Darway Healthcare and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Darway Healthcare and Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Mar 10, 2023

  Based on observation and staff interview, it was determined that the facility failed to store and prepare food items in a safe and sanitary manner in the facility's main kitchen. Findings include: Observation of the facility's main kitchen with Employee 3, dietary manager, on March 7, 2023, at 9:39 AM revealed the following: Five plastic scoop plates (adaptive feeding plate with raised edges) were observed on a shelf below the food serving line with dried food debris on the plates. The plates were also stained and discolored. The wall behind the coffee maker contained three holes 1 to 2 inches in diameter, dried food/liquid splatter was also observed on several areas of the wall. […]

• No harm, potential for more than minimal, widespreadF812Mar 21, 2022

  Based on observation and staff interview, it was determined that the facility failed to store, prepare, and serve food in a manner to prevent the potential spread of foodborne illness in the main kitchen. Findings include: Observation of the facility's kitchen on March 15, 2022, revealed the following: At 9:19 AM Employee 5, universal employee, assists as needed in housekeeping, maintenance, and the dietary departments, was standing near the stove and coffee preparation areas without a hairnet. Employee 5 acknowledged the observation and placed a hairnet on his head. At 9:25 AM observation of the reach-in refrigerator by the can opener identified an undated and unlabeled container of a cooked yellow substance resembling scrambled eggs. […]

• No harm, potential for more than minimal, patternF759Jan 10, 2025

  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). 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. […]

• No harm, potential for more than minimal, patternF756Feb 23, 2024

  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. […]

• No harm, potential for more than minimal, patternF758Feb 23, 2024

  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. […]