Health inspection·February 23, 2024

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on review of select facility policies, clinical record review, and staff interview, it was determined that the facility failed to develop and implement an abuse prohibition policy that ensured a complete and thorough investigation of an incident involving the potential for neglect for one of 14 residents reviewed (Resident 24). Residents Affected - Few Findings include: The facility policy entitled Darway Rehabilitation Center Abuse Policy last reviewed without changes on January 18, 2024, revealed that the facility residents will be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or corporal punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident(s) requires but the facility fails to provide them to the resident(s) that has resulted in or may result in physical harm, pain, mental anguish, or emotional distress. The facility will report all alleged violations of abuse, neglect, exploitation or mistreatment and the results of all investigations of alleged violations. Clinical record review for Resident 24 revealed nursing documentation dated August 9, 2023, at 9:32 PM that Resident 24 was found sitting in front of her chair facing the nurse's station in the TV area. The chair alarm was not sounding when checked, it was not turned on. Review of the facility's investigation dated August 9, 2023, confirmed that the alarm was turned off and that the facility had two staff complete statements, both of which indicated that they did not witness Resident 24's fall. There was no investigation to determine who was the assigned staff member that failed to turn the alarm on at the time of placing Resident 24 in her chair, a statement from this staff member indicating if they did or did not turn the alarm on, and/or documentation which indicated that Resident 24 turns her alarms off on her own or is non-compliant with alarm usage. There was also no documentation regarding the identification of potential neglect by the assigned staff member who failed to turn Resident 24's chair alarm on, reporting of this potential neglect to the appropriate state agencies, or completion of staff education regarding implementation of fall interventions, including ensuring chair alarms are turned on at the time of placement into the chair. Page 1 of 12 395909 395909 02/23/2024 Darway Healthcare and Rehabilitation Center 5865 Route 154 Forksville, PA 18616

F 0610 This information was reviewed during an interview with the Director of Nursing on February 23, 2024, at 12:12 PM. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.18(b)(1)(3) Management Residents Affected - Few 28 Pa. Code 201.19 Personnel policies and procedures 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.12(d)(1)(5) Nursing services 395909 Page 2 of 12 395909 02/23/2024 Darway Healthcare and Rehabilitation Center 5865 Route 154 Forksville, PA 18616

F 0623 Level of Harm - Potential for minimal harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on clinical record review and staff interview, it was determined that the facility failed to notify a resident and/or their responsible party in writing of a transfer to the hospital for two of two residents reviewed (Residents 32 and 48). Findings include: Clinical record review for Resident 48 revealed that they were transferred to the hospital on February 16, 2024, after a change in their condition. There was no documentation that the facility provided written notification to the resident or the resident's responsible party regarding the transfer that included the required contents: reason for the transfer, effective date of the transfer, location to which the resident was transferred, contact and address information for the Office of the State Long-Term Care Ombudsman, and information for the agency responsible for the protection and advocacy of individuals with developmental disabilities. The surveyor reviewed the above information for during an interview with the Nursing Home Administrator and Director of Nursing on February 23, 2024, at 10:04 AM. Clinical record review for Resident 32 revealed nursing documentation dated October 26, 2023, at 10:44 AM that nursing staff informed the physician of laboratory values and after the physician spoke to Resident 32's son, the physician instructed staff to send Resident 32 to the hospital. An ambulance arrived and transported Resident 32 to the hospital. Nursing documentation dated October 26, 2023, at 5:45 PM indicated that the hospital admitted Resident 32 with diagnoses that included a urinary tract infection, pneumonia (infection of the lungs), and CHF (congestive heart failure, the inability of the heart to pump sufficiently resulting in the retention of fluids in the lungs). Resident 32's clinical record contained no evidence that the facility provided written notice to Resident 32's responsible party of his transfer. Interview with the Nursing Home Administrator on February 22, 2024, at 2:32 PM confirmed that the facility was not mailing the required transfer notices to residents' responsible parties. The facility could not provide evidence that Resident 32's responsible party received the required transfer notice. 28 Pa. Code 201.14 (a) Responsibility of license 28 Pa. Code 201.29(a) Resident rights 395909 Page 3 of 12 395909 02/23/2024 Darway Healthcare and Rehabilitation Center 5865 Route 154 Forksville, PA 18616

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident or resident representative received written notice of the facility bed hold policy at the time of transfer for two of two residents reviewed for hospitalizations (Residents 32 and 48). Findings include: Clinical record review for Resident 48 revealed that was transferred to the hospital on February 16, 2024, after they had a change in condition. There was no documentation available that the facility provided written notice regarding a bed hold to the resident and/or the resident's responsible party upon transfer out to the hospital. The surveyor reviewed the above information for during an interview with the Nursing Home Administrator and Director of Nursing on February 23, 2024, at 10:04 AM. Clinical record review for Resident 32 revealed nursing documentation dated October 26, 2023, at 10:44 AM that nursing staff informed the physician of laboratory values and, the physician instructed staff to send Resident 32 to the hospital. An ambulance arrived and transported Resident 32 to the hospital. Nursing documentation dated October 26, 2023, at 5:45 PM indicated that the hospital admitted Resident 32 with diagnoses that included a urinary tract infection, pneumonia (infection of the lungs), and CHF (congestive heart failure, the inability of the heart to pump sufficiently resulting in the retention of fluids in the lungs). Resident 32's clinical record contained no evidence that the facility provided written notice to Resident 32's responsible party that specified the duration of the state bed-hold policy upon Resident 32's transfer to the hospital. Interview with the Nursing Home Administrator on February 22, 2024, at 2:32 PM confirmed that the facility was not mailing the required bed-hold policy notice to residents' responsible parties. The facility could not provide evidence that Resident 32's responsible party received the required bed-hold notice upon his transfer to the hospital. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29(f) Resident rights 395909 Page 4 of 12 395909 02/23/2024 Darway Healthcare and Rehabilitation Center 5865 Route 154 Forksville, PA 18616

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on clinical record review, observation, and staff interview, it was determined that the facility failed to develop a comprehensive plan of care regarding pacemaker care for one of 14 residents reviewed (Resident 32). Findings include: Clinical record review for Resident 32 revealed an active physician's order dated October 31, 2023, for staff to ensure pacemaker (small device implanted into the chest used to control the heartbeat) monitoring was in place. There were no other specified directions from this physician's order; the physician's order did not specify the type of pacemaker or monitoring Resident 32 utilized. Observation of Resident 32's room on February 23, 2024, at 10:55 AM revealed a registered nurse donned with personal protective equipment (gown, gloves, mask, and face shield due to isolation precautions in place secondary to COVID-19 infection) inside the room. The registered nurse held up a cell phone plugged into Resident 32's bedside receptacle to inform the surveyor that the cell phone was in place for Resident 32's pacemaker monitoring. The registered nurse stated that an application on Resident 32's cell phone called, myMerlin Pulse, was used for the pacemaker monitoring. Information obtained from myMerlin mobile application website indicated that the phone application communicated with an insertable cardiac monitor (ICM) to provide information that a doctor needs for an accurate diagnosis. Six tips listed for staying connected to the application (and cardiac monitoring) included: DO NOT QUIT (all in capital letters) the app. Remember to relaunch the app any time the phone is restarted. Keep the phone CLOSE (all in capital letters) (within 5 feet or 1.5 meters) even while sleeping. Keep the smartphone CONNECTED (all in capital letters) to Wi-Fi or cellular data with a STRONG (all in capital letters) signal (signal is strong enough if you can access a website). Keep Bluetooth ON (all in capital letters) to allow the smartphone to connect to the heart monitor. ALLOW (all in capital letters) notifications from the myMerlin mobile app; and turn ON (all in capital letters) app background refresh/background data usage. Turn OFF (all in capital letters) power save/battery optimization/low power features in the phone's settings. Interview with Employee 1 (registered nurse who stated that she provided regional support during Department surveys) on February 23, 2024, from 11:11 AM through 11:15 AM revealed that she did not find any specific instructions pertaining to Resident 32's pacemaker monitoring in his physical chart. Employee 1 confirmed with the surveyor that Resident 32's electronic care plan indicated that he had a pacemaker; however, no information regarding a cell phone, a cell phone application, or required Bluetooth, cellular, or Wi-Fi services were included as individualized necessary interventions. 395909 Page 5 of 12 395909 02/23/2024 Darway Healthcare and Rehabilitation Center 5865 Route 154 Forksville, PA 18616

F 0656 Level of Harm - Minimal harm or potential for actual harm Interview with the Director of Nursing on February 23, 2024, at 11:36 AM revealed that staff log Resident 32's schedule for pacemaker checks on a physical daily calendar kept on the nursing supervisor's desk not on Resident 32's care plan, physician orders, or electronic medical record. The surveyor requested that the Director of Nursing provide information regarding the most recent four pacemaker checks for Resident 32 (e.g., physician ordered frequency, date of completion, and findings). Residents Affected - Few The surveyor reiterated the request for pacemaker information during an interview with the Director of Nursing on February 23, 2024, at 1:44 PM. The Director of Nursing confirmed that specific interventions required for the use of the myMerlin cell phone application were not included in Resident 32's plan of care. The Director of Nursing confirmed that staff need to ensure the ongoing functioning of the cellular phone and application within the facility environment that consistently has poor cellular phone service due to its geographic location. The interview confirmed that Resident 21's plan of care did not include any emergency procedures to address potential power or Wi-Fi outages; or contact information for Resident 32's cardiologist (doctor who specializes in heart and blood vessel diseases/arrythmia [abnormal heartbeat]). The facility failed to ensure that Resident 32's plan of care included individualized treatment and services necessary to maintain his required pacemaker monitoring. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395909 Page 6 of 12 395909 02/23/2024 Darway Healthcare and Rehabilitation Center 5865 Route 154 Forksville, PA 18616

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on clinical record review and staff interview, it was determined that the facility failed to ensure an appropriate physician response to consultant pharmacist recommendations for three of five residents reviewed for potentially unnecessary medications (Residents 22, 41, and 46). Findings include: Clinical record review for Resident 22 revealed a consultant pharmacist recommendation dated July 28, 2023, that requested the physician evaluate a gradual dose reduction (GDR) of Resident 22's Quetiapine Fumarate (Seroquel, an antipsychotic medication used to treat mood/mental disorders). The physician's response on August 7, 2023, declined to reduce Resident 22's Quetiapine medication with the rationale, Pt (patient) hasn't tolerated GDR in the past currently stable on current meds. Physician orders active at the time of the July 28, 2023, pharmacist recommendation instructed staff to administer Seroquel 200 mg by mouth at bedtime. Resident 22's total daily intake of Seroquel was reduced from 250 mg to 225 mg on February 11, 2023. Resident 22's total daily intake of Seroquel was reduced from 225 mg to 200 mg on June 28, 2023. There was no evidence of an increase in Resident 22's problematic target behaviors between February 11, 2023, and August 7, 2023, when the physician indicated Resident 22 had failed a GDR in the past. A consultant pharmacist recommendation dated January 23, 2024, again requested that the physician evaluate a possible GDR of the Quetiapine medication. The physician disagreed with the recommendation on February 11, 2024, with the rationale, Benefits > (greater than) Risks. The physician did not provide a clinically significant rationale as the basis for declining the consultant pharmacist's recommendations. Interview with the Director of Nursing on February 23, 2024, at 12:09 PM confirmed the above findings for Resident 22. Clinical record review for Resident 41 revealed a consultant pharmacist recommendation dated June 23, 2023, that requested the physician evaluate Resident 41's Seroquel medication for a GDR. The physician disagreed on June 28, 2023, with the rationale, Pt continues to have symptoms agitation, yelling, etc. Social services quarterly assessment documentation dated April 25, 2023, at 7:58 AM stipulated that, (Resident 41) had 0 (zero) days of adverse behaviors throughout the review period. Review of interdisciplinary progress note documentation dated April 25, 2023, through June 28, 2023, revealed one entry (June 24, 2023, at 6:43 PM) when staff documented Resident 41 was easily agitated but was redirected and calmed, after short while. 395909 Page 7 of 12 395909 02/23/2024 Darway Healthcare and Rehabilitation Center 5865 Route 154 Forksville, PA 18616

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview with the Director of Nursing on February 23, 2024, at 12:09 PM revealed that the facility could not provide evidence of Resident 41's ongoing symptoms of agitation, yelling, etc., that the physician referred to in the June 28, 2023, response. A consultant pharmacist recommendation dated December 19, 2023, again requested that the physician evaluate Resident 41's Seroquel medication for a GDR. The physician disagreed on December 31, 2023, with the rationale, Benefits > (greater than) risk. The physician did not provide a clinically significant rationale as the basis for declining the consultant pharmacist's recommendations. Clinical record review for Resident 46 revealed a consultant pharmacist recommendation dated April 27, 2023, that requested the physician evaluate a possible GDR of Resident 46's Seroquel dose. The physician disagreed on May 1, 2023, with the rationale, Pt is still agitated, combative . There was additional handwriting following that statement; however, the surveyor, Director of Nursing, and the Nursing Home Administrator could not decipher the comment when reviewed on February 23, 2024, at 9:45 AM. Review of interdisciplinary progress note documentation dated March 1, 2023, through May 1, 2023, revealed numerous entries that Resident 46 was kind, smiling, had no signs or symptoms of depression, was calm, cooperative, and pleasant. Social services documentation dated March 30, 2023, at 9:25 AM revealed that Resident 46 had one day of physical behavior and one day of care rejection throughout the review period (one quarter, approximately three months). Care plan interdisciplinary documentation dated April 5, 2023, at 1:49 PM reiterated that Resident 46 had one day of physical behavior and one day of care rejection throughout the review period. Interview with the Director of Nursing on February 23, 2024, at 12:09 PM revealed that the facility could not provide evidence of Resident 46's ongoing episodes of agitation and combativeness that the physician referred to in the May 1, 2023, response. A consultant pharmacist recommendation dated October 18, 2023, again requested the physician review Resident 46's Seroquel dose for a GDR. The physician's response dated October 23, 2023, indicated that Resident 46 continued to have behavioral symptoms, i.e., combative, yelling, etc.; and that the GDR was not advised. Interdisciplinary documentation dated October 5, 2023, at 2:10 PM indicated that Resident 46 went to the common areas to socialize with other residents and staff, he participated in group activities, and that he had only one day of physical behaviors throughout the review period. Review of interdisciplinary progress note documentation dated October 5, 2023, through October 23, 2023, revealed several entries that staff assessed no behaviors for Resident 46. One entry dated October 7, 2023, at 3:57 indicated Resident 46 yelled if another resident and went near him; however, there was no indication of a physically aggressive action. Progress note documentation beginning October 17, 2023, at 6:48 AM revealed that Resident 46 began abnormal respiratory symptoms such as coughing and abnormal lung sounds. Nursing documentation dated October 20, 2023, at 5:28 PM revealed that Resident 46's physician 395909 Page 8 of 12 395909 02/23/2024 Darway Healthcare and Rehabilitation Center 5865 Route 154 Forksville, PA 18616

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some ordered antibiotic therapy for Resident 46. Although nursing documentation dated October 20, 2023, at 11:37 PM indicated that Resident 46 had physical behaviors noted only during care, Resident 46 was experiencing acute illness at that time. Interview with the Director of Nursing on February 23, 2024, at 12:09 PM confirmed that the facility had no behavior tracking other than the above progress note documentation. The facility could not provide evidence of ongoing behavioral symptoms referred to by the physician in his October 23, 2023, declination of the consultant pharmacist's recommendation to GDR the antipsychotic medication. 28 Pa. Code 211.2(d)(3)(8)(9) Medical director 28 Pa. Code 211.9(k) Pharmacy services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395909 Page 9 of 12 395909 02/23/2024 Darway Healthcare and Rehabilitation Center 5865 Route 154 Forksville, PA 18616

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 a review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure residents' medication regime was free from potentially unnecessary medication for three of five residents reviewed for medication regime review (Residents 22, 41, and 46). Findings include: The facility policy entitled, Tapering Medications and Gradual Drug Dose Reduction, last reviewed without changes on January 18, 2024, revealed that all medications will be considered for possible tapering. Tapering that is applicable to antipsychotic medications will be referred to as gradual dose reduction. Residents who use antipsychotic drugs shall receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, to discontinue these drugs. Periodically, the staff and practitioner will review the continued relevance of each resident's medications. The attending physician and staff will identify target symptoms for which a resident is receiving various medications. The staff will monitor for improvement in those target symptoms and provide the physician with that information. The staff and practitioner will consider tapering medications as one approach to finding an optimal dose or determining whether continued use of a medication is benefitting the resident. The staff and practitioner will consider tapering under certain circumstances, including when: The resident's clinical condition has improved or stabilized; The underlying causes of the original target symptoms have resolved; Non-pharmacological interventions, including behavioral interventions, have been effective in reducing symptoms The physician will review periodically whether current medications are still necessary in their current doses; for example, whether an individual's conditions or risk factors are sufficiently prominent or enduring that they require medication therapy to continue in the current dose, or whether those conditions and risks could potentially be equally well managed or controlled without certain medications, or with a lower dose. When a medication is tapered or stopped, the staff will closely monitor the resident and will inform the physician if there is a return or worsening of symptoms. When a medication is tapered or stopped, the staff and practitioner shall document the rationale for any decisions to restart a medication or reverse a dose reduction, for example, because of a return of clinically significant symptoms. Within the first year after a resident is admitted on an antipsychotic medication or after the resident has been started on an antipsychotic medication, the staff and practitioner shall attempt a GDR (gradual dose reduction) in two separate quarters (with at least one month between the attempts), unless clinically contraindicated. After the first year, the facility shall attempt a GDR at least annually, unless clinically contraindicated. Clinical record review for Resident 22 revealed Resident 22's total daily intake of the antipsychotic, Seroquel, was reduced from 250 mg to 225 mg on February 11, 2023. Resident 22's total daily intake of Seroquel was reduced from 225 mg to 200 mg on June 28, 2023. 395909 Page 10 of 12 395909 02/23/2024 Darway Healthcare and Rehabilitation Center 5865 Route 154 Forksville, PA 18616

F 0758 Level of Harm - Minimal harm or potential for actual harm Physician orders dated May 1, 2023, instructed staff to track verbally abusive behavior (threatening others, screaming/yelling at others, cursing/swearing), socially inappropriate or disruptive behavior (self-injury (scratch/hit), pacing/wandering, disrobing, sexual acts/comments, masturbation/self-stimulation, rummaging, stealing, fecal manipulation, screaming/yelling out), and refusal of care as needed and provide additional details as needed in progress notes. Residents Affected - Some Review of interdisciplinary progress note documentation dated June 28, 2023, through August 28, 2023, revealed no socially inappropriate, disruptive, or abusive behaviors that were not related to Resident 22's refusal of care. Nursing documentation dated July 28, 2023, at 10:24 AM through August 4, 2023, at 8:38 PM revealed that Resident 22 received antibiotics for a right elbow skin infection. A physician's order dated August 28, 2023, instructed staff to reverse Resident 22's Seroquel dose reduction and resume dosing at the increased 225 mg daily. Resident 22's clinical record did not contain evidence that the staff and practitioner documented a rationale for the decisions to reverse the dose reduction (e.g., a return or worsening of clinically significant symptoms). Interview with the Director of Nursing on February 23, 2024, at 12:09 PM confirmed that Resident 22 entered the facility in January 2018, with an antipsychotic medication; and that the facility had no evidence of a failed GDR that was evidenced by a return or worsening of target behaviors. The facility was unable to provide documentation of the clinically significant symptom that required the resumption of Resident 22's antipsychotic medication, Seroquel, at 225 mg daily. The interview confirmed that Resident 22's clinical record indicated that he tolerated a gradual dose reduction of the Seroquel medication February 11, 2023, through August 27, 2023, based on no evidence of an increase in his behaviors or a decline in his functioning. Clinical record review for Resident 41 revealed that the facility admitted him on January 17, 2023. admission physician orders for Resident 41 instructed staff to administer Seroquel 25 mg twice a daily (total 50 mg daily dose). Physician orders dated May 1, 2023, instructed staff to track Resident 41's target behaviors as subsequently described as: socially inappropriate or disruptive behavior (i.e., self-injury (scratch/hit), pacing/wandering, disrobing, sexual acts/comments, masturbation/self-stimulation, rummaging, stealing, fecal manipulation, screaming/yelling out) and refusals of care. Staff were to track by occurrence as needed and provide any additional details as needed in Resident 41's progress notes. Resident 41's clinical record did not contain any evidence that the facility attempted a gradual dose reduction of Resident 41's antipsychotic in two separate quarters (with at least one month between the attempts) during his first year in the facility. Interview with the Director of Nursing on February 23, 2024, at 12:05 PM confirmed that the facility did not have behavior tracking to support that the staff monitored Resident 41 for improvement in target symptoms to find an optimal dose or determine whether continued use of the medication was benefitting Resident 41. Clinical record review for Resident 46 revealed that the facility admitted him on March 22, 2022. 395909 Page 11 of 12 395909 02/23/2024 Darway Healthcare and Rehabilitation Center 5865 Route 154 Forksville, PA 18616

F 0758 Level of Harm - Minimal harm or potential for actual harm Physician orders dated June 4, 2022, instructed staff to administer Seroquel 25 mg during the day and 50 mg at bedtime. Physician orders for Resident 46 continued the Seroquel medication at the total daily dose of 75 mg from June 4, 2022, through September 25, 2023. Residents Affected - Some There was no evidence in Resident 46's clinical record that the facility attempted a gradual dose reduction during the first year after Resident 46 started the antipsychotic medication. Review of interdisciplinary progress note documentation dated March 1, 2023, through May 1, 2023, revealed numerous entries that Resident 46 was kind, smiling, had no signs or symptoms of depression, was calm, cooperative, and pleasant. Social services documentation dated March 30, 2023, at 9:25 AM revealed that Resident 46 had one day of physical behavior and one day of care rejection throughout the review period (one quarter, approximately three months). Care plan interdisciplinary documentation dated April 5, 2023, at 1:49 PM reiterated that Resident 46 had one day of physical behavior and one day of care rejection throughout the review period. Social services documentation dated June 30, 2023, at 7:53 AM for a quarterly assessment, revealed that Resident 46 had two days of care refusal behavior throughout the review period. Physician orders dated September 25, 2023, instructed staff to increase Resident 46's Seroquel dose to 50 mg twice daily (a total of 100 mg in a day). Social services documentation dated October 2, 2023, at 7:35 AM for a quarterly assessment, revealed that Resident 46 had one day of physical behaviors throughout the review period. Interdisciplinary documentation dated October 5, 2023, at 2:10 PM indicated that Resident 46 went to the common areas to socialize with other residents and staff, he participated in group activities, and that he had only one day of physical behaviors throughout the review period. Review of interdisciplinary progress note documentation dated October 5, 2023, through October 23, 2023, revealed several entries that staff assessed no behaviors for Resident 46. One entry dated October 7, 2023, at 3:57 indicated Resident 46 yelled if another resident and went near him; however, there was no indication of a physically aggressive action. Interview with the Director of Nursing on February 23, 2024, at 12:09 PM confirmed that the facility had no behavior tracking, other than interdisciplinary progress note documentation. The facility could not provide evidence that continuing the antipsychotic at the same dose from June 2022 to September 2023, benefitted the resident given no significant change in the frequency or severity of his target behaviors per the social services documentation above. The facility could not provide evidence of an increase in target behaviors before increasing Resident 46's Seroquel medication in September 2023. 28 Pa. Code 211.2(d)(3) Medical director 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395909 Page 12 of 12