Pennsylvania Department of Health
CRAWFORD CARE CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 41 surveys for this facility. Please select a date to view the survey results.

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CRAWFORD CARE CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on May 7, 2024, it was determined that Crawford Care Center was not in compliance with the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(a), 416.54(a), 418.113(a), 441.184(a), 482.15(a), 483.475(a), 483.73(a), 484.102(a), 485.542(a), 485.625(a), 485.68(a), 485.727(a), 485.920(a), 486.360(a), 491.12(a), 494.62(a) STANDARD Develop EP Plan, Review and Update Annually:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

§403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a).

The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements:

(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following:

* [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach.

* [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually.

* [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years.

.

Observations:
Name: - Component: -- - Tag: 0004

Based on document review and interview, the facility failed to maintain emergency preparedness guidelines for one of one emergency preparedness plan.

Findings include:

Document review on May 7, 2024, at 11:00 a.m., revealed the facility's last documented annual review date occurred January 18, 2023.

Interview with the maintenance supervisor on May 7, 2024, at 11:00 a.m., confirmed the facility did not have an updated annual review date.

Plan of Correction - To be completed: 05/29/2024

1.The Maintenance Supervisor and Nursing Home Administrator reviewed and updated the established Emergency Preparedness Manual. A new Adoption of Policy and Procedure form was signed and placed in its binder.
2.The Maintenance Supervisor was in-serviced by the Nursing Home Administrator on the Federal/State guidelines of creating, maintaining, and current updating of the Emergency Preparedness Manual annually.
3.The Emergency Preparedness Manual will be submitted to the QAPI Committee for review and recommendations at the monthly meeting.

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID #193002
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 7, 2024, it was determined that Crawford Care Center was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type V (111), protected, wood frame building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0100

Based on observation and interview, the facility failed to maintain portable floor plans that outlined designated rated partitions, affecting the entire facility.

Findings include:

Document review on May 7, 2024, at 9:00 a.m., revealed the facility failed to provide a set of accurate, portable floor plans. The Division of Safety Inspection is requiring that all facilities under its jurisdiction provide a portable, accurate floor plan on-site, to be used during the Life Safety Code Survey.

The Life Safety Code Floor Plan shall include the following:
a. Smoke barrier walls (outside wall to outside wall);
b. Fire barrier walls (1-2 hour walls);
c. Horizontal exits;
d. Rated rooms (storage rooms, soiled utility rooms, designated medical gas rooms) will be clearly designated. It is the facility's responsibility to have all rated rooms indicated on its Life Safety Code Floor Plan;
e. Required exits should be clearly noted;
f. Shaft walls.

Interview with the maintenance supervisor on May 7, 2024, at 9:00 a.m., confirmed the facility's Life Safety Code Floor Plan did not include the above listed items.

Plan of Correction - To be completed: 05/29/2024

1.All facility floor plans were updated to include smoke barrier walls, fire barrier walls, horizontal exits, rated rooms, exits clearly marked for egress and shaft walls.
2.The new facility floor plans will be posted throughout the facility for public view.
3.The facility floor plans will be submitted to the QAPI Committee for review and recommendations at the monthly meeting.

NFPA 101 STANDARD Egress Doors:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

Egress Doors
Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements:
CLINICAL NEEDS OR SECURITY THREAT LOCKING
Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times.
18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6
SPECIAL NEEDS LOCKING ARRANGEMENTS
Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation.
18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4
DELAYED-EGRESS LOCKING ARRANGEMENTS
Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS
Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted.
18.2.2.2.4, 19.2.2.2.4
ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS
Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0222

Based on observation and interview, the facility failed to meet egress door requirements for one of over five wings.

Findings include:

Observation on May 7, 2024, at 10:24 a.m., revealed the B wing had an orange barrier blocking the corridor exit egress with a sign stating, "no residents past this point."

Interview with the maintenance supervisor on May 7, 2024, at 10:24 a.m., confirmed the deficiency and removed the barrier onsite.

Plan of Correction - To be completed: 05/29/2024

1.The identified "STOP" sign and orange barrier blocking the corridor on B Wing was removed at the time of the survey.
2.The Nursing Home Administrator will monitor and audit all facility exits to ensure there are no barriers to egress.
3.The Nursing Home Administrator will submit all audits to the QAPI Committer for review at the monthly meeting.

NFPA 101 STANDARD Doors with Self-Closing Devices:

Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0223

Based on observation and interview, the facility failed to meet self-closing door requirements for one of over ten doors.

Findings include:

Observation on May 7, 2024, at 10:44 a.m., revealed the kitchen door leading to the dining room had a missing self-closing device arm.

Interview with the maintenance supervisor on May 7, 2024, at 10:44 a.m., confirmed the deficiency.

Plan of Correction - To be completed: 05/29/2024

1.The identified door with existing door closure hardware was re-attached by the Maintenance Department to meet the Life Safety Code.
2.The Maintenance Director will submit notice to the QAPI Committee for review.

NFPA 101 STANDARD Fire Drills:

Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on documentation review and interview, the facility failed to perform one of twelve required fire drills.

Findings include:

Document review on May 7, 2024, at 10:00 a.m., revealed the facility lacked documentation for a fourth quarter, third shift fire drill.

Interview with the maintenance director on May 7, 2024, at 10:00 a.m., confirmed the facility lacked fire drill documentation.

Plan of Correction - To be completed: 05/29/2024

1.The Maintenance Director obtained documentation from the Fire Alarm Company showing an actual event occurred and was recorded for the fourth quarter, third shift fire drill.
2.The Maintenance Director was educated on the documentation requirements for conducting fire drills.
3.The Maintenance Director will submit a copy of all once conducted to the QAPI Committee for review at the monthly meeting.

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