Harmar Village Health & Rehab: Missed Weight Gain Alert - PA
The resident, identified in inspection records as Resident R7, weighed 130.4 pounds on October 9, 2025. By November 5, she weighed 144 pounds. Her care plan called for weekly weights. The weights were being taken. The numbers were there. No one notified a physician.
A progress note from November 8 documented that R7 and her family had already begun complaining — increased abdominal distention, shortness of breath, swelling in both lower legs severe enough to leave a deep pit in the skin when pressed. A one-time dose of Lasix, a diuretic used to push excess fluid out of the body, was ordered. One dose.
Four days later, on the night of November 12, a nurse found her lying in bed, exhausted, struggling to breathe on four liters of supplemental oxygen through a nasal cannula. Her abdomen was distended and firm. The swelling in her legs had not resolved. Breath sounds in her right lower lobe, left lower lobe, and right middle lobe were diminished, with rhonchi throughout — the sound of air moving through partially obstructed airways, a sign that fluid had reached her lungs.
Emergency services transported her to the hospital at 8:55 that night.
By November 15, when state inspectors arrived at the facility, she was still there. The diagnosis: COPD exacerbation and right-sided heart failure.
Her care plan had noted a heart failure diagnosis. It contained no goals or interventions related to it.
Federal inspectors reviewed the electronic medical record and found no documentation that anyone had ever notified a provider about the fifteen-pound weight gain. A medical records employee confirmed on November 13 that she was current on scanning and uploading any paper notifications that had been completed. There were none to upload.
The administrator and director of nursing, interviewed together on the afternoon of November 15, confirmed what the records already showed: the facility had failed to notify a medical provider of a change in condition for two of the seven residents whose charts inspectors reviewed.
Harmar Village is a 120-bed skilled nursing facility on Freeport Road in Cheswick, a borough northeast of Pittsburgh along the Allegheny River.
The violation was cited at a level of minimal harm or potential for actual harm — the lower end of the federal harm scale. Whether that characterization accounts for a hospitalization with a heart failure diagnosis is a question the inspection report does not answer.
What the report does show is a gap between observation and action that stretched across more than a month. The weights were logged. The symptoms appeared. The family complained. A single diuretic was given. And when the fluid finally reached her lungs and her oxygen levels required four liters of supplemental flow just to keep her breathing, the response was to call 911.
As of November 15, Resident R7 remained hospitalized.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Harmar Village Health & Rehab Center from 2025-11-15 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
HARMAR VILLAGE HEALTH & REHAB CENTER in CHESWICK, PA was cited for violations during a health inspection on November 15, 2025.
The resident, identified in inspection records as Resident R7, weighed 130.4 pounds on October 9, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.