Health inspection·December 12, 2025

F 0637 Assess the resident when there is a significant change in condition 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, observation, and staff and resident interview, it was determined that the facility failed to complete a significant change Minimum Data Set (MDS) assessment for two of 13 residents reviewed (Residents 2 and 44). Findings include: Clinical record review for Resident 2 revealed that he had a fall on October 17, 2025, and sustained a fracture of his left eighth rib. Review of Resident 2's most recent MDS assessment dated [DATE], revealed that he declined in the following areas and was dependent for personal hygiene, dependent with rolling left to right, required substantial to maximum assistance to go from sitting to lying, lying to sitting, and going from sitting to standing, he was dependent for chair to bed and bed to chair transfers, toilet transfers, and transferring to tub/shower Clinical record review for Resident 2 revealed his previous quarterly MDS (Minimum Data Set, an assessment completed at intervals by the facility to determine care needs of the resident) dated July 28, 2025, indicated he only required partial to moderate assistance with personal hygiene, he was independent with rolling left to right, going from sitting to lying and lying to sitting, going from sitting to standing, transferring from chair to bed, and transferring to tub/shower. Clinical record review revealed that there was no significant change MDS (an assessment completed by the facility when a resident has a major decline or improvement in status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions. The decline is not considered self-limiting and impacts more than one area of the resident's health status. The decline requires an interdisciplinary review and/or revision of the care plan) completed on Resident 2 despite his decline in the above noted areas that did not resolve until December 1, 2025. Interview with the Director of Nursing and Nursing Home Administrator on December 11, 2025, at 2:15 PM confirmed the above noted findings related to Resident 2's decline as noted above, and that a significant change MDS was not completed. Observation and interview with Resident 44 on December 9, 2025, at 11:47 AM revealed that the resident was in her wheelchair with heel boots (soft/thick covering of the foot and heel) on both feet. Resident 44 stated she was receiving treatment to ulcers on both of her feet for the past two to three months and had not been able to wear shoes or walk since that time. Clinical record review for Resident 44 revealed a physician's order dated July 21, 2025, for the resident to be only toe touch weight bearing during transfers and a wheelchair was to be used for ambulation to keep pressure off the left sole of the foot. A physician's order dated October 21, 2025, required staff to apply heel boots to her bilateral feet at all times and to remove them for transfers. An Annual MDS assessment dated [DATE], determined the resident had no impairment in range of motion for her upper or lower extremities, was independent with transferring to the shower, and walking 10 feet, 50 feet, and 150 feet. Review of a quarterly MDS for Resident 44 dated November 12, 2025, revealed the resident was now assessed as having range of motion impairment on both lower extremities, needing partial/moderate assistance with showers transfer, and walking was marked as not attempted due to medical Residents Affected - Few Page 1 of 4 395909 395909 12/12/2025 Darway Healthcare and Rehabilitation Center 5865 Route 154 Forksville, PA 18616

F 0637 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few condition or safety concerns, and the question for walking 10 feet, 50 feet and 150 feet were disabled due to that response. Interview with Employee 1, licensed practical nurse assessment coordinator, on December 12, 2025, at 1:05 PM confirmed Resident 44 had declined in multiple areas such as range of motion, the ability to complete some transfers independently, and was no longer able to ambulate due to the treatment of her ulcer condition on her feet/heels since July 2025 when the resident was ordered to utilize a wheelchair for ambulation.Clinical record review revealed that there was no significant change MDS assessment completed on Resident 44 despite her decline in the above noted areas that continued as of the time the review above was completed. The above information regarding Resident 44 was reviewed with the Director of Nursing on December 12, 2025, at 1:30 PM. 28 Pa. Code 211.5(f)(ix) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services 395909 Page 2 of 4 395909 12/12/2025 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 that the resident's attending physician addressed a pharmacy recommendation appropriately for one of five residents reviewed (Resident 8). Findings include: Review of Resident 8's clinical record revealed that the pharmacist made a recommendation on September 5, 2025, for the physician to consider a gradual dose reduction or to discontinue Resident 8's Remeron (a medication used to treat depression) 15 mg and Risperdal (a medication used to treat mental health disorders such as schizophrenia or bipolar disorder)1 mg. The physician responded to the recommendation on September 16, 2025, indicating that the family declined a gradual dose reduction. Interview with the Director of Nursing and the Nursing Home Administrator on December 11, 2025, at 2:20 PM confirmed the above noted findings that Resident 8's physician did not respond to the pharmacy recommendation with an appropriate response indicating why a gradual dose reduction or discontinuation of the medications was clinically contraindicated. The facility failed to ensure an appropriate physician response to Resident 8's pharmacy recommendation. 483.45(c)(1)(2)(4)(5) Drug Regimen Review, Report Irregular, Act OnPreviously cited deficiency January 10, 2025 28 Pa. Code 211.9 (d)(k) Pharmacy services 28 Pa. Code 211.12(d)(3)(5) Nursing services 395909 Page 3 of 4 395909 12/12/2025 Darway Healthcare and Rehabilitation Center 5865 Route 154 Forksville, PA 18616

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to implement the highest practicable care regarding infection control measures for one of one resident reviewed for transmission-based precautions (Resident 10 ). Findings include: An observation of Resident 10's room on December 9, 2025, at 1:25 PM revealed signage outside the resident's door, which indicated contact precautions (a transmission based preventative measure to prevent the spread of infection) were in place for the room, and anyone entering the room must use hand hygiene. The sign also indicated that all staff and providers must wear a gown and gloves when entering the room. Concurrent observation and interview with Employee 2 (housekeeper) revealed she was in Resident 10's room with no gloves or gown on. Interview with Employee 2 revealed that she was told she did not need a gown or gloves since she was not providing care or touching the resident. Interview with Employee 3, Registered Nurse, on December 10, 2025, at 1:30 PM revealed that Resident 10 is only on enhanced barrier precautions (infection control measures that are used for high-contact care activities in residents with multidrug-resistant organisms, those with chronic wounds, or indwelling devices to prevent germ spread) for a history of MRSA (methicillin resistant staph aureus, a type of staph bacteria that is resistant to several common antibiotics) in his urine. She indicated she was not sure why the sign on the door indicated contact precautions instead of enhanced barrier precautions. Interview with the Director of Nursing on December 10, 2025, at 1:35 PM revealed that the resident is on contact precautions and has been since he had a urine culture that came back with MRSA on November 28, 2025. The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on December 11, 2025, at 2:25 PM. The facility failed to ensure the highest practicable care regarding infection control measures for Resident 10. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Residents Affected - Few 395909 Page 4 of 4