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 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 395909 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395909 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Darway Healthcare and Rehabilitation Center 5865 Route 154 Forksville, PA 18616 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)