Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Darway Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to ensure that all staff received required abuse prevention and reporting training after a confirmed abuse incident involving a resident with dementia, bipolar disorder, anxiety disorder, and impulse disorder who was resistant to care and appeared anxious when approached. Following an event in which a nurse aide verbally abused and struck this resident during incontinence care, the facility initiated whole-house education on abuse and staff reporting responsibilities. Review of in-service records and interviews with the NHA and DON showed that one activities aide hired before the incident, and still working with residents, had no documented completion of these abuse-related trainings, contrary to facility policy requiring ongoing abuse education for all staff.
Failure to Complete Significant Change MDS Assessments: The facility did not complete significant change MDS assessments for two residents who had major declines in function. One resident fell and sustained a rib fracture, then became dependent for personal hygiene, bed mobility, and transfers compared with a prior quarterly MDS showing much greater independence. Another resident had bilateral foot ulcers, was placed on weight-bearing restrictions and heel boots, and later showed new ROM impairment, reduced transfer ability, and inability to ambulate, yet no significant change MDS was completed.
A resident’s chart showed that the pharmacist recommended considering a gradual dose reduction or discontinuation of Remeron 15 mg and Risperdal 1 mg, but the physician’s response only noted that the family declined a GDR. The DON and NHA confirmed that the response did not explain why the GDR or discontinuation was clinically contraindicated.
A resident with a history of MRSA in the urine was placed on transmission-based precautions, but the door signage indicated contact precautions while staff reported the resident was on enhanced barrier precautions. A housekeeper entered the room without a gown or gloves and said she had been told PPE was not needed because she was not providing care or touching the resident. The RN was unsure why the signage did not match the resident’s precautions, and the DON stated the resident had been on contact precautions since a urine culture was positive for MRSA.
A facility failed to maintain a medication error rate below five percent, resulting in a 9.68 percent error rate. An LPN crushed medications that should not be crushed for a resident with Parkinson's disease, and another LPN allowed a resident to improperly self-administer Flonase nasal spray without documented approval. The Director of Nursing confirmed these findings.
A facility failed to notify a physician in a timely manner about a resident's declining condition after a fall. The resident, who initially had a bruise on her knee, later showed signs of swelling and bruising on her right arm and hand, and experienced significant pain. Despite these changes, the physician was not informed until several days later, delaying necessary medical intervention. An x-ray eventually revealed a fracture, prompting further action.
A facility failed to follow its bowel protocol for a resident diagnosed with constipation. Despite having physician orders to administer specific medications if no bowel movement occurred within a set timeframe, the staff did not offer or document the administration of these medications over several days. This was confirmed by the DON, indicating a lapse in providing the highest practicable care.
The facility failed to develop and implement individualized person-centered care plans for two residents diagnosed with dementia. Despite assessments confirming their diagnoses, no care plans addressing dementia and cognitive loss were created or implemented. The absence of documentation was confirmed by the Nursing Home Administrator and DON.
A facility failed to ensure a consultant pharmacist reported a medication irregularity for a resident prescribed Latuda without a schizophrenia diagnosis. The resident continued receiving the medication for major depressive disorder, despite a recommendation for dose reduction. The physician disagreed, citing the resident's history of aggressive behaviors. The deficiency was confirmed through record review and an interview with the DON.
A registered nurse worked seven shifts without a valid license, providing clinical care and assessments for two residents. Despite being notified of the license expiration, the RN continued to work until the license was renewed. The facility's management confirmed the RN's unlicensed work period.
Failure to Ensure All Staff Received Required Abuse Prevention Training After Confirmed Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to fully implement its abuse prevention and reporting policies through required staff training following a substantiated abuse incident. Facility policy on abuse prevention requires training all staff on resolving conflicts, managing stress and emotions, and understanding and managing residents’ verbal or physical aggression, as well as providing information on abuse prevention, intervention, detection, and reporting requirements during orientation and ongoing training. After an incident in which a nurse aide verbally abused a resident and then smacked the resident on the back while attempting incontinence care, the facility initiated whole-house education on abuse and employee reporting responsibilities. However, review of in-service training records for the abuse-related trainings showed no evidence that one activities aide (Employee 2), who was hired before the incident and remained an active employee, completed these trainings. Resident 1, the victim in the original abuse incident, had diagnoses including dementia, bipolar disorder, anxiety disorder, and impulse disorder. Nursing documentation noted that the resident was resistant to care, pulled away, did not want to be touched, and appeared anxious and annoyed when staff approached, requiring two staff for shower care. The abuse incident was reported through the Event Reporting System, and the facility’s investigation confirmed the aide’s abusive behavior. Subsequent review of personnel training records and interviews with the Nursing Home Administrator and DON confirmed that Employee 2’s signature was absent from the abuse-related in-service training sign-in sheets, despite the expectation that all staff receive this education and despite Employee 2 continuing to work with residents after the incident.
Failure to Complete Significant Change MDS Assessments
Penalty
Summary
The facility failed to complete a significant change MDS assessment for two residents who experienced major declines in function. One resident had a fall and sustained a fracture of the left eighth rib, and compared with the prior quarterly MDS, he declined from needing partial to moderate assistance with personal hygiene and being independent with bed mobility and transfers to being dependent for personal hygiene, dependent with rolling left to right, and requiring substantial to maximum assistance for bed mobility and transfers. The record showed that no significant change MDS was completed even though the decline did not resolve until December 1, 2025. A second resident was observed in a wheelchair wearing heel boots on both feet and stated she had been receiving treatment for ulcers on both feet for two to three months and had not been able to wear shoes or walk during that time. Her record showed physician orders limiting weight bearing and requiring heel boots, and later MDS documentation reflected new lower-extremity range of motion impairment, reduced transfer ability, and inability to ambulate due to medical condition or safety concerns. Despite these changes continuing since July 2025, the facility did not complete a significant change MDS assessment for this resident.
Physician Did Not Provide an Appropriate Response to Pharmacy Recommendation
Penalty
Summary
The facility failed to ensure that the attending physician appropriately addressed a pharmacy recommendation for Resident 8. Review of the resident’s clinical record showed that on September 5, 2025, the pharmacist recommended that the physician consider a gradual dose reduction or discontinuation of Remeron 15 mg, a medication used to treat depression, and Risperdal 1 mg, a medication used to treat mental health disorders such as schizophrenia or bipolar disorder. The physician responded on September 16, 2025, stating that the family declined a gradual dose reduction, but the response did not indicate why a gradual dose reduction or discontinuation was clinically contraindicated. Interview with the DON and NHA on December 11, 2025, at 2:20 PM confirmed that the physician did not provide an appropriate response to the pharmacy recommendation.
Infection Control Precautions Not Followed for Resident with MRSA History
Penalty
Summary
The facility failed to implement the highest practicable care regarding infection control measures for one resident on transmission-based precautions. Observation of the resident’s room revealed signage outside the door indicating contact precautions were in place and that anyone entering the room must use hand hygiene, a gown, and gloves. During the observation, a housekeeper was in the resident’s room without a gown or gloves, and she stated she had been told she did not need them because she was not providing care or touching the resident. The resident was identified by the RN as being on enhanced barrier precautions for a history of MRSA in the urine, while the DON stated the resident had been on contact precautions since a urine culture came back with MRSA on November 28, 2025. The RN stated she was not sure why the door sign indicated contact precautions instead of enhanced barrier precautions. The findings were reviewed with the NHA and DON, and the facility was cited for failing to ensure the highest practicable care regarding infection control measures for the resident.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 9.68 percent based on 31 medication opportunities with three errors. One incident involved an LPN who crushed Carbidopa/Levodopa and Effexor XR, both of which are medications that should not be crushed according to the facility's guidelines and the American Society of Consultant Pharmacists. This error occurred during a medication administration pass for a resident with Parkinson's disease symptoms, and the Director of Nursing confirmed the findings. Another incident involved an LPN allowing a resident to self-administer Flonase nasal spray without following proper administration procedures. The resident did not blow her nose or occlude the opposite nostril as recommended in the Flonase package insert. Additionally, there was no documented evidence that the resident was approved for self-administration of the nasal spray, despite a physician's order indicating that nursing staff should administer it. The Director of Nursing confirmed these findings as well.
Failure to Timely Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to notify the physician of a resident's change in condition in a timely manner, which is a requirement for ensuring appropriate medical interventions. The deficiency involved a resident who was found on the floor with a bruise on her left knee on December 30, 2024, and the physician was notified at that time. However, subsequent changes in the resident's condition, including swelling and bruising of the right hand and arm, were not communicated to the physician until January 4, 2025, despite the resident experiencing pain and exhibiting signs of injury. The resident's condition continued to decline, with further documentation on January 6, 2025, noting pain, swelling, and bruising, and the resident's inability to use her right hand. An x-ray on January 7, 2025, revealed an acute comminuted fracture of the right humeral head, and the physician was notified again. The Director of Nursing confirmed the lack of documented evidence of timely physician notification regarding the resident's declining condition after the initial fall notification.
Failure to Follow Bowel Protocol for a Resident
Penalty
Summary
The facility failed to adhere to its bowel protocol medication administration for Resident 203, who was diagnosed with constipation. The facility's policy, last reviewed on October 21, 2024, required monitoring and documenting residents' bowel movements per shift and implementing a bowel management protocol if no bowel movement occurred by the ninth shift (72 hours). Despite these guidelines, the clinical records for Resident 203 showed no bowel movements from December 28, 2024, to January 5, 2025, and there was no evidence that the prescribed PRN medications were offered or refused by the resident. The physician orders for Resident 203 included administering Milk of Magnesia if no bowel movement occurred by the third day, followed by a Dulcolax suppository if there was no bowel movement within 24 hours after the Milk of Magnesia, and a Fleet's Enema if there was still no bowel movement by the end of the following shift. However, these orders were not followed, as confirmed by the Director of Nursing on January 9, 2025. This oversight resulted in a failure to provide the highest practicable care for Resident 203, as required by the facility's policies and procedures.
Failure to Implement Person-Centered Care Plans for Dementia
Penalty
Summary
The facility failed to develop and implement individualized person-centered care plans for two residents diagnosed with dementia. Resident 23 was admitted on July 31, 2018, and was diagnosed with dementia on May 23, 2024. Despite the diagnosis, a review of Resident 23's care plan revealed no indication that a person-centered care plan addressing dementia and cognitive loss was developed or implemented. The facility had assessed the resident's needs through the Minimum Data Set Assessment, but did not follow through with the necessary care planning. Similarly, Resident 47, admitted on July 5, 2023, with a diagnosis of Alzheimer's dementia, also lacked a person-centered care plan to address his cognitive loss. The facility's assessment through the MDS confirmed the diagnosis, yet no individualized care plan was created or implemented. The Nursing Home Administrator and Director of Nursing confirmed the absence of documentation for individualized care plans for both residents during a review on January 9, 2025.
Failure to Report Medication Irregularity for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that the consultant pharmacist identified and reported a medication irregularity for a resident who was receiving Latuda, an antipsychotic medication. The resident was admitted without a schizophrenia diagnosis, yet was prescribed Latuda 40 mg daily for schizophrenia. Later, the medication was continued for major depressive disorder. The consultant pharmacist recommended a gradual dose reduction or trial discontinuation of Latuda, but the physician disagreed, citing the resident's history of aggressive behaviors and mood stability. The deficiency was confirmed through a clinical record review and an interview with the Director of Nursing. The review of the resident's behavior tracking showed aggressive behaviors on three days in November, but none in December. Despite these observations, the facility did not ensure that the consultant pharmacist reported the lack of a clinical indication for the continued use of Latuda, as required by their policies and procedures.
Unlicensed RN Worked Shifts and Provided Care
Penalty
Summary
The facility failed to ensure that professional staff were licensed, certified, or registered in accordance with state laws, specifically concerning a registered nurse, referred to as Employee 4. Employee 4's registered nurse license expired and was not renewed for a period during which the employee continued to work. Despite being notified by human resources about the expiration, Employee 4 worked seven shifts without a valid license. During this time, Employee 4 provided clinical care and assessments for two residents, documenting nursing care for one resident and conducting a skilled nursing assessment for another. The Nursing Home Administrator and Director of Nursing confirmed that Employee 4 worked these shifts without a valid license until the renewal was completed.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Forksville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Highlands Rehabilitation And Healthcare | 8.7 mi | ★★★★★ | 12 | 0 |
| Robert Packer Hospital Skilled Care And Rehabilit | 20.9 mi | ★★★★★ | 15 | 0 |
| Muncy Place | 22.4 mi | ★★★★★ | 0 | 0 |
| Valley View Rehab And Nursing Center | 22.8 mi | ★★★★★ | 16 | 0 |
| Wecare At Sycamore Rehabilitation And Nursing Cent | 24.4 mi | ★★★★★ | 41 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.