Harmar Village Health & Rehab Center

Review of Resident R1's clinical record revealed Resident R1 was admitted to the facility on [DATE].

Review of 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 R1's clinical record including diagnosis list revealed Dysphagia (difficulty swallowing) with a diagnosis date of 9/18/24.

Review of 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 R1's physician's order dated 8/20/25, revealed, Give meds crushed in pudding or applesauce until cleared by speech.

Review of 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 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 R1's medications uncrushed.

Employee E1 revealed Resident R1 began coughing.

Licensed Employee E1 revealed Resident R1 began experiencing respiratory distress and additional staff responded. LPN Employee E1 revealed he removed 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 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 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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/15/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Harmar Village Health & Rehab Center

715 Freeport Road Cheswick, PA 15024

SUMMARY STATEMENT OF DEFICIENCIES

Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]

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 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 R1.

During an interview on 11/13/25, at approximately 11:45 a.m. LPN Employee E1 stated that 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 R1 her medications uncrushed. LPN Employee E1 stated that Resident R1 began coughing. LPN Employee E1 stated that Resident R1 began experiencing respiratory distress and additional staff responded. LPN Employee E1 stated that he removed 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 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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/15/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Harmar Village Health & Rehab Center

715 Freeport Road Cheswick, PA 15024

SUMMARY STATEMENT OF DEFICIENCIES

Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]

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 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 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 R1 her medications uncrushed. LPN Employee E1 stated that Resident R1 began coughing. LPN Employee E1 stated that Resident R1 began experiencing respiratory distress and additional staff responded. LPN Employee E1 stated that he removed 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 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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/15/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Harmar Village Health & Rehab Center

715 Freeport Road Cheswick, PA 15024

SUMMARY STATEMENT OF DEFICIENCIES

Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]

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 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 R1 her medications uncrushed. LPN Employee E1 stated that Resident R1 began coughing. LPN Employee E1 stated that Resident R1 began experiencing respiratory distress and additional staff responded. LPN Employee E1 stated that he removed 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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/15/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Harmar Village Health & Rehab Center

715 Freeport Road Cheswick, PA 15024

SUMMARY STATEMENT OF DEFICIENCIES

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 R2, R3, R4, and 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 R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, and 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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/15/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Harmar Village Health & Rehab Center

715 Freeport Road Cheswick, PA 15024

SUMMARY STATEMENT OF DEFICIENCIES

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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/15/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Harmar Village Health & Rehab Center

715 Freeport Road Cheswick, PA 15024

SUMMARY STATEMENT OF DEFICIENCIES

During a review of current residents on 11/14/25, it was noted that four residents (Residents R2, R3, R4, and 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 R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, and 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 R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, and 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 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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/15/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Harmar Village Health & Rehab Center

715 Freeport Road Cheswick, PA 15024

SUMMARY STATEMENT OF DEFICIENCIES

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 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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/15/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Harmar Village Health & Rehab Center

715 Freeport Road Cheswick, PA 15024

SUMMARY STATEMENT OF DEFICIENCIES

Review of Resident R14's physician's order revealed Resident R14 required crushed medications.

Resident R16's name was written in on the report sheet, with no designation on how medications were administered.

Resident R16 was admitted on [DATE].

Resident R17 was documented on the report sheet as a full code.

Review of Resident R17's physician order dated [DATE], indicated DNR/DNI.

Review of the banner information at the top of Resident R17's electronic chart indicated DNR/DNI.

Resident R32's bed location did not include any information.

Resident R32 was admitted on [DATE], and readmitted from a hospitalization on [DATE].

Resident R33 was documented on the report sheet as a full code.

Review of Resident R33's physician's order dated [DATE], indicated DNR/DNI.

Review of the banner information at the top of Resident R33's electronic chart indicated DNR.

Resident R37's name was missing in the bed location on the report sheet.

Resident R38's name was written in but had discharged from the facility on [DATE].

Resident R39's name was written in on the report sheet, with no designation on how medications were administered.

Resident R39 was admitted on [DATE].

Resident R40's name was missing in the correct bed location on the report sheet.

Resident R21's name was written in for R40's bed location.

The printed information next to Resident R21's name indicated Full code.

Review of Resident R21's physician's order dated [DATE], indicated DNR.

Resident R40's correct bed location was blank.

Resident R41's name was written in on the report sheet, with no designation on how medications were administered.

Resident R41 was transferred to that bed location on [DATE].

Resident R42's name written in on the report sheet.

Resident R42 had discharged from the facility on [DATE].

Resident R43's name was written in on the report sheet.

The pre-printed information next to her name indicated Resident R43 was a full code.

Review of Resident R43's physician order dated [DATE], indicated DNR/DNI.

Resident R44 was documented on the report sheet as a full code.

Review of Resident R44's physician order dated [DATE], indicated full code, limited DNI.

Review of the banner information at the top of Resident R44's electronic chart indicated DNR.

Resident R45's information was included on the report sheet but had discharged on [DATE].

Resident R46's information was included on the report sheet, but Resident R46 had ceased to breathe on [DATE].

Review of the electronic medical record indicated Resident R33 was assigned to Resident R46's former location, but no information for Resident R33 was listed on the report sheet.

During an interview on [DATE], 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], 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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/15/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Harmar Village Health & Rehab Center

715 Freeport Road Cheswick, PA 15024

SUMMARY STATEMENT OF DEFICIENCIES

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.

Facility ID: