Harmar Village Health & Rehab Center

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Procedures, and Programs, revealed that Resident Resident R6 utilized oxygen therapy. Review of the plan of care for nutrition/hydration initiated 8/4/25, indicated for staff to monitor weight per protocol. Further review of the care plan failed to reveal goals and interventions related a heart failure diagnosis. Review of a physician's order dated 7/26/25, indicated for staff to obtain weight upon admission, then weekly x4. Review of Resident Resident R7's weight record indicated that on 10/9/25, Resident Resident R7's weight was 130.4 pounds, and on 11/5/25, was 144 pounds. Review of progress notes failed to reveal a notification to a provider of a fifteen-pound weight gain in four weeks. During an interview on 11/13/25, at approximately 2:00 p.m.

Medical Records Employee E5 confirmed that she was up to date on scanning and uploading any paper notifications that may have been completed. Review of the electronic medical record confirmed that documentation of a paper notification to a provider of the weight gain was not uploaded. Review of a progress note dated 11/8/25, at 2:21 p.m. indicated that Resident Resident R7 and family had complaints of increased abdominal distention, shortness of breath, and +3 lower leg edema (a moderate grade of pitting edema, characterized by a noticeably deep pit, around 5-6 mm, that takes between 15 and 60 seconds to fully disappear after pressure is applied). A one-time order for Lasix (a diuretic medication) 20 mg was received. Review of a progress note dated 11/12/25, at 8:45 p.m. indicated, Resident was observed while lying in her bed. Resident reports feeling very tired and SOB (short of breath). Resident is on 4L NC (nasal canula). Resident's abdomen is distended and firm but she denies nausea. she has +3 B/L LE edema.

Resident's LLL and RLL (right and left lower lobe) and RML (right middle lobe) are diminished and have rhonchi (breath sounds caused by partial obstruction of the small breathing tubes in the lung) throughout.

VS (vital signs) obtained. Review of a progress note dated 11/12/25, at 8:55 p.m. indicated that emergency services transported Resident Resident R7 to the hospital. Review of a progress note dated 11/15/25, at 1:46 p.m. confirmed Resident Resident R7 remained in the hospital for COPD exacerbation and right sided heart failure.

During an interview on 11/15/25, at approximately 12:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to notify the medical provider of a change in condition for two of seven residents. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 201.29(d) Resident rights. 28 Pa.

Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Harmar Village Health & Rehab Center

715 Freeport Road Cheswick, PA 15024

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

review of facility policy, clinical records, and staff interviews, it was determined the facility failed to implement policies and procedures to protect residents from neglect that resulted in the actual harm of choking and subsequent death for one of five residents (Resident Resident R1).Findings include: Review of facility Pennsylvania Resident Abuse Policy dated 10/23/25, revealed neglect is 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. Review of Resident Resident R1's clinical record revealed Resident Resident R1 was admitted to the facility on [DATE REDACTED]. Review of Resident Resident R1's Minimum Data Set assessment (MDS, periodic assessment of resident care needs) dated 10/8/25, included diagnoses of Dementia (group of symptoms that affects memory, thinking and interferes with daily life), and Chronic Obstructive Pulmonary Disease (COPD, group of progressive lung disorders characterized by increasing breathlessness). Review of Resident Resident R1's clinical record including diagnosis list revealed Dysphagia (difficulty swallowing) with a diagnosis date of 9/18/24. Review of Resident Resident R1's plan of care for increased nutrition/hydration risk initiated 9/22/23, including the intervention of, Continue to adhere to STRICT aspiration precautions. Further review of the plan of care failed to reveal goals and interventions developed for dysphagia or the need to have crushed medications. Review of Resident Resident R1's physician's order dated 8/20/25, revealed, Give meds crushed in pudding or applesauce until cleared by speech. Review of Resident Resident R1's progress notes dated 11/6/25, Resident CTB (cease to breath) after going into respiratory failure post aspiration coughing event. Crash cart brought into the room and RN supervisors notified.

Resident identified as a DNR (do not resuscitate) finger sweep, suction, Heimlich maneuver was not successful and patient CTB at 1800 (6:00 p.m.). Death was pronounced by [RN Employee E3] and [RN Supervisor Employee E2]. During an interview on 11/13/25, at approximately 11:45 a.m. Licensed Practical Nurse (LPN) Employee E1 revealed Resident Resident R1 had asked if (he/she) could take (his/her) medications whole, as (his/her) diet order had recently changed. Employee E1 confirmed that he provided Resident Resident R1's medications uncrushed. Employee E1 revealed Resident Resident R1 began coughing. Licensed Employee E1 revealed Resident Resident R1 began experiencing respiratory distress and additional staff responded. LPN Employee E1 revealed he removed Resident Resident R1's upper denture and completed a finger sweep (first-aid technique to remove a visible foreign object from a person's mouth during a choking emergency) which brought forth food matter. During an interview on 11/13/25, at approximately 3:35 p.m. RN Supervisor Employee E2 stated when LPN Employee E1 performed a finger sweep whole pills were removed from Resident Resident R1's mouth/throat. During review of facility documents on 11/15/25, revealed, LPN Employee E1 was given a disciplinary action for neglecting to provide medication in the form ordered by the physician.

During an interview on 11/15/25, at approximately 12:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to implement policies and procedures to protect Resident Resident R1 from neglect that resulted in the actual harm of aspiration and respiratory failure. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 201.18 (b) (1) (e) (1) Management.28 Pa. Code: 211.12 (d) (1) (2) (5) Nursing services.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Harmar Village Health & Rehab Center

715 Freeport Road Cheswick, PA 15024

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to implement policies and procedures to report possible neglect one of five residents (Resident Resident R1).Findings include: Review of facility Pennsylvania Resident Abuse Policy dated 10/23/25, indicated all allegations of neglect must reported immediately to the Administrator, Director of Nursing (DON) and to the applicable State Agency. If the event that caused the allegation involves an allegation of abuse or serious bodily injury, it should be reported to the DOH (Department of Health) immediately, but not later than two hours after the allegation is made. Review of the clinical record indicated Resident Resident R1 was admitted to the facility on [DATE REDACTED] Review of the Minimum Data Set (MDS, periodic assessment of resident care needs dated 10/8/25, included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness). Review of the facility diagnosis list included dysphagia (difficulty swallowing) with a diagnosis date of 9/18/24. Review of the plan of care for increased nutrition/hydration risk initiated 9/22/23, included the approach of, Continue to adhere to STRICT aspiration precautions. Further review of the plan of care failed to reveal goals and interventions developed specifically for dysphagia or the need to have crushed medications. Review of a physician's order dated 8/20/25, indicated, Give meds crushed in pudding or applesauce until cleared by speech. Review of a progress note dated 11/6/25, at Resident CTB (cease to breath) after going into respiratory failure post aspiration coughing event. Crash cart brought into the room and RN supervisors notified. Resident identified as a DNR (do not resuscitate) finger sweep, suction, Heimlich maneuver was not successful and patient CTB at 1800 (6:00 p.m.). Death was pronounced by [RN Employee E3] and [RN Supervisor Employee E2]. During an interview on 11/13/25, at approximately 11:20 a.m. the Director of Nursing was asked to provide the investigation documents for Resident Resident R1's choking incident. The Director of Nursing stated an investigation was not completed. Review of documentation submitted by the facility to the State Survey Agency failed to include a report of possible neglect to Resident Resident R1. During an interview on 11/13/25, at approximately 11:45 a.m. LPN Employee E1 stated that Resident Resident R1 had asked if she could take her medications whole, as her diet order had recently changed. LPN Employee E1 confirmed that he provided Resident Resident R1 her medications uncrushed. LPN Employee E1 stated that Resident Resident R1 began coughing. LPN Employee E1 stated that Resident Resident R1 began experiencing respiratory distress and additional staff responded. LPN Employee E1 stated that he removed Resident Resident R1's upper denture and completed a finger sweep (first-aid technique to remove a visible foreign object from a person's mouth

during a choking emergency) which brought forth food matter. During an interview on 11/13/25, at approximately 3:35 p.m. RN Supervisor Employee E2 stated that when LPN Employee E1 performed a finger sweep whole pills were removed from Resident Resident R1's mouth/throat. During an interview on 11/15/25, at approximately 12:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to implement policies and procedures to report possible neglect one of five residents. 28 Pa.

Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 201.18 (b) (1) (e) (1) Management.28 Pa. Code: 211.12 (d) (1) (2) (5) Nursing services.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Harmar Village Health & Rehab Center

715 Freeport Road Cheswick, PA 15024

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610

Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to implement policies and procedures to investigate a choking incident to rule out possible neglect one of five residents (Resident Resident R1).Review of facility Pennsylvania Resident Abuse Policy dated 10/23/25, indicated it is that facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation of residents, misappropriation of resident property and injuries of unknown source. Review of the clinical record indicated Resident Resident R1 was admitted to the facility on [DATE REDACTED] Review of the Minimum Data Set (MDS, periodic assessment of resident care needs dated 10/8/25, included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness). Review of the facility diagnosis list included dysphagia (difficulty swallowing) with a diagnosis date of 9/18/24. Review of the plan of care for increased nutrition/hydration risk initiated 9/22/23, included the approach of, Continue to adhere to STRICT aspiration precautions. Further review of the plan of care failed to reveal goals and interventions developed specifically for dysphagia or the need to have crushed medications. Review of a physician's order dated 8/20/25, indicated, Give meds crushed in pudding or applesauce until cleared by speech. Review of a progress note dated 11/6/25, at Resident CTB (cease to breath) after going into respiratory failure post aspiration coughing event. Crash cart brought into the room and RN supervisors notified. Resident identified as a DNR (do not resuscitate) finger sweep, suction, Heimlich maneuver was not successful and patient CTB at 1800 (6:00 p.m.). Death was pronounced by [RN Employee E3] and [RN Supervisor Employee E2]. During an interview on 11/13/25, at approximately 11:20 a.m. the Director of Nursing was asked to provide the investigation documents for Resident Resident R1's choking incident. The Director of Nursing stated an investigation was not completed. During an interview on 11/13/25, at approximately 11:45 a.m.

LPN Employee E1 stated that Resident Resident R1 had asked if she could take her medications whole, as her diet order had recently changed. LPN Employee E1 confirmed that he provided Resident Resident R1 her medications uncrushed. LPN Employee E1 stated that Resident Resident R1 began coughing. LPN Employee E1 stated that Resident Resident R1 began experiencing respiratory distress and additional staff responded. LPN Employee E1 stated that he removed Resident Resident R1's upper denture and completed a finger sweep (first-aid technique to remove a visible foreign object from a person's mouth during a choking emergency) which brought forth food matter. During an interview on 11/13/25, at approximately 3:35 p.m. RN Supervisor Employee E2 stated that when LPN Employee E1 performed a finger sweep whole pills were removed from Resident Resident R1's mouth/throat. During an interview on 11/15/25, at approximately 12:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to investigate a choking incident to rule out possible neglect for one of five residents. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa.

Code: 211.10(d) Resident care policies.28 Pa. Code: 201.18 (b) (1) (e) (1) Management.28 Pa. Code: 211.12 (d) (1) (2) (5) Nursing services.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Harmar Village Health & Rehab Center

715 Freeport Road Cheswick, PA 15024

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a

review facility policy, clinical records, and staff interviews, it was determined that the facility failed to develop

a person-centered care plan related to the need for crushed medications for one of five residents (Resident Resident R1).Findings include: Review of the facility policy Comprehensive Care Plan dated 10/23/25, indicated an interdisciplinary plan of care will be established for every resident and updated in accordance with State, and Federal requirements and on an as needed basis. Review of the clinical record indicated Resident Resident R1 was admitted to the facility on [DATE REDACTED] Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 10/8/25, included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness). Review of the facility diagnosis list included dysphagia (difficulty swallowing) with a diagnosis date of 9/18/24. Review of the plan of care for increased nutrition/hydration risk initiated 9/22/23, included the approach of, Continue to adhere to STRICT aspiration precautions. Further review of the plan of care failed to reveal goals and interventions developed specifically for dysphagia or the need to have crushed medications. Review of a physician's order dated 8/20/25, indicated, Give meds crushed in pudding or applesauce until cleared by speech. Review of a progress note dated 11/6/25, at Resident CTB (cease to breath) after going into respiratory failure post aspiration coughing event. Crash cart brought into the room and RN supervisors notified. Resident identified as a DNR (do not resuscitate) finger sweep, suction, Heimlich maneuver was not successful and patient CTB at 1800 (6:00 p.m.). Death was pronounced by [RN Employee E3] and [RN Supervisor Employee E2]. During an interview on 11/13/25, at approximately 11:45 a.m. LPN Employee E1 stated that Resident Resident R1 had asked if she could take her medications whole, as her diet order had recently changed.

LPN Employee E1 confirmed that he provided Resident Resident R1 her medications uncrushed. LPN Employee E1 stated that Resident Resident R1 began coughing. LPN Employee E1 stated that Resident Resident R1 began experiencing respiratory distress and additional staff responded. LPN Employee E1 stated that he removed Resident Resident R1's upper denture and completed a finger sweep (first-aid technique to remove a visible foreign object from a person's mouth during a choking emergency) which brought forth food matter.During an interview on 11/15/25, at approximately 12:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to develop a person-centered care plan related to the need for crushed medications for one of five residents. 28 Pa. Code: 211.12 (d) (1) (2) (5) Nursing services.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Harmar Village Health & Rehab Center

715 Freeport Road Cheswick, PA 15024

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, clinical record review, and resident and staff interview, it was determined that the facility failed to procure physician's orders for the need to have crushed medications for 29 of 33 residents (Resident Resident R8, Resident R9, Resident R10, Resident R11, Resident R12, Resident R13, Resident R14, Resident R15, Resident R16, Resident R17, Resident R18, Resident R19, Resident R20, Resident R21, Resident R22, Resident R23, Resident R24, Resident R25, Resident R26, Resident R27, Resident R28, Resident R29, Resident R30, Resident R31, Resident R32, Resident R33, Resident R34, Resident R35, and Resident R36). Findings include: Review of the Facility assessment dated [DATE REDACTED], indicated the facility will provide speech therapy services. During an interview on 11/13/25, at 2:25 p.m. Speech Therapist Employee E7 stated that the speech department adjusts diet consistency orders but does not address the need for a physician's order for crushed medications. When asked how nursing staff are aware of the need for a resident to have medications crushed, Speech Therapist Employee E7 stated, I would assume the staff know. During a review of current residents on 11/14/25, it was noted that four residents (Residents Resident R2, Resident R3, Resident R4, and Resident R5) had physician orders for crushed medications. During a review

on 11/15/25, at approximately 10:30 a.m. of a speech therapy audit completed by Speech Therapist Employee E7 on 11/14/25, it was noted that 29 additional facility residents were documented as needing their medications crushed (Resident Resident R8, Resident R9, Resident R10, Resident R11, Resident R12, Resident R13, Resident R14, Resident R15, Resident R16, Resident R17, Resident R18, Resident R19, Resident R20, Resident R21, Resident R22, Resident R23, Resident R24, Resident R25, Resident R26, Resident R27, Resident R28, Resident R29, Resident R30, Resident R31, Resident R32, Resident R33, Resident R34, Resident R35, and Resident R36). During an

interview on 11/15/25, at approximately 12:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to procure physician's orders for the need to have crushed medications for 29 of 33 residents. 28 Pa. Code 211.2(d)(10) Medical Director.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Harmar Village Health & Rehab Center

715 Freeport Road Cheswick, PA 15024

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Minimal harm or potential for actual harm

approximately 12:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to assure that the Director of Nursing displayed the appropriate competencies and skills to recognize, report, and investigate possible neglect leading to death for one of five residents. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 201.18 (b) (1) (e) (1) Management.28 Pa. Code: 211.12 (d) (1) (2) (5) Nursing services.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Harmar Village Health & Rehab Center

715 Freeport Road Cheswick, PA 15024

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

11/14/25 by 3 pm to discuss deficient practice and immediate Plan of Correction with the Interdisciplinary Team. During a review of current residents on 11/14/25, it was noted that four residents (Residents Resident R2, Resident R3, Resident R4, and Resident R5) had physician orders for crushed medications. During a review of the speech therapy audits on 11/15/25, at approximately 10:30 a.m. it was noted that 29 additional residents were documented as needing their medications crushed, (Resident Resident R8, Resident R9, Resident R10, Resident R11, Resident R12, Resident R13, Resident R14, Resident R15, Resident R16, Resident R17, Resident R18, Resident R19, Resident R20, Resident R21, Resident R22, Resident R23, Resident R24, Resident R25, Resident R26, Resident R27, Resident R28, Resident R29, Resident R30, Resident R31, Resident R32, Resident R33, Resident R34, Resident R35, and Resident R36).

Interviews conducted with staff on 11/15/25, beginning at approximately 11:15 a.m., five of five LPNs and two of two RNs on confirmed they received re-education on medication administration, following physician orders, and were able to demonstrate in the electronic charting system where to access if a resident required their medication to be crushed. The Immediate Jeopardy was removed on 11/15/25, at 12:25 p.m. when the action plan implementation was verified. During an interview on 11/15/25, at approximately 12:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to accurately document the need to crush medications for 29 of 33 residents (Resident Resident R8, Resident R9, Resident R10, Resident R11, Resident R12, Resident R13, Resident R14, Resident R15, Resident R16, Resident R17, Resident R18, Resident R19, Resident R20, Resident R21, Resident R22, Resident R23, Resident R24, Resident R25, Resident R26, Resident R27, Resident R28, Resident R29, Resident R30, Resident R31, Resident R32, Resident R33, Resident R34, Resident R35, and Resident R36) and failed to ensure that residents are free of significant medication errors which resulted in an immediate jeopardy situation for one of five residents (Resident Resident R1). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1) Management.28 Pa. Code: 211.10 (c)(d) Resident Care policies.28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Harmar Village Health & Rehab Center

715 Freeport Road Cheswick, PA 15024

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Level of Harm - Minimal harm or potential for actual harm

Based on review of job descriptions, clinical records, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to protect residents from significant medication errors. This failure resulted in a resident with an active order to have medications crushed receive their medications whole, leading the resident ceasing to breathe after going into respiratory failure post-aspiration coughing event, which created an Immediate Jeopardy situation for one of five residents (Resident Resident R1). Findings include: Review of the facility-provided Nursing Home Administrator (NHA) job description indicated, The primary purpose of your job is to lead, direct, and manage the overall operations of the community in accordance with policies and procedures and current federal, state and local standards, guidelines and regulations that govern the community. As the Administrator, it is your responsibility to organize, develop, and direct resources to maintain the highest degree of quality care is maintained for each resident at all times. Review of the facility-provided Director of Nursing (DON) job description indicated, As the Director of Nursing it is your responsibility to organize, develop, manage, and direct the overall operations of the Nursing Service Department in accordance with policies and procedures and current federal, state and local standards, guidelines and regulations that govern the community. The Director of Nursing is to work directly with the Administrator and the Medical Director to ensure the highest degree of quality care is maintained for each resident at all times. Follows all health, sanitary, and infection control policies and maintains established standards of practice set forth by the community's administration and Nursing Policies and Procedures. Based on findings identified in this report, the facility failed to prevent

the failed protect residents significant medication errors. The NHA and the DON failed to fulfill their essential job duties to ensure the federal and state guidelines and regulations were followed. During an

interview on 11/15/25, at approximately 12:30 p.m. the NHA and DON confirmed that they failed to effectively manage the facility to protect residents from significant medication errors. This failure resulted in

a resident with an active order to have medications crushed receive their medications whole, leading the resident ceasing to breathe after going into respiratory failure post-aspiration coughing event, which created an Immediate Jeopardy situation for one of five residents. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Harmar Village Health & Rehab Center

715 Freeport Road Cheswick, PA 15024

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Resident R48's information still present in the bed location. Resident Resident R47 had ceased to breathe on [DATE REDACTED]. The code status for Resident Resident R47 DNR/DNI (do not resuscitate / do not intubate) remained printed on the report sheet. Resident Resident R8 was a full code (directive given by a patient that instructs healthcare providers to use all possible life-saving measures, including cardiopulmonary resuscitation (CPR), if their heart and lungs stop working). Resident Resident R14's name was written in on the report sheet, with no designation on how medications were administered. Resident Resident R14 was admitted on [DATE REDACTED]. Review of Resident Resident R14's physician's order revealed Resident Resident R14 required crushed medications. Resident Resident R16's name was written in on the report sheet, with no designation on how medications were administered. Resident Resident R16 was admitted on [DATE REDACTED].

Resident Resident R17 was documented on the report sheet as a full code. Review of Resident Resident R17's physician order dated [DATE REDACTED], indicated DNR/DNI. Review of the banner information at the top of Resident Resident R17's electronic chart indicated DNR/DNI. Resident Resident R32's bed location did not include any information. Resident Resident R32 was admitted on [DATE REDACTED], and readmitted from a hospitalization on [DATE REDACTED]. Resident Resident R33 was documented on the report sheet as a full code. Review of Resident Resident R33's physician's order dated [DATE REDACTED], indicated DNR/DNI. Review of the banner information at the top of Resident Resident R33's electronic chart indicated DNR. Resident Resident R37's name was missing in the bed location on the report sheet. Resident Resident R38's name was written in but had discharged from the facility on [DATE REDACTED]. Resident Resident R39's name was written in on

the report sheet, with no designation on how medications were administered. Resident Resident R39 was admitted

on [DATE REDACTED]. Resident Resident R40's name was missing in the correct bed location on the report sheet. Resident Resident R21's name was written in for Resident R40's bed location. The printed information next to Resident Resident R21's name indicated Full code. Review of Resident Resident R21's physician's order dated [DATE REDACTED], indicated DNR. Resident Resident R40's correct bed location was blank. Resident Resident R41's name was written in on the report sheet, with no designation on how medications were administered. Resident Resident R41 was transferred to that bed location on [DATE REDACTED]. Resident Resident R42's name written in on the report sheet. Resident Resident R42 had discharged from the facility

on [DATE REDACTED]. Resident Resident R43's name was written in on the report sheet. The pre-printed information next to her name indicated Resident Resident R43 was a full code. Review of Resident Resident R43's physician order dated [DATE REDACTED], indicated DNR/DNI. Resident Resident R44 was documented on the report sheet as a full code. Review of Resident Resident R44's physician order dated [DATE REDACTED], indicated full code, limited DNI. Review of the banner information at

the top of Resident Resident R44's electronic chart indicated DNR. Resident Resident R45's information was included on the report sheet but had discharged on [DATE REDACTED]. Resident Resident R46's information was included on the report sheet, but Resident Resident R46 had ceased to breathe on [DATE REDACTED]. Review of the electronic medical record indicated Resident Resident R33 was assigned to Resident Resident R46's former location, but no information for Resident Resident R33 was listed on the report sheet. During an interview on [DATE REDACTED], at approximately 12:00 p.m. the Director of Nursing confirmed that a lack of communication was identified between the speech therapy department and the nursing department regarding what residents required physician orders for crushed medications.

During an interview on [DATE REDACTED], at approximately 12:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed report sheets used by staff were inaccurate and further confirmed that the facility failed to make certain that medical records on each resident are complete and accurately documented for 14 of 104 residents.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Harmar Village Health & Rehab Center

715 Freeport Road Cheswick, PA 15024

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

that when LPN Employee E1 performed a finger sweep (first-aid technique to remove a visible foreign object from a person's mouth during a choking emergency) whole pills were removed from Resident Resident R1's mouth/throat. RN Supervisor Employee E2 confirmed Resident Resident R1's oxygen saturation had risen slightly on

the concentrator and that if there had been high-level oxygen replacement had been available, it may have provided additional time to clear Resident Resident R1's airway. During an observation on 11/13/25, at approximately 3:50 p.m. of the Third Floor Emergency Cart Daily Checklist for November 2025 revealed:11/1/25: No documentation a check was completed.11/2/25: Documented that no items were available on the cart.11/3/25: No documentation a check was completed.11/4/25: No documentation a check was completed.11/5/25: Documented that no items were available on the cart.11/6/25: No documentation a check was completed.11/7/25: No documentation a check was completed.11/8/25: Documented that no items were available on the cart.11/9/25: Documented that no items were available on the cart.11/10/25: Documented that no items were available on the cart.11/11/25: Documented that no items were available

on the cart.11/12/25: Documented that no items were available on the cart. During an observation on 11/13/25, at approximately 3:55 p.m. of the Second Floor Emergency Cart Daily Checklist for November 2025 revealed:11/1/25: No documentation a check was completed.11/2/25: No documentation a check was completed.11/3/25: No documentation a check was completed.11/4/25: No documentation a check was completed.11/5/25: No documentation a check was completed.11/6/25: No documentation a check was completed.11/7/25: No documentation a check was completed.11/8/25: No documentation a check was completed.11/9/25: Documented that no items were available on the cart.11/10/25: No documentation a check was completed.11/11/25: Documented that no items were available on the cart.11/12/25: Documented that no items were available on the cart. During an interview on 11/14/25, at approximately 10:00 a.m. LPN Employee E6 was asked to provide the Third Floor nursing unit crash cart checklists. When

the binder was provided, the checklist for August 2025 was observed, with multiple dates not documented, and no checklists were available for September and October 2025. During an interview on 11/15/24, at approximately 12:30 pm. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to make certain that equipment was in safe operating condition for two of two crash carts which caused the actual harm of a delay in emergency care for one of five residents. 28 Pa Code: 201.14(a) Responsibility of licensee.

Event ID:

Facility ID:

If continuation sheet