptoms, implement prompt isolation and further evaluation for COVID-19 infection.

Review of clinical documents revealed eight residents (Residents Resident R1, Resident R3, Resident R5, Resident R7, Resident R9, Resident R11, Resident R13, Resident R15) tested positive for COVID-19 and remained cohorted with their roommates and the roommates (Residents Resident R2, Resident R4, Resident R6, Resident R8, Resident R10, Resident R12, Resident R14, Resident R16) were not tested .

Further review of clinical records revealed that Residents Resident R17, Resident R18, Resident R19, and Resident R20 exhibited symptoms of COVID-19 and were not tested .

During an interview on 7/31/24, at 11:50 a.m. the IP confirmed that the facility does not COVID-19 test residents unless they present with a fever, and that the facility follows, PAHAN 741, New Respiratory Virus Guidance (General Guidance for Community Settings) dated 3/15/24, which indicated to refer to CDC guidance and that fever is listed at the top of the symptom list, and that residents must have a fever before any other symptoms are considered to testing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 11 395853 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395853 B. Wing 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)

F 0882 Observation on 8/01/24, between 12:10 p.m. and 12:25 p.m. revealed COVID positive resident rooms 201, 202, 203, 104, 110, 108, 109, and 107 lacked signage indicating the presence of a respiratory infection and Level of Harm - Minimal harm or the necessary precautions and lacked provision of appropriate PPE upon entry into COVID positive resident potential for actual harm rooms.

Residents Affected - Some During an interview on 8/01/24, at approximately 12:30 p.m. Registered Nurse Employee E1 confirmed the lack of signage and provision of PPE at COVID positive resident rooms, and that not all staff wear N95's when entering COVID positive resident rooms.

During an interview on 8/01/24, at 2:45 p.m. the Assistant Director of Nursing confirmed that COVID positive resident rooms lacked signage and the provision of PPE.

28 Pa. Code 201.18(e)(1) Management

28 Pa. Code 211.10(d) Resident care policies

28 Pa. Code 211.12(d)(1)(5) Nursing services

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 11 395853