Every finding on record at Darway Healthcare and Rehabilitation Center

Based on a review of select facility policies and procedures, staff interview, and review of personnel training records, it was determined that the facility failed to implement measures to protect residents from abuse for one of nine employees reviewed (Employee 2, Resident 1).Findings include: The facility policy entitled, Abuse Policy, last reviewed November 18, 2025, revealed that prevention includes training all staff and practitioners how to resolve conflicts appropriately, helping staff to deal appropriately with stress and emotions, and training staff to understand and manage a resident's verbal or physical aggression. The facility during its orientation program and through ongoing training programs provides all employees with information regarding abuse, including prevention, intervention, and detection and related reporting requirements. Steps will be taken to prevent further potential abuse that include corrective measures. The facility policy entitled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, last reviewed November 18, 2025, revealed that all reports of resident abuse, neglect, exploitation, or misappropriation of resident property are reported to local, state, and federal agencies as required by current regulations and thoroughly investigated by facility management. Findings of all investigations are documented and reported. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies that included the state licensing/certification agency responsible for surveying/licensing the facility. The follow-up investigation report will provide sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified. Clinical record review for Resident 1 revealed that his diagnoses list included dementia (a syndrome characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities), bipolar disorder (also known as manic depressive illness or manic depression, is a mental health condition characterized by significant mood swings, including manic (or hypomanic) episodes and depressive episodes), anxiety disorder (a mental health condition characterized by excessive, uncontrollable worry about everyday issues, affecting daily functioning and quality of life), and impulse disorder (a psychiatric condition characterized by the inability to resist urges or impulses that may harm oneself or others). Nursing documentation dated October 18, 2025, at 9:12 AM noted that Resident 1 was, .resistant with cares. Pulling away and not wanting to be touched. Two staff to give a shower to this morning. Unable to verbalize but seems anxious and annoyed when staff approaches. Review of an ERS (Event Reporting System, electronic system of communication between nursing facilities and the local field office of the Department of Health to provide a system to insure consistent data entry and submission of facility events) report dated November 7, 2025, revealed that Employee 1 (nurse aide) verbally abused Resident 1 before another staff witnessed her smack Resident 1 on the back while attempting incontinence care. Review of the facility's investigation of the incident indicated that on November 10, 2025, after the facility completed the investigation, Employee 1 was terminated; and, Whole house education on Abuse and employee's reporting responsibilities initiated. A review of the list of active employees provided by the facility during the onsite survey revealed that Employee 2 (activities aide) was hired on May 26, 2023. Review of the in-service training records entitled, Recording Policy, Etiquette with Residents, and Abuse, dated November 7, 2025, revealed no evidence that Employee 2 completed the trainings initiated in response to Resident 1's incident noted above. Interview with the Nursing Home Administrator and the Director of Nursing on April 25, 2026, at 2:40 PM confirmed that Employee 2's signature was not on the signature sheets that evidenced completed trainings for all staff. The interview confirmed that Employee 2's date of hire was before the November 2025 incident, and that Employee 2 has continued to work with residents since the November 2025 incident for which all staff were to receive education. 28 Pa. Code 201.20(d) Staff development 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.12(d)(1)(2)(3) Nursing services

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 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

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

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

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. 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

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). 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. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

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). 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

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

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). 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

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. 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

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. 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 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

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. 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. 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. 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. 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

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). 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. This information was reviewed during an interview with the Director of Nursing on February 23, 2024, at 12:12 PM. 28 Pa. Code 201.18(b)(1)(3) Management 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

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. 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). 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

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 hospitalization s (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

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

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. The exhaust vent covering the stove and cooktop area contained peeling and chipping paint on the exterior and interior side of the vent. An open pot of peas and carrots was observed being cooked on the stove top. A small upright freezer located near the exit door to the dining room was observed with a thick buildup of ice and frost on the freezer shelves. A concrete wall and ledge area in the lower basement level storage area, which extended to an outside exit, contained dust/debris and chipped concrete. An inverted stack of disposable meal trays were observed stored directly on the concrete ledge uncovered. A chest freezer labeled number five in the lower-level storage area was observed with debris and a frozen white colored substance on the interior base of the freezer. Frozen food products were stored in plastic milk crates in the freezer, several of the crates appeared dirty. An upright freezer labeled number one contained debris in the interior base of the freezer. The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on March 8, 2023, at 2:30 PM. 483.60(i)(1)(2) Food Procurement, Store/Prepare/Serve-Sanitary Previously cited 3/21/22 28 Pa. Code 211.6 (c)(d) Dietary services

Based on observation and resident and staff interview, it was determined that the facility failed to provide a clean, homelike environment on one of one nursing units (Residents 36, 30, 6, and 35, and activities room, patio, and sitting area). Findings include: An observation on March 7, 2023, at 11:44 AM of Resident 36's room revealed heating units along the window side wall of the room. Peeling and chipped paint was observed covering the heating units. The bathroom interior and exterior door frame was significantly marred, deep gouges were observed in the exposed wood with some splintering. The concrete wall between the bathroom and closet contained chipped paint and concrete. Ceiling tiles above the entry/exit door of the room and corner of the room on the window side contained several ceiling tiles with brown stains. An observation of Resident 30's room on March 7, 2023, at 12:07 PM revealed peeling paint and significantly marred and gauged bathroom door frame on the exterior and interior of the door frame. Dirt and debris buildup was observed along cove base of the wall near the bathroom, and behind the door to the room. An observation of unoccupied resident room [ROOM NUMBER], which was available and ready for residents to reside in, revealed significant marring and peeled paint on the interior and exterior bathroom door frame. A concrete wall between the bathroom door frame and closets had marring and peeled paint, which also extended on the frames of three closets located in the room. The environmental concerns identified in the rooms of Resident 36, 30, and room [ROOM NUMBER], were reviewed with the Nursing Home Administrator and Director of Nursing on March 8, 2023, at 2:30 PM. An observation on March 7, 2023, at 11:48 AM revealed a large brown stain on a ceiling tile above a bookshelf in the activities room. An observation on March 8, 2023, at 10:14 AM of a patio area next to the main nurse's station revealed several areas of chipped paint on the walls. A protective metal radiator cover had a broken (missing) and jagged section that was six inches by three inches in size. The tile on top of the protective radiator cover was broken and jagged with the wood showing underneath. The floor at the perimeter where it met the walls had a significant accumulation of debris that included dirt and pieces of a cookie. An observation on March 8, 2023, at 10:20 AM revealed a resident sitting area next to the main nurse's station. A cloth chair was observed that had a significant amount of torn black fabric visible coming from underneath the chair. An observation on March 8, 2023, at 12:21 PM revealed an electric fireplace that was on in the main lobby of the facility. The upper right corner of the protective cover was loose and coming away from the framing of the fireplace. There was a piece of crumbled tissue observed on the bottom of the fireplace inside of the protective covering. The top of the mantle over the fireplace had a significant build-up of dust and debris that also included a large amount of glitter. Observation of Resident 6's bedside table on March 9, 2023, at 8:55 AM revealed a chipped and damaged edge in several locations. The environmental concerns identified in Resident 6's room, the activities room, patio, and sitting area were reviewed with the Nursing Home Administrator and Director of Nursing on March 8, 2023, at 2:15 PM. The bedside table was discussed with the Director of Nursing on March 10, 2023, at 10:15 AM. Observation of Resident 35's room on March 8, 2023, at 9:57 AM revealed an overbed table on which Resident 35's television was positioned. A large portion (approximately greater than eight inches by four inches) of the overbed table's laminate was peeled off, exposing a porous surface. The edges of the remaining laminate presented as lifted, sharp, edges. Resident 35, on the date and time of the interview, directed the surveyor's attention to her second overbed table (used for meal trays and personal items), which had at least three areas of missing and peeling laminate (approximately one-half inch, one inch, and greater than two inches) along the edge of the table. The edges of the remaining peeling laminate presented as lifted, sharp, edges. There also was a box of Resident 35's ostomy supplies (e.g., pouches secured to the abdomen via adhesive dressings used to collect stool excreted from a surgically made abdominal opening) stored directly on the floor at the foot of her bed. The surveyor reviewed the above concerns regarding Resident 35's environment during an interview with the Nursing Home Administrator and the Director of Nursing on March 8, 2023, at 2:05 PM. 28 Pa. Code 207.2(a) Administrators responsibility

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to provide the highest practical care to promote pressure ulcer healing for two of three sampled residents identified with skin issues (Residents 6 and 15). Findings include: Clinical record review for Resident 6 revealed a diagnoses list that included pressure ulcers: left buttocks, right lateral thigh, and right heel. A current care plan for Resident 6 indicated actual skin breakdown related to pressure ulcers and an intervention noted indicated to administer treatment per physician orders. Clinical record review for Resident 6 revealed a nursing note dated March 4, 2023, at 9:55 AM that revealed the right lateral thigh and heel remain the same; the right thigh measured 4.0 x 0.8 x 0.5 centimeters (cm) with moderate serous drainage (pale yellow or transparent colored drainage). The right heel was epithelialized (a type of tissue that forms over a healing wound). Treatment continues as ordered. A current physician's order for Resident 6 dated January 25, 2023, instructed staff to apply Santyl external ointment (an ointment to help heal pressure ulcers) 250 units per gram (units/gm) daily to the right lateral thigh topically for a Stage IV (full thickness skin loss with exposed bone, tendon, or muscle) pressure area; cleanse the right thigh open area with normal saline (a solution that can be used to irrigate and clean wounds); pat dry; apply Santyl to the slough area (area of dead skin) only; fill the remaining wound bed with quarter-strength Dakin's (skin wound cleanser) moistened gauze; and to cover with a bordered foam dressing and change daily. Another current physician's order for Resident 6 revealed a wound consult evaluation and treat as necessary. Wound consultation documentation dated January 19 and 26, 2023, and February 2, 16, and 27, 2023, also revealed a Stage IV pressure ulcer/injury to the right lateral thigh. The plan of care noted for each consult instructed to Cleanse site with normal saline only! Observation of wound care treatment for Resident 6 with Employee 2, registered nurse, visually confirmed the resident had a pressure sore to the right lateral thigh. Employee 2 proceeded to cleanse the wound with a sterile water-soaked gauze pad and not normal saline as directed by the current physician order and wound consultation documentation. Further observation of Resident 6's wound care revealed Employee 2 completed the dressing change and then proceeded to write (the current date, her initials, and time) with a black-colored pen directly on the dressing that was just applied to Resident 6's right lateral thigh instead of doing so prior to the dressing being applied. Resident 6's current care plan indicated actual skin breakdown related to pressure ulcers and an intervention noted included to encourage/assist to suspend/float heels as able when in bed. The care plan indicated this also showed on the Kardex (an electronic device that includes pertinent resident information used for care). Wound consultation documentation dated January 26, 2023, and February 2, 16, and 27, 2023, indicated a plan of care that included to offload heels while in bed. Clinical record review of the tasks for Resident 6 revealed a current task dated January 18, 2023, that indicated Device - Application boots to bilateral heels every shift. A review of the past 30 days revealed no documented evidence that the heel boots were being applied and noted No Data Found. Observation of Resident 6 on March 8, 2023, at 9:15 AM revealed the resident was in bed with no heel protectors on and no evidence of any intervention that the resident's heels were offloaded or suspended or floated to relieve pressure. Two heel boots were observed in the room not in use. Observation of Resident 6 on March 9, 2023, at 8:55 AM revealed the resident was in bed with no heel protectors on and no evidence of any intervention that the resident's heels were offloaded or suspended or floated to relieve pressure. Two heel boots were observed in the room not in use. A concurrent interview with Employee 5, licensed practical nurse, revealed that she was unaware if the resident was to use the heel boots. A review of the Kardex with Employee 5 revealed the heel boots were not listed as an intervention. Observation of Resident 6 on March 9, 2023, at 1:53 PM during wound care, revealed the resident was in bed with no heel protectors on and no evidence of any intervention that the resident's heels were offloaded or suspended or floated to relieve pressure. Two heel boots were observed in the room not in use. The above findings for Resident 6 were reviewed in an interview with the Director of Nursing on March 10, 2023, at 9:10 AM. The Director of Nursing stated that it would be an expectation that the heel boots would be used if listed under tasks but would check. A further interview with the Director of Nursing on March 10, 2023, at 9:30 AM confirmed the heel boots were not listed on the Kardex and the Director of Nursing had staff add the boots to the Kardex. Interview with Resident 15 on March 7, 2023, at 10:07 AM revealed that he has had pressure ulcers, down to the bone, on his butt, for years. Resident 15 stated that he leaves the facility to attend appointments at a wound clinic as well as receives services from a wound consultant in the facility weekly. Clinical record review for Resident 15 revealed wound consulting CRNP's (certified registered nurse practitioner's) documentation dated February 2, 16, and 27, 2023, that noted a Stage IV pressure injury of his coccyx (tailbone) that measured 2 cm by 2 cm by 1 cm. The plan for Resident 15's Stage IV pressure injury of the coccyx was to cleanse the wound with one-quarter strength Dakin's (dilute solution of sodium hypochlorite (bleach) and other stabilizing ingredients, traditionally used as an antiseptic, to cleanse wounds in order to prevent infection) solution, apply skin protectant to the area around the wound, apply 0.1 percent gentamicin (antibiotic) to the wound base, gently fill the cavity with gauze moistened with normal sterile saline, and cover with a bordered foam dressing. Review of physician orders active since February 7, 2023, for Resident 15's Stage IV coccyx pressure ulcer treatment, instructed staff to cleanse with normal sterile saline moistened gauze, apply gentamicin sulfate ointment 0.1 percent, then cover with bordered foam dressing daily per the wound clinic every day shift. The active physician order did not implement the wound consultant's plan to cleanse the wound with one-quarter strength Dakin's solution or to gently fill the wound cavity with gauze moistened with normal sterile saline before the application of a bordered foam dressing. Observation of Resident 15's pressure ulcer treatment on March 9, 2023, at 1:15 PM with Employee 2 (registered nurse) revealed that the soiled dressings were already removed from Resident 15's coccyx wound before the surveyor's observation. Employee 2 cleansed the coccyx wound with gauze moistened with normal sterile saline. After performing hand hygiene, Employee 2 used a sterile cotton-tipped applicator to apply gentamicin ointment to the coccyx wound base and covered the wound with a bordered foam dressing. Employee 2 did not insert any moistened gauze packing to the wound before the application of the bordered foam dressing. Interview with Employee 2 on March 9, 2023, at 2:24 PM confirmed that the active physician's order as written since February 7, 2023, did not instruct the nurse to use moistened gauze packing in Resident 15's coccyx wound despite the plan stipulated in the wound consultant's documentation that listed the intervention on three appointment dates. Interview with the Nursing Home Administrator and the Director of Nursing on March 10, 2023, at 11:12 AM confirmed that Resident 15's physician's orders, and implemented treatments by staff, did not include loosely packing Resident 15's coccyx wound with moistened gauze. The interview indicated that the facility nursing staff were waiting for clarification from the wound care consultants before rewriting all physician orders pertaining to Resident 15's pressure ulcer treatments. 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.5(h) Clinical records

Based on clinical record review, observations, and resident and staff interview, it was determined that the facility failed to accommodate resident needs regarding the accessibility to a call bell for one of 14 residents reviewed (Resident 41) and accessibility of a call bell and a bed control unit for one of 14 residents reviewed (Resident 6). Findings include: Clinical record review for Resident 41 revealed a diagnoses list that included: muscle weakness abnormalities of gait and mobility, and reduced mobility. A current care plan revealed Resident 41 was at risk for falls due to the medical history and a goal was to minimize risk for injury related to falls. An intervention listed on the care plan included having the call bell in reach. Observation of Resident 41 on March 8, 2023, at 10:04 AM revealed the resident was in bed and the call bell was underneath the bed on the floor. Interview with Employee 4, nurse aide, on March 8, 2023, at 10:08 AM confirmed the call bell location and stated the cord didn't have a clip on it and that is probably why it's on the floor. Clinical record review for Resident 6 revealed a diagnoses list that included: muscle weakness, abnormalities of gait and mobility, and lack of coordination. A current care plan for Resident 6 revealed he was at risk of falls due to the medical history. An intervention listed on the care plan included having the call bell in reach. Observation of Resident 6 on March 8, 2023, at 9:15 AM revealed the resident was in bed with the head of the bed elevated in the high semi-fowler's position. The call bell was not readily visible from the bedside. The bed control was hanging on a drawer handle of a dresser that was located two feet from the bed and not within reach of the resident. A concurrent interview with Resident 6 revealed he did not know where the call bell was. When asked he stated, I have no idea where it is now. The resident further reported he liked to put the head of the bed down after he eats, but was unable to access the controller, I use it if I could reach it. It is out of my reach now. Interview with Employee 4 revealed Resident 6's call bell was found draped over the very top of the bed and partially under Resident 6's pillow. Employee 4 verbalized in reference to the call bell, I guess you can't reach it. Employee 4 then proceeded to put the head of the bed down for the resident and placed the bed controller within his reach. The above information for Residents 6 and 41 was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on March 8, 2023, at 2:15 PM. 28 Pa. Code 211.12(d)(5) Nursing services

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to implement interventions to prevent resident accidents for two of three sampled residents (Residents CR1 and 26). Findings include: The facility policy entitled, Falls Management Guideline, last reviewed June 1, 2015, revealed that the facility will have a care plan and interventions initiated for residents identified as a fall risk. Following a resident's fall, a licensed nurse will initiate an investigation to include obtaining witness statements. The facility will implement appropriate interventions. Closed clinical record review for Resident CR1 revealed nursing documentation dated July 12, 2015, at 11:46 PM indicating that staff found Resident CR1 on the floor in front of her wheelchair beside her bed. Review of the facility's investigation of the incident identified non-compliance as one of the predisposing factors contributing to her fall. The nursing documentation noted that staff educated Resident CR1 on the importance of asking for help. Review of Resident CR1's plans of care initiated by the facility on April 1, 2014, revealed that the facility identified Resident CR1 has impaired cognitive skills that included a short-term memory problem. A fall management plan of care review revealed that the facility discontinued the pressure alarm used to alert staff of Resident CR1's unassisted transfers on May 29, 2014, and a clip alarm on August 19, 2014. The plan of care included no interventions to address Resident CR1's known non-compliance with asking for assistance other than encouraging her to do so (despite her known short-term memory problem). Nursing documentation dated December 20, 2015, at 6:46 PM revealed that staff found Resident CR1 sitting on the floor. The documentation indicated that Resident CR1 was transferring from the toilet to the wheelchair without assistance, slipped, and fell . Review of the facility's investigation of the December 20, 2015, fall identified that Resident CR1's ambulating without assistance and non-compliance were predisposing factors to the fall. The interdisciplinary team documentation regarding the investigation dated December 22, 2015, concluded that, (Resident CR1) did not ring her call bell and states she knows she needs help but forgot. There was no evidence that the facility implemented any new interventions directed towards preventing, or alerting staff of, Resident CR1's known behavior of attempting unassisted transfers (e.g. reinstituting the personal alarms, more frequent checks, revising her toileting plan, etc.). Nursing documentation dated February 11, 2016, at 7:54 PM revealed that Resident CR1 again fell in her bathroom while trying to self-transfer to the toilet. Resident CR1 did not ring for assistance. The documentation indicated that Resident CR1 landed on her back and hit her head on the door sustaining an abrasion to her left hip. The documentation notes that staff has reinforced multiple times the importance of ringing for assist and not to self-transfer. Social services documentation dated February 12, 2016, at 10:33 AM assessed Resident CR1 as having severely impaired cognition, and impaired decision-making. Review of the facility's investigation of the February 11, 2016, fall again identified that Resident CR1's ambulating without assistance and non-compliance were predisposing factors to the fall. The interdisciplinary team documentation regarding the investigation dated February 12, 2016, contained no evidence that the facility implemented any new interventions directed towards preventing, or alerting staff of Resident CR1's known behavior of attempting transfers unassisted. Nursing documentation dated April 13, 2016, at 6:37 AM noted that staff found Resident CR1 lying face down on the floor beside the bed with a, pool of blood, under her face. Staff assessed a, mark, across Resident CR1's nose and swelling with bleeding from both nostrils. Resident CR1 complained of pain when staff applied pressure to her nose to control the bleeding. Nursing documentation dated April 13, 2016, at 6:15 AM noted that the facility sent Resident CR1 to the hospital via an ambulance. A soft tissue neck CT (computer-processed combinations of many x-ray images taken from different angles) radiology report dated April 16, 2016, diagnosed Resident CR1 with multiple maxillofacial (facial areas that may include the nose, upper and lower jaw, cheekbone, forehead, and eye orbits) fractures with accompanying hemosinus (blood in the sinus cavities) and bloody secretions within the nasal cavity and posterior nasopharynx (space between the internal nares and above the oral cavity). A chest CT radiology report dated April 16, 2016, diagnosed a complete collapse of the left lung with heterogeneous material (non-uniform comprising parts or resulting from differing causes) within the carina (point at which the trachea (windpipe) branches to form the two bronchi (tube that conducts air in to the lungs from the trachea)) extending to the left main stem bronchus (left lung windpipe) - likely blood products. Interview with the Nursing Home Administrator and Director of Nursing on May 6, 2016, at 11:48 AM confirmed the above findings for Resident CR1. The facility was unable to provide evidence that the interdisciplinary team increased the supervision or implemented interventions to alert staff of Resident CR1's attempts to transfer without assistance despite multiple falls because of that behavior. Clinical record review for Resident 26 revealed nursing documentation dated February 5, 2016, at 11:30 AM noting that staff found Resident 26 sitting on her buttocks in front of her wheelchair in the community room. Review of the facility's investigation of the February 5, 2016, fall revealed interdisciplinary documentation dated February 8, 2016, indicating that the facility applied a chair alarm to Resident 26's chair. Nursing documentation dated February 11, 2016, at 7:46 PM revealed that Resident 26, was out by nurse's station, leaned forward, and fell on floor . The documentation did not note if Resident 26 fell from her wheelchair; however, review of the facility's investigation of the fall noted that Resident 26 leaned forward too far in her wheelchair and fell out of the wheelchair. The fall investigation indicated that no staff witnessed the event; and the investigation did not include any documented staff witness statements. The incident investigation did not indicate the presence of a chair alarm alerting staff of Resident 26's fall. Review of Resident 26's clinical record and review of the facility's investigation documentation failed to provide evidence that the facility ensured the presence of a chair alarm at the time of the February 11, 2016, fall. Nursing documentation dated February 14, 2016, at 9:50 AM revealed that staff found Resident 26 on the floor in front of her wheelchair. Review of the facility's investigation of Resident 26's February 14, 2016, fall revealed that no staff witnessed the fall and that the investigation did not substantiate the presence of a personal alarm device. A witness statement noted that staff observed a male resident bending over reaching, which cued the staff to see that the male resident was reaching to assist Resident 26 off the floor. The statement did not mention the presence of a personal alarm signaling staff of Resident 26's fall. The facility failed to implement the interdisciplinary team's decision to apply a chair alarm for Resident 26 in an effort to prevent future falls. Interview with the Nursing Home Administrator and Director of Nursing on May 6, 2016, at 2:45 PM confirmed the above findings for Resident 26. 483.25 (h) Free of Accident Hazards/supervision/devices Previously cited deficiency 7/10/15. 28 Pa. Code 211.12 (d)(1)(5) Nursing services. Previously cited 7/10/15.

Based on clinical record review, observation, review of select facility policy and procedures, and staff interview, it was determined that the facility failed to assess and provide interventions to prevent skin breakdown for two of 15 sampled residents (Residents 2 and 53). Findings include: The policy entitled "Management of Skin Conditions," reviewed on March 30, 2011, indicates that staff is to implement interventions to prevent pressure sores and/or enhance the wound healing process. Key areas for pressure ulcer development include the heels and other areas of the skin subject to friction. Clinical record review for Resident 2 revealed a "Weekly Skin Alteration Measurement Tool," dated September 24, 2011, indicating that staff observed a Stage II pressure ulcer (partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater) intact blister measuring 1.5 centimeters (cm) long by 1.0 cm wide on Resident 2's left heel. Investigation into the cause of the blister revealed it was due to a crack in Resident 2's shoe. Staff padded the shoe to protect the heel. A physician's orders [REDACTED]. Review of Resident 2's "Medication Administration Record," dated September 2011, indicated staff administered the Liquid Shield only one time, September 24, 2011. An interview with Employee 5 (licensed practical nurse) who identified herself as the nurse in charge of Resident 2's care for the day, on October 5, 2011, at 10:55 AM revealed that she was not aware that Resident 2 had a blister on his left heel. Employee 5 and Employee 6 (nurse aide) transferred Resident 2 from his chair to his bed. Observation of Resident 2 revealed that he was wearing shoes, identified by Employee 6 as the shoes with the crack. The shoes were not padded. Observation of Resident 2's left heel revealed an intact blister. Measurement of the blister on Resident 2's left heel on October 5, 2011, indicated that the blister had increased in size to 1.9 cm in length and 1.4 cm in width. Staff had assessed Resident 2 on November 16, 2010, and with his most recent plan of care as being at low risk for developing a pressure ulcer. The facility failed to prevent Resident 2 from developing a pressure ulcer. After identifying the pressure ulcer, the facility failed to implement physician's orders [REDACTED]. The facility investigated the cause and determined it was due to a crack in the shoe that needed padded. The facility continued to have the resident wear the cracked shoe without the padding resulting in the pressure ulcer increasing in size.An interview with the Nursing Home Administrator and Employee 7 (quality assurance consultant) on October 6, 2011, at 11:05 AM confirmed that staff failed to implement measures to prevent Resident 2 from developing a pressure sore on his left heel.Clinical record review for Resident 53 revealed a physician's orders [REDACTED]. A physician's orders [REDACTED]. Resident 53's clinical record contained no evidence that staff routinely assessed Resident 53's left heel (measurements, skin condition/color, absence/presence of drainage, etc.). Interview with Employee 11, licensed practical nurse, on October 7, 2011, at 9:40 AM, confirmed that the facility could not provide evidence of ongoing monitoring of the condition of Resident 53's left heel to evaluate the impact of interventions on wound healing; or revise approaches as appropriate. The surveyor was unable to assess the status of Resident 53's heels as he was transferred to the hospital the second day of the survey. 28 Pa. Code 211.10(a) Resident care policies.Previously cited 5/27/11 28 Pa. Code 211.10(d) Resident care policies.Previously cited 5/27/11 and 8/2/11 28 Pa. Code 211.12(d)(1) Nursing services.Previously cited 8/2/11 28 Pa. Code 211.12(d)(5) Nursing services.Previously cited 5/27/11 and 8/2/11