Health inspection·January 10, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on clinical record review and staff interview, it was determined that the facility failed to notify the physician of a resident's change in condition requiring interventions for one of 12 residents reviewed (Resident 24). Findings include: Clinical record review for Resident 24 revealed nursing documentation dated December 30, 2024, noting Resident 24 was found on the floor. Documentation revealed Resident 24 was checked for injury and a bruise was noted to her left knee. Resident 24's physician was notified at this time. Nursing documentation dated January 2, 2025, at 6:21 PM revealed staff were concerned with Resident 24's right hand and arm. The registered nurse assessment noted Resident 24's right hand and fingers were slightly swollen, and her right upper arm was bruised with edema (swelling). Nursing documentation dated January 3, 2025, at 9:22 PM noted Resident 24's right hand and arm continued with dependent edema. Nursing documentation dated January 4, 2025, at 5:23 AM noted during morning care nurse aides moved Resident 24's right arm to wash her and she yelled out in pain. Resident 24 was asked how bad it hurt, and Resident 24 stated bad and indicated the pain was from the shoulder to her wrist. Nursing documentation dated January 4, 2025, at 5:26 AM indicated that the registered nurse noted she observed Resident 24 getting washed up and Resident 24 was grimacing and guarding her right arm. The registered nurse noted Resident 24 had a bruise from her bicep to elbow that was being monitored. Documentation noted Resident 24 stated hurts bad during range of motion. Resident 24's physician was notified at this time. Nursing documentation dated January 6, 2025, at 3:10 PM noted Resident 24 complains pain with movement to her right arm and forearm. The registered nurse observed Resident 24 sitting in her wheelchair with bruising to her right upper arm from her mid upper arm to elbow area. The registered nurse also noted swelling to the area. Documentation revealed Resident 24 does not voluntarily attempt to move her right arm or hand. All fingers on Resident 24's right hand were noted with dependent edema. The registered nurse noted Resident 24 makes no attempts to try and feed self, or hold a cup in her right hand, even though she is right-handed. Resident 24's physician was notified. Nursing documentation dated January 6, 2025, at 4:40 PM noted the facility received a call from mobile x-ray indicating they were unable to come tonight and would come the next morning. Page 1 of 8 395909 395909 01/10/2025 Darway Healthcare and Rehabilitation Center 5865 Route 154 Forksville, PA 18616

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Nursing documentation dated January 7, 2025, at 10:05 AM noted the mobile x-ray was completed. Resident 24 continues with edema of her lower forearm, hand, and fingers. Bruising of Resident 24's elbow and forearm were noted in varying degrees of healing and pain was noted with supination (outward rolling) and pronation (inward rolling) of Resident 24's hand and wrist. Nursing documentation dated January 7, 2025, at 2:49 PM noted the facility received a right shoulder and wrist x-ray report, which noted an acute comminuted fracture of Resident 24's right humeral head. Resident 24's physician was notified and ordered Resident 24 to be non-weight bearing to her right arm and to wear a sling when out of bed. Interview with the Director of Nursing on January 10, 2025, at 10:10 AM confirmed that there was no documented evidence of the facility notifying Resident 24's physician of her declining condition after the initial notification of her fall on December 30, 2024, until January 4, 2025. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395909 Page 2 of 8 395909 01/10/2025 Darway Healthcare and Rehabilitation Center 5865 Route 154 Forksville, PA 18616

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding bowel protocol medication administration for one of one resident reviewed (Resident 203). Residents Affected - Few Findings include: A review of the policy titled, Bowel Policy and Procedure, last reviewed on October 21, 2024, revealed a purpose to promote regular bowel function and prevent complications related to constipation (difficulty having a bowel movement) by establishing clear guidelines for monitoring, documenting, and managing residents' bowel movements. The policy further noted that all residents will have their bowel movements monitored and recorded in the electronic health record (EHR) per shift. The staff will follow the facility's bowel protocol, which will be per order established by the physician. The facility will monitor and address any absence of bowel movements within a specified timeframe, adhering to physician orders or standing facility procedures. The policy noted that, If no bowel movement is recorded by the ninth shift (72 hours), follow the physician's pre-existing bowel management order or implement the facility's standing bowel protocol. Clinical record review for Resident 203 revealed a diagnoses list that included constipation. Review of the admission Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated January 2, 2025, for Resident 203 revealed that staff documented, Yes to the question asking if constipation was present. Clinical record review for Resident 203 revealed the following physician orders dated December 27, 2024, to promote bowel movements: Milk of Magnesia Suspension 400 mg (milligrams) per 5 ml (milliliters) (MOM, laxative that pulls water into bowel to soften bowel contents). Give 30 ml by mouth as needed (PRN) for constipation and administer if no bowel movement by the third day (nine shifts) and document effectiveness. Dulcolax suppository (Bisacodyl, a laxative medication used to relieve constipation) insert one suppository rectally as needed for constipation for no bowel movement within 24 hours after administration of Milk of Magnesia. Fleet's Enema 7-19 gm (grams) per 118 ml (Sodium Phosphates, liquid medication inserted into the rectum to treat constipation). Insert 1 applicatorful rectally as needed for constipation for no bowel movement by the end of the following shift after administration of suppository. Notify the physician if ineffective. Review of bowel elimination records for Resident 203 revealed that staff documented no bowel movements for December 28-31, 2024, and January 1-5, 2025. There was no indication that staff offered (as per the physician orders and bowel management protocol), or Resident 203 refused, any of the PRN medications to promote a bowel movement. The Director of Nursing confirmed on January 9, 2025, at 1:46 PM that the bowel protocol was not followed for Resident 203. 395909 Page 3 of 8 395909 01/10/2025 Darway Healthcare and Rehabilitation Center 5865 Route 154 Forksville, PA 18616

F 0684 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 395909 Page 4 of 8 395909 01/10/2025 Darway Healthcare and Rehabilitation Center 5865 Route 154 Forksville, PA 18616

F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by two of three residents reviewed (Residents 23 and 47). Residents Affected - Few Findings include: Clinical record review for Resident 23 revealed the facility admitted her on July 31, 2018. A diagnosis of dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life) was added on May 23, 2024. A review of Resident 23's most recent annual Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated April 15, 2024, indicated that the facility assessed Resident 23 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 23's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. Clinical record review for Resident 47 revealed that the facility admitted him on July 5, 2023, with diagnoses including Alzheimer's dementia. A review of Resident 47's most recent annual MDS dated [DATE], indicated that the facility assessed Resident 47 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 47's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. The findings were reviewed with the Nursing Home Administrator and Director of Nursing on January 9, 2025, at 2:05 PM. They confirmed that the facility had no further documentation that the facility developed and implemented an individualized person- centered care plan to address Residents 23 and 47's dementia. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services 395909 Page 5 of 8 395909 01/10/2025 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 - Few 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 the consultant pharmacist identified and reported an irregularity to the physician for one of five residents reviewed for potentially unnecessary medications (Resident 23). Findings include: Clinical record review revealed the facility admitted Resident 23 on July 31, 2018. Review of Resident 23's physician orders revealed Resident 23 was admitted on Latuda (an antipsychotic medication used to treat schizophrenia) 40 milligrams (mg), one tablet one time a day for schizophrenia. Further review of Resident 23's clinical record revealed no schizophrenia diagnosis. Review of Resident 23's current physician orders revealed Resident 23 continued to receive Latuda 40 mg, one tablet at bedtime now related to major depressive disorder. A consultant pharmacist report dated September 11, 2024, requested the physician consider a gradual dose reduction, or trial discontinuation of Resident 23's Latuda. Resident 23's physician disagreed with the recommendation on September 23, 2024, indicating Resident 23 has a longstanding history with aggressive behaviors and mood stability. Review of Resident 23's Behavior/Side Effect Tracking for November 2024, revealed staff documented Resident 23 had aggressive behaviors three of the 30 days. Review of Resident 23's Behavior/Side Effect Tracking for December 2024, revealed staff documented Resident 23 had no aggressive behaviors. Interview with the Director of Nursing on January 10, 2025, at 10:47 AM confirmed these findings. The facility failed to ensure the consultant pharmacist identified and reported a medication irregularity to the physician ensuring a clinical indication for Resident 23's Latuda. 28 Pa. Code 211.9 (k) Pharmacy services 28 Pa. Code 211.12(d)(3)(5) Nursing services 395909 Page 6 of 8 395909 01/10/2025 Darway Healthcare and Rehabilitation Center 5865 Route 154 Forksville, PA 18616

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, clinical record review, review of select manufacturer's guidelines, and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent (Residents 25 and 18). Residents Affected - Some Findings include: The facility's medication error rate was 9.68 percent based on 31 medication opportunities with three medication errors. Observation of a medication administration pass on January 8, 2025, at 9:02 AM revealed Employee 3 (licensed practical nurse, LPN) preparing to administer Resident 25's Carbidopa 25 milligram (mg)/ Levodopa 100 mg (medication used to treat Parkinson disease symptoms) two tablets and Effexor (antidepressant medication) XR extended release 150 mg, one tablet. Employee 3 proceeded to crush both the Carbidopa/Levodopa and Effexor EX extended release. Review of the facilities Medications Not to Be Crushed, list by the American Society of Consultant Pharmacists, dated February 2024, revealed that both the Carbidopa/Levodopa and Effexor EX extended release should not be crushed. Interview with the Director of Nursing on January 9, 2025, at 9:18 AM confirmed these findings for Resident 25. Observation of a medication administration pass on January 7, 2025, at 9:15 AM, revealed Employee 2, LPN, preparing to administer medications to Resident 18. Employee 2 handed the Flonase (treats seasonal or year-round allergies) nasal spray to Resident 18. Resident 18 then proceeded to administer one spray of the Flonase to both nostrils. Resident 18 did not blow her nose prior to the administration, nor did she occlude the opposite nostril while spraying. Employee 2 indicated at this time that Resident 18, likes to administer it herself. Review of the Flonase package insert revised January 2019, indicates that users should blow their nose to clear their nostrils prior to administration. Users are to close one nostril, while administering a dose in the opposite nostril. Review of Resident 18's clinical record revealed a physician's order dated December 20, 2024, that indicates nursing staff are to administer two sprays of the Flonase to Resident 18 daily. There was no documented evidence to indicate that Resident 18 was approved for self-administration of the Flonase nasal spray. Interview with the Director of Nursing on January 9, 2025, at 9:16 AM confirmed the above findings for Resident 18. 28 Pa. Code 211.10(a) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services 395909 Page 7 of 8 395909 01/10/2025 Darway Healthcare and Rehabilitation Center 5865 Route 154 Forksville, PA 18616

F 0839 Employ staff that are licensed, certified, or registered in accordance with state laws. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to ensure professional staff were licensed, certified, or registered in accordance with state laws for one of three staff members reviewed (Employee 4; Residents 3 and 50). Residents Affected - Few Findings include: Review of facility documentation revealed that Employee 4, registered nurse, had a registered nurse license that expired [DATE]. A review of the current license for Employee 4 revealed the Status Effective Date was documented as [DATE]. An interview with the Nursing Home Administrator on [DATE], at 10:24 AM revealed that Employee 4's license had expired on [DATE], and was not renewed until [DATE]. Human resources had contacted Employee 4 on [DATE], to advise of the expiration date of Employee 4's license. A review of the facility document titled, Time Cards, for Employee 4 revealed that the staff member had worked seven shifts during the time period the facility reported the license was expired: [DATE]/15, 2024 [DATE]/19, 2024 [DATE]/20, 2024 [DATE]/22, 2024 [DATE]/23, 2024 [DATE]/24, 2024 [DATE]/25, 2024 Review of the clinical documentation for two residents reviewed revealed that Employee 4 had documented clinical care and/or clinical assessment during the time periods listed above: Nursing documentation for Resident 3 on [DATE], at 9:22 PM; and skilled nursing documentation of an assessment of Resident 50 on [DATE], at 9:44 PM. The above information for Employee 4 was reviewed with the Nursing Home Administrator and Director of Nursing on [DATE], at 12:05 PM who confirmed that Employee 4 had worked seven shifts, as noted above, without a valid license until license renewal on [DATE]. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services 395909 Page 8 of 8