Harmar Village: 8.33% Medication Error Rate - PA
State inspectors documented three medication errors during 36 opportunities on April 1, creating an 8.33% error rate. Federal standards require nursing homes to keep medication errors below 5%.
The most serious violation involved Resident R61's Ingreeza medication, prescribed to treat involuntary movements. The resident's care plan required all medications to be crushed, but Licensed Practical Nurse Employee E14 prepared the 40-milligram capsule softened in pudding instead of sprinkling the contents as required.
"She failed to prepare and administer Resident R61's Ingreeza by sprinkling the contents of capsule in pudding," the Assistant Director of Nursing confirmed during inspection interviews.
The same nurse also failed to give the resident two other prescribed medications that morning: fluticasone propionate nasal spray for allergy symptoms and olopatadine eye drops for itching. Both medications were simply unavailable, Employee E14 told inspectors.
During her 9:23 a.m. interview, the nurse acknowledged all three failures. She confirmed missing the Flonase nasal spray and eye drops "due to the medications not being available" and admitted improperly preparing the Ingreeza capsule.
The Assistant Director of Nursing called the Ingreeza error "significant" during her interview with inspectors. Ingreeza treats tardive dyskinesia, a condition causing involuntary muscle movements, and chorea associated with Huntington's disease. Proper administration requires the capsule contents to be sprinkled in soft food, not left intact.
Inspectors observed the medication errors during routine monitoring on April 1. They watched Employee E14 at 8:56 a.m. as she prepared medications for multiple residents, documenting each mistake in real time.
The facility's Nursing Home Administrator acknowledged the violation during his interview at 9:56 a.m. He confirmed the facility "failed to ensure that it was free from a medication error rate of five percent or greater based on three medication errors out of 36 opportunities."
Medication availability problems suggested broader supply chain issues at the facility. When prescribed medications aren't available, nursing staff must either obtain them immediately or document why residents didn't receive their treatments. The inspection report contains no evidence that Employee E14 took either step.
The crushing requirement for Resident R61 likely stemmed from swallowing difficulties, a common issue among nursing home residents. When medications must be crushed or altered, staff must follow specific preparation methods to ensure residents receive the full prescribed dose.
Ingreeza capsules contain small pellets designed to release medication slowly. Opening the capsule and sprinkling contents in pudding maintains this controlled release, while leaving the capsule intact in pudding could prevent proper absorption.
Federal regulations require nursing homes to maintain detailed medication administration records and ensure residents receive all prescribed treatments. The 5% error threshold exists because medication mistakes can cause serious harm, especially among elderly residents taking multiple drugs.
State inspectors classified the violations as causing "minimal harm or potential for actual harm" but affecting "few" residents. However, the error rate calculation suggests systemic problems beyond the three documented mistakes.
The inspection occurred April 3, just two days after observers documented the medication failures. The timing indicates inspectors may have conducted unannounced monitoring after receiving complaints or during routine surveillance.
Harmar Village operates at 715 Freeport Road in Cheswick, about 15 miles northeast of Pittsburgh. The facility must submit a correction plan addressing how it will reduce medication errors below the 5% threshold and ensure prescribed medications remain available for residents who need them.
The violations cite Pennsylvania regulations governing pharmacy services and nursing care standards. Both require facilities to maintain safe medication practices and ensure residents receive prescribed treatments without unnecessary delays or errors.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Harmar Village Health & Rehab Center from 2026-04-03 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Harmar Village Health & Rehab Center
- Browse all PA nursing home inspections
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 14, 2026 · Our methodology
HARMAR VILLAGE HEALTH & REHAB CENTER in CHESWICK, PA was cited for violations during a health inspection on April 3, 2026.
State inspectors documented three medication errors during 36 opportunities on April 1, creating an 8.33% error rate.
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.
Frequently Asked Questions
- What happened at HARMAR VILLAGE HEALTH & REHAB CENTER?
- State inspectors documented three medication errors during 36 opportunities on April 1, creating an 8.33% error rate.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in CHESWICK, PA, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from HARMAR VILLAGE HEALTH & REHAB CENTER or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 396048.
- Has this facility had violations before?
- To check HARMAR VILLAGE HEALTH & REHAB CENTER's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.